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1. Section = Characteristics of disorders Subsection = An Anxiety Disorder: PTSD An example of an effective disorder is Post Traumatic Stress Disorder (PTSD). PTSD can…
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  • 1. Section = Characteristics of disorders Subsection = An Anxiety Disorder: PTSD An example of an effective disorder is Post Traumatic Stress Disorder (PTSD). PTSD can only be diagnosed in people who have experienced a severe trauma where they were in danger of their lives or of severe injury, and even among those who have experienced such a trauma both the severity of the trauma and individual differences will affect the likelihood of them developing symptoms of PTSD. For example, in the Vietnam War of those who fought in prolonged combat about 70% experienced symptoms of PTSD, and of concentration camp sufferers 90% still experienced disturbing symptoms 20 years later. In a study assessing survivors of the Herald of Free Enterprise Hodgkinson and Stewart (1991) found that a year after the event 90% were found to be suffering from PTSD. PTSD is a disorder classified in DSM IV (first included in DSM III in 1980) DSM IV gives 3 main groups of clear symptoms with the aim being to make it possible to distinguish between a “normal” reaction to a traumatic event and an “abnormal” one: 1. re-experiencing phenomena – the traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event or recurrent distressing dreams during which the event is replayed. In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment. Intense psychological distress or physiological reactivity often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g. anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for a woman who was raped in an elevator). 2. avoidance or numbing reactions – such as efforts to avoid the thoughts or feelings associated with the trauma, and feeling detached from other people. Many survivors of the ferry disaster “not only shunned the prospect of ferry travel again but could not even bear to see the sea, and in the immediate aftermath of the disaster could not face taking a bath or shower”. Diminished responsiveness to the external world, referred to as "psychic numbing" or "emotional anaesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities, of feeling detached or estranged from other people, or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness, and sexuality). 3. symptoms of increased arousal –such as difficulty stating asleep, irritability and outbursts of anger. DSM also requires that the full symptom picture must be present for more than 1 month (especially since most people experience PTSD type symptoms as a part of the normal post- event reaction for about the first month) and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. PTSD is cyclical and the symptoms can disappear and reappear, and can appear for the first time months or even years after the event, and the delayed versions are no less severe.
  • 2. Section = Explanations of one disorder: the anxiety disorder PTSD Subsection = Behavioural The disorder chosen is the anxiety disorder PTSD (post traumatic stress disorder). A Behavioural explanation for PTSD is Mowrer’s two-factor model of conditioning: According to this model both classical and operant conditioning can explain the disorder: 1. through classical conditioning the person learns to fear a neutral stimulus (the CS, conditioned stimulus) with an intrinsically aversive stimulus (the UCS) 2. through operant conditioning the person gains relief from this conditioned fear by avoiding the CS. The avoidant response is maintained by its reinforcing consequence of reducing the amount of fear the person experiences. This two factor model explains that a person with PTSD had a negative social experience, the traumatic experience (such as experiencing a natural disaster e.g. a tsunami, or experiencing a technological disaster such as the capsize of the Herald of Free Enterprise in Zeebrugge harbour, or the experience of a woman being raped), and becomes classically conditioned to fear similar situations. In the case of a woman who was raped she may associate the area she was raped in as the CS which triggers her anxiety/fear symptoms (UCS). Her avoidant behaviour in not going to this area is reinforcing for her as it stops her experiencing the fear she associates with that area. However, her avoidant behaviour also interferes with the chances of her fear becoming extinguished, thus maintaining her symptoms. A survivor of the Herald of Free Enterpise may see cross channel ferries (the CS) as the object of fear/anxiety (UCS), or simply being on the water in any kind of boat. They therefore avoid boats of any kind. Again, their avoidance does not help them overcome their fear but acts to reinforce it. This two factor model of conditioning offers a behavioural model that helps to explain the creation and maintenance of PTSD. Section = Explanations of one disorder: the anxiety disorder PTSD Subsection = Biological The anxiety disorder PTSD (post traumatic stress disorder) can be explained by neurobiological factors, related to the hippocampus. The hippocampus is an area of the brain known for its role in memory, including emotional memory. In brain-imaging studies the hippocampus has been shown to be smaller in those people who experience PTSD following a traumatic event and those who do not. In 2002 Gilbertson carried out a study of multiple pairs of twins, one of each pair of twins had served in Vietnam and one had not, and showed that PTSD and hippocampal volume are related. This was an especially revealing study since it showed that nonveteran twins with a smaller than average hippocampus were significantly more likely to have a veteran twin who developed PTSD after military service. This study therefore indicates that a smaller-than- average hippocampus probably precedes the onset of the disorder and also that people with smaller than average hippocampal volume may be biologically predisposed to develop symptoms of PTSD. This finding was among the first to indicate brain characteristics that may biologically predispose someone to experiencing an anxiety disorder such as PTSD.
