Disorders of extreme stress following war-zone military trauma: associated features of posttraumatic stress disorder or comorbid but distinct syndromes?

Disorders of extreme stress not otherwise specified (DESNOS) and posttraumatic stress disorder (PTSD) were found to be comorbid but distinct among military veterans seeking inpatient PTSD treatment: 31% qualified for both conditions, 29% were diagnosed PTSD only, 26% were classified DESNOS only, and 13% met criteria for neither. PTSD diagnosis was associated with elevated levels of war-zone trauma exposure and witnessing atrocities and with impairment on the Mississippi Scale for Combat-Related PTSD and the Penn Inventory. DESNOS classification (but not PTSD) was associated with (a) early childhood trauma and participation in war-zone atrocities, (b) extreme levels of intrusive trauma reexperiencing, (c) impaired characterological functioning (object relations), and (d) use of intensive psychiatric services. PTSD and DESNOS may be comorbid but distinct posttraumatic syndromes and, as such, warrant careful clinical and scientific investigation.     

Combat-Induced Dissociative Amnesia

Abstract

Dissociative amnesia following combat trauma in various wars has been extensively documented. In this article, we describe theoretical constructs related to dissociative amnesia, and integrate them with clinical practice through the presentation of a case. Although there is ample documentation of this condition in combat soldiers, in actual clinical practice such dissociative amnesia is probably underdiagnosed and undertreated. This may be detrimental to therapeutic progress, given the fact that ongoing memory deficits constitute one of the core symptoms of chronic PTSD in combat veterans. As illustrated in our case example of combat-induced generalized dissociative amnesia, combat-induced amnesia may also reflect previously existing dissociated traumatic memories that become reactivated during trauma. In this case, intensive treatment using hypnosis within a larger therapeutic milieu involved both the uncovering and processing of recent dissociated traumatic experiences, and, by necessity, other traumas of the past.     

Evidence for a Dissociative Subtype of Post-Traumatic Stress Disorder Among Help-Seeking Childhood Sexual Abuse Survivors

ABSTRACT

This study examined evidence for a dissociative subtype of post-traumatic stress disorder (PTSD) among women seeking psychotherapy for childhood sexual abuse (CSA). One hundred and twenty-two women seeking treatment for CSA completed a battery of questionnaires assessing PTSD, dissociative symptoms, and child maltreatment. Using signal detection analysis, we identified high and low dissociation PTSD subgroups. A constellation of three PTSD symptoms-hypervigilance, sense of foreshortened future, and sleep difficulties–discriminated between these two subgroups (OR = 8.15). Further evidence was provided by the finding of a nonlinear relationship between severity of childhood maltreatment and dissociation in the women with PTSD. These results provide support for a dissociative subtype of PTSD that may stem from more severe childhood experiences of neglect and abuse.     

Childhood Psychological and Physical Abuse: Psychopathology,Dissociation, and Axis I Diagnosis

ABSTRACT

The present study compared (1) college students who reported childhood physical and psychological abuse (combined; N = 35) with (2) students who reported psychological abuse alone (psychological; N = 30), and with (3) students who reported no history of childhood abuse (no abuse; N = 35). Combined abuse and psychological abuse participants were more likely to receive an Axis I diagnosis on a structured interview and to report more dissociative experiences than were no abuse participants. In addition, a structured interview for dissociative disorders was the single measure that differentiated psychologically abused participants from participants reporting combined abuse and no abuse. However, the most psychological impairment was evident in the combined abuse group. Relative to participants who reported no abuse history, combined abuse participants reported more dissociative symptoms on a structured interview and more symptoms of general psycho-pathology, depression, and state and trait anger on self-report measures.     

Peritraumatic Somatoform and Psychological Dissociation in Relation to Recall of Childhood Sexual Abuse

Abstract

Objective: Overwhelming experience can evoke psychological dissociation during or immediately after the event, including dissociative amnesia. Whereas some data suggest that such peritraumatic dissociation can also find expression in somatoform symptoms, only a limited range of such symptoms has been systematically studied. The present study hypothesized that peritraumatic psychological and somatoform dissociation are associated with each other, with delayed recall of childhood sexual abuse (CSA), and with CSA severity. Because current somatoform dissociation is most strongly associated with recalled childhood physical abuse (CPA), we also hypothesized that peritraumatic somatoform dissociation is associated with reported CPA over and above CSA.

Method: Thirty-four Dutch women who reported CSA were interviewed using a modified version of the Traumatic Memory Inventory (TMI) which assesses the characteristics of traumatic memories. The participants also completed the Traumatic Experiences Checklist, the Peritraumatic Dissociation Experiences Questionnaire, and the Peritraumatic Somatoform Dissociation Questionnaire.

Results: Peritraumatic psychological and somatoform dissociation were associated with each other, with delayed recall of trauma, and with severity of reported CS A. Reported CPA predicted peritraumatic somatoform dissociation over and above the severity of CS A in terms of the acts involved. Approximately 44% of the women reported independent corroboration of the abuse. Similar proportions of delayed, partial, and continuous CSA memories were corroborated.

Conclusions: This retrospective study suggested that delayed recall of CSA is associated with peritraumatic dissociation and CSA severity. It also suggested that trauma-especially that which involves serious threat to the integrity of the body-may evoke somatoform dissociation. Based on patient report, delayed recall of some CSA memories was as accurate as continuous recall of CSA.     

