Chapter Introduction

CHAPTER
6

Disorders of Trauma and Stress

176

177

TOPIC OVERVIEW

Stress and Arousal: The Fight-or-Flight Response

Acute and Posttraumatic Stress Disorders

What Triggers Acute and Posttraumatic Stress Disorders?

Why Do People Develop Acute and Posttraumatic Stress Disorders?

How Do Clinicians Treat Acute and Posttraumatic Stress Disorders?

Dissociative Disorders

Dissociative Amnesia

Dissociative Identity Disorder

How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder?

How Are Dissociative Amnesia and Dissociative Identity Disorder Treated?

Depersonalization-Derealization Disorder

Putting It Together: Getting a Handle on Trauma and Stress

Specialist Latrell Robinson, a 25-year-old single African American man, was an activated National Guardsman [serving in the Iraq war]. He [had been] a full-time college student and competitive athlete raised by a single mother in public housing…. Initially trained in transportation, he was called to active duty and retrained as a military policeman to serve with his unit in Baghdad. He described enjoying the high intensity of his deployment and [became] recognized by others as an informal leader because of his aggressiveness and self-confidence. He [had] numerous [combat] exposures while performing convoy escort and security details [and he came] under small arms fire on several occasions, witnessing dead and injured civilians and Iraqi soldiers and on occasion feeling powerless when forced to detour or take evasive action. He began to develop increasing mistrust of the [Iraq] environment as the situation “on the street” seemed to deteriorate. He often felt that he and his fellow soldiers were placed in harm’s way needlessly.

On a routine convoy mission [in 2003], serving as driver for the lead HUMVEE, his vehicle was struck by an Improvised Explosive Device showering him with shrapnel in his neck, arm, and leg. Another member of his vehicle was even more seriously injured…. He was evacuated to the Combat Support Hospital (CSH) where he was treated and returned to duty … after several days despite requiring crutches and suffering chronic pain from retained shrapnel in his neck. He began to become angry at his command and doctors for keeping him in [Iraq] while he was unable to perform his duties effectively. He began to develop insomnia, hypervigilance, and a startle response. His initial dreams of the event became more intense and frequent and he suffered intrusive thoughts and flashbacks of the attack. He began to withdraw from his friends and suffered anhedonia, feeling detached from others, and he feared his future would be cut short. He was referred to a psychiatrist at the CSH….

After two months of unsuccessful rehabilitation for his battle injuries and worsening depressive and anxiety symptoms, he was evacuated to a … military medical center [in the United States]…. He was screened for psychiatric symptoms and was referred for outpatient evaluation and management. He met … criteria for acute PTSD and was offered medication management, supportive therapy, and group therapy…. He was ambivalent about taking passes or convalescent leave to his home because of fears of being “different, irritated, or aggressive” around his family or girlfriend. After three months at the military service center, he was [deactivated from service and] referred to his local VA Hospital to receive follow-up care.

(National Center for PTSD, 2008)

During the horror of combat, soldiers often become highly anxious and depressed, confused and disoriented, even physically ill. Moreover, for many, like Latrell, these and related reactions to extraordinary stress or trauma continue well beyond the combat experience itself.

Of course, it is not just combat soldiers who are affected by stress. Nor does stress have to rise to the level of combat trauma to have a profound effect on psychological and physical functioning. Stress comes in all sizes and shapes, and we are all greatly affected by it.

We feel some degree of stress whenever we are faced with demands or opportunities that require us to change in some manner. The state of stress has two components: a stressor, the event that creates the demands, and a stress response, the person’s reactions to the demands. The stressors of life may include annoying everyday hassles, such as rush-hour traffic; turning-point events, such as college graduation or marriage; long-term problems, such as poverty or poor health; or traumatic events, such as major accidents, assaults, tornadoes, or military combat. Our response to such stressors is influenced by the way we judge both the events and our capacity to react to them in an effective way (Biron & Link, 2014; Smith & Kirby, 2011; Lazarus & Folkman, 1984). People who sense that they have the ability and the resources to cope are more likely to take stressors in stride and to respond well.

178

Different strokes for different folks Some people are exhilarated by the opportunity to chase bulls through the streets of Pamplona, Spain, during the annual “running of the bulls” (left). Others are terrified by such a prospect and prefer instead to engage tamer animals, such as ostriches, during the “running of the ostriches” fiesta in Irurzun, Spain (right). Photo credits: Reuters/Corbis, Jon Dimis/AP Photo

BETWEEN THE LINES

Top Stressors in the U.S.

  • 1. Job pressure

  • 2. Money

  • 3. Health

  • 4. Relationships

  • 5. Poor nutrition

  • 6. Media overload

  • 7. Sleep deprivation

(APA,2013)

When we view a stressor as threatening, a natural reaction is arousal and a sense of fear—a response frequently discussed in Chapter 5. As you saw in that chapter, fear is actually a package of responses that are physical, emotional, and cognitive. Physically, we perspire, our breathing quickens, our muscles tense, and our heart beats faster. Turning pale, developing goose bumps, and feeling nauseated are other physical reactions. Emotional responses to extreme threats include horror, dread, and even panic, while in the cognitive realm fear can disturb our ability to concentrate and remember and may distort our view of the world. We may, for example, remember things incorrectly or exaggerate the harm that actually threatens us.

Stress reactions, and the sense of fear they produce, are often at play in psychological disorders. People who experience a large number of stressful events are particularly vulnerable to the onset of the anxiety disorders that you read about in Chapter 5. Similarly, increases in stress have been linked to the onset of depression, schizophrenia, sexual dysfunctioning, and other psychological problems.

Extraordinary stress and trauma play an even more central role in certain psychological disorders. In these disorders, the reactions to stress become severe and debilitating, linger for a long period of time, and may make it impossible for the individual to live a normal life. Under the heading “Trauma- and Stressor-Related Disorders,” DSM-5 lists several disorders in which trauma and extraordinary stress trigger a wide range of stress symptoms, including heightened arousal, anxiety and mood problems, memory and orientation difficulties, and behavioral disturbances. Two of these disorders, acute stress disorder and posttraumatic stress disorder, are discussed in this chapter. In addition, DSM-5 lists the “dissociative disorders,” a group of disorders also triggered by traumatic events, in which the primary symptoms are severe memory and orientation problems. These disorders—dissociative amnesia, dissociative identity disorder (multiple personality disorder), and depersonalization-derealization disorder—are also examined in this chapter.

To fully understand these various stress-related disorders, it is important to appreciate the precise nature of stress and how the brain and body typically react to stress. Thus let’s first discuss stress and arousal, then move on to discussions of acute and posttraumatic stress disorders and the dissociative disorders.

179