  • 3. Section = Explanations of one disorder: the anxiety disorder PTSD Subsection = Cognitive Explanation 1 – Information Processing Theory of PTSD The Information Processing Theory of PTSD proposes that information about a traumatic event is stored in the brain in "fear networks." These networks consist of memories of traumatic stimuli and responses along with their meanings. The entire network is designed to stimulate avoidance behaviour in the trauma survivor to prevent future threat to survival. Unfortunately, as researchers have discovered, these "fear networks" seem to be responsible for a set of beliefs or expectations (schemata) of trauma survivors that causes them to have an attentional bias toward evidence of threat, ambiguous or otherwise, and to disregard evidence to the contrary. Such attention to cues of threat serves to trigger typical fear responses of escape and avoidance, and seems to account for the re-experiencing phenomena of PTSD. How rape survivors interpret the trauma (the meaning or cognitive appraisal of the event) effects subsequent reactions to the experience. Studies have found that rape survivors who experience conflict between their prior beliefs and the rape experience are more likely to have more severe reactions to the rape and to have more difficulty recovering. Examples of schema conflicts are "Rape doesn't happen to nice women", a prior belief that the situation in which an assault occurred had been safe, or that the victim was somehow particularly invulnerable to crime. A healthy resolution to this would be to assume that “bad things happen to good people sometimes”, but unhealthy resolutions include maladaptive ideas such as “no one can ever be trusted” or “I can never be safe”. As a result of unhealthy resolution of such schema conflicts, feelings of shame, guilt, humiliation, anger, betrayal, anxiety and especially confusion are commonly seen in sexual assault survivors with PTSD.
  • 4. Subsection = Cognitive Explanation 2 - Dissociation The anxiety disorder PTSD (post traumatic stress disorder) can be explained by the cognitive process of dissociation whereby some aspects of cognition or experience are consciously inaccessible. Dissociation involves the failure of consciousness to perform its usual role of integrating our cognitions, emotions, motivations and other aspects of experience in our awareness. Dissociation is believed by psychologists to be an avoidance response that protects the person from consciously experiencing stressful events. People who have symptoms of dissociation (including depersonalization, derealization, amnesia and out-of-body experiences) at the time of a traumatic event are more likely to develop PTSD, as are people who try to suppress memories of the trauma. Dissociation and memory suppression may play a role in maintaining the disorder, as they keep the person from confronting memories of the traumatic event. A study by Griffin et al (1997) of dissociation assessed rape victims confirms this. The women were interviewed within two weeks of the event and asked questions about the rape and about neutral topics. Their psychophysiological arousal was measured when asked questions about dissociation during the rape, such as “did you feel numb?”, “did you have moments of losing track of what was going on?”. Women were classified into low dissociation and high dissociation victims. Women in the high dissociation group showed lower arousal responses when talking about the rape then the low dissociation group. However, those in the high dissociation group were much more likely to experience PTSD symptoms. Further studies have confirmed that dissociation experiences in rape victims correlates highly with the development of PTSD. Dissociation therefore is a cognitive explanation of the formation and maintenance of PTSD as it suggests that people who employ dissociative coping strategies, that is they avoid thinking about the trauma, are more likely to experience PTSD symptoms.
  • 5. Section = Treatments for one disorder: the anxiety disorder PTSD Subsection = Cognitive Behavioural Therapy e.g. Cognitive Processing therapy for sexual assault victims experiencing symptoms of PTSD Key Concept: CBT Cognitive Behaviour Therapy: - In general, cognitive therapy aims to change the way a person thinks and so change the way a person feels and behaves. - CBT changes the way a person thinks (the cognitive part) AND the way a person behaves (the behavioural part), and usually includes both cognitive therapy elements and behavioural techniques such as exposure therapy. - CBT may focus on how a person responds to a particular situation. This is done not by going back to the cause of the problem but by focusing on present symptoms. - CBT works by looking at how a person thinks about how an event has affected how he or she felt and what he or she did. - CBT operates on the assumption that if negative thoughts can be reinterpreted or changed for more positive or realistic thoughts then the person will feel better and their behaviour will change. Cognitive Processing Therapy (CPT): a form of Cognitive Behaviour Therapy for sexual assault survivors with PTSD, devised by Resick and Schnicke, (1992). CPT includes cognitive therapy which addresses rape survivors' intense feelings of anger, betrayal, disgust, shame, guilt, humiliation, anxiety and confusion by identifying and modifying schema conflicts (and addressing "stuck points", i.e., inadequately processed emotions about the trauma). CPT operates on the belief that many of the problems of rape survivors result from schema conflicts, that is failure to resolve ideas and beliefs they held before the assault and the beliefs they now hold as a result of the assault. CPT also has an exposure element. At times therapy reveals previously existing distorted or dysfunctional thinking patterns, such as the false belief that “nice women don’t get raped”, and ways of coping with emotions which are activated by the assault. In such cases CPT addresses these problems by teaching clients how to recognize and challenge faulty thinking patterns, for example by understanding that “bad things do happen to good people sometimes”, and how to cope with distressing emotions. These methods of CPT are similar to the established Beckian method of cognitive therapy for depression. Exposure methods used in CPT involve writing narratives of the rape in detail and reading the narratives aloud in session and for homework. Clients write about the meaning of the rape, and themes of safety, trust, power, esteem, and intimacy are addressed. Clients are provided basic
  • 6. education about feelings, given information about how self-statements affect emotions, and are encouraged to identify "stuck points" (i.e., inadequately processed emotions about the trauma) in their narratives. Specific cognitive strategies are used to challenge maladaptive beliefs about the rape (e.g., self blame), helping the victim accommodate her experience in a healthy manner and maintain a balanced and realistic perception of the world. Cognitive Processing Therapy for sexual assault survivors consists of 12 weekly group sessions of 1.5 hours in duration each. In the latter sessions, CPT explores and helps survivors modify "stuck points" in the five major areas of functioning that are usually affected by victimization: safety, trust, power and control, esteem, and intimacy. Empirical Support for the Effectiveness of CPT with PTSD Sufferers Resick and Schnicke carried out a study aiming 1. To examine the effectiveness of CPT in a group format in the treatment of chronic, rape-induced PTSD. 2. To examine the effectiveness of CPT in also reducing symptoms of depression among 19 study participants. Findings: The study showed that group Cognitive Processing Therapy was effective in reducing symptoms of chronic PTSD: • CPT resulted in significant improvements in both PTSD and depression among study participants • When treatment ended, none of the study participants met full criteria for PTSD and this was maintained at the 6-month follow-up • At the end of treatment 42% (5 subjects) met criteria for depression compared to 99% at pre-treatment, but by the six-month follow-up, only 1 study participant still met criteria for depression • Many study participants reported substantial improvements in the quality of their lives as a result of participating in the treatment Do the following tasks: 1. Explain what is meant by “Cognitive Behaviour Therapy” 2. What is the full name of the form of CBT used for sexual assault survivors? 3. Which cognitive theory is this method based on? 4. Explain how CPT is carried out 5. What symptoms of PTSD do you think could be treated using CPT? 6. Does this therapy raise any ethical concerns? 7. Explain what is meant by “schema conflicts” 8. Is CPT wholly effective in treating PTSD in sexual assault survivors?
  • 7. Section = Treatments for one disorder: the anxiety disorder PTSD Subsection = Behavioural Eg. Exposure Therapy for PTSD – elements of this therapy are behavioural. Over time, people with PTSD may develop fears of reminders of their traumatic event. These reminders may be in the environment. For example, certain pictures, smells, or sounds may bring about thoughts and feelings connected with the traumatic event. These reminders may also be in the form of memories, nightmares, or intrusive thoughts. Because these reminders often bring about considerable distress, a person may fear and avoid them. The goal of exposure therapy is to help reduce the level of fear and anxiety connected with these reminders, thereby also reducing avoidance. This is usually done by having the client confront (or be exposed to) the reminders that he fears without avoiding them. Exposure therapy can include a range of behavioural techniques, including systematic desensitization (imaginal or in vivo). This may be done by actively exposing someone to reminders (for example, showing someone a picture that reminds him of his traumatic event) or through the use of imagination. By dealing with the fear and anxiety, the patient can learn that anxiety and fear will lessen on its own, eventually reducing the extent with which these reminders are viewed as threatening and fearful. Exposure therapy is usually paired with teaching the patient different relaxation skills. That way the patient can better manage his anxiety and fear when it occurs (instead of avoiding). The behavioural part of this is that the fear is extinguished (the association between the reminders of the event and anxiety is broken).
  • 8. Section = Treatments for one disorder: the anxiety disorder PTSD Subsection = Biological e.g. Drug therapy – Medications for PTSD A number of medications for PTSD exist. Medications are increasingly being used to treat anxiety disorders, and they have generally been found to be successful in helping people with their symptoms. No medications have been specifically designed to treat the symptoms of PTSD, although some medications commonly used to treat anxiety disorders and depression have been found to be effective in helping people manage their symptoms, e.g SSRIs. Selective Serotonin Reuptake Inhibitors (SSRIs) are generally considered "anti-depressant medications" and include the popular medication Prozac (fluoxetine). Serotonin is a chemical in your brain that is involved in your mood. Some people do not have the appropriate levels of serotonin in their brain, leading to feelings of depression and/or anxiety. SSRIs prevent the breakdown or "reuptake" of serotonin by your brain, increasing the available levels of serotonin, which is thought to eventually improve mood. Several studies have found that selective serotonin reuptake inhibitors (SSRIs) may be useful in the treatment of PTSD. Evaluation: • While studies generally found that SSRIs were successful in addressing many PTSD symptoms, findings were not quite as strong as what is found in studies examining the success of cognitive behavioral treatments for PTSD. • In addition, SSRIs may not address all PTSD symptoms. For example, one study found that SSRIs (particularly fluoxetine which is more commonly known as Prozac) improved numbing and hyperarousal symptoms of PTSD, but not re-experiencing symptoms. • As with all medications there are potential problems with unpleasant side effects, tolerance, addiction and withdrawal. • Medications may often be paired with psychological treatments for PTSD, such as cognitive-behavioural therapy. On their own, medications and psychotherapy may be effective; however, by pairing them together, their effectiveness may be boosted.
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