Dissociative subtype of posttraumatic stress disorder in women in partial and residential levels of psychiatric care

ABSTRACT

The dissociative subtype of posttraumatic stress disorder (PTSD) is estimated to characterize about 12-30% of those with PTSD. Some research links this subtype with increased severity of PTSD symptoms compared to samples with “classic” PTSD. However, prevalence and severity rates reported in the literature have varied. One possible explanation for these discrepancies could be related to where the populations were sampled. Therefore, we investigated whether these differences are still observed when holding level of care constant. We collected data from 104 women at a partial and residential psychiatric hospital program focused on trauma-related disorders. Participants completed self-report questionnaires assessing trauma exposure, symptoms and provisional diagnosis of PTSD, trauma-related thoughts and beliefs, and feelings of shame. All participants reported a history of childhood and/or adulthood trauma exposure. Eighty-eight (85%) met criteria for PTSD, and of those, seventy-three (83%) met criteria for the dissociative subtype as assessed by the Dissociative Subtype of PTSD Scale. A series of independent t-tests revealed no significant differences between the “classic” and dissociative PTSD groups with respect to lifetime or childhood trauma exposure, posttraumatic cognitions, shame, or overall PTSD severity. Our results suggest that samples with classic PTSD and the dissociative subtype may not differ in some types of symptom severity when holding level of care constant. Importantly, however, we found at partial/residential level of care the majority of patients with PTSD were dissociative. Given the elevated prevalence rate in this sample, these findings support the need to assess dissociative symptoms, particularly in more acute psychiatric settings.     

The Relationship Between Pathological Dissociation,Self-Injury and Childhood Trauma in Patients with Personality Disorders Using Taxometric Analyses

ABSTRACT

Objective: Dissociative phenomena exist on a spectrum ranging from psychological absorption to highly symptomatic disruptions of identity and memory. A statistical methodology called taxometric analysis has established a set of indicators that identify patients who have pathological dissociation, a qualitatively different form of dissociative phenomena. Using taxometric methodology, this study examines the relationship of pathological dissociation to personality diagnosis and self-directed injury, including suicide and history of childhood abuse, in a sample of outpatients with personality disorders.

Method: Patients were recruited from advertisements or referred from local clinicians. Participants completed a diagnostic interview and rating scales for dissociation, self-injury and childhood trauma. Pathological dissociation was identified using the Dissociative Experiences Scale-Taxon (DES-T; Waller, Putnam, & Carlson, 1996). Membership in the pathological dissociation taxon was established by calculating Bayesian posterior taxon membership probabilities; the method advocated by Waller, and compared to an approximation, used widely in the literature, based simply on the unweighted mean of the DES-T items.

Results: Overlapping, but not identical groups of patients were identified, indicating that the two methods are not interchangeable in this sample of personality disordered individuals. Surprisingly, no associations were detected between indices of childhood trauma and membership in the pathological dissociation taxon nor for the high dissociators identified through the approximation method.

Conclusions: This study serves as a replication of the ability to detect pathological dissociation as measured by the DES-T. Nonetheless, the failure to confirm our hypotheses regarding an association between pathological dissociation, childhood trauma, and personality diagnosis raise a challenge to some parts of existing etiologic theories.     

Dissociative Experiences in China

ABSTRACT

The Dissociative Experiences Scale was administered to a non-clinical sample in Shanghai, China (N = 618) and the results were compared with a previous sample of the general population from Winnipeg, Canada (N = 1055). The Dissociative Disorders Interview Schedule was administered to the 618 Chinese participants and results were compared with those of the Canadian participants (N = 502). In addition, both measures were administered to a sample of Chinese psychiatric in-patients (N = 423) and outpatients (N = 304). Rates of childhood trauma and dissociation were far lower in the Chinese non-clinical sample than in the two Chinese psychiatric patient groups, and far lower than in the Canadian general population. Among the 618 respondents in the Chinese non-clinical sample, no childhood sexual abuse was reported and only one person reported childhood physical abuse. These rates of childhood abuse were far lower than in other non-clinical samples from China; for example, rates were 16.7% for sexual abuse of girls and 10.5% for sexual abuse of boys in a previous study. Among the more traumatized Chinese psychiatric patients, and among the Canadian respondents, dissociative experiences were much more common than in the Chinese general population. The data provide a base frequency for dissociation in non-clinical samples reporting little or no childhood physical and sexual abuse.     

Dissociative Depression Among Women with Fibromyalgia or Rheumatoid Arthritis

The aim of this study was to inquire about the possible relations of childhood trauma, anger, and dissociation to depression among women with fibromyalgia or rheumatoid arthritis. Fifty female patients diagnosed as having fibromyalgia (n = 30) or rheumatoid arthritis (n = 20) participated in the study. The Childhood Trauma Questionnaire, Somatoform Dissociation Questionnaire (SDQ), Dissociation Questionnaire (DIS-Q), Beck Depression Inventory (BDI), Spielberger State-Trait Anger Expression Inventory, and Dissociative Disorders Interview Schedule were administered to all participants. Women with a lifetime diagnosis of depressive disorder had higher scores for somatoform and psychoform dissociation than the nondepressive patients. However, childhood trauma scores did not differ between the 2 groups. In regression analysis, current severity of depression (BDI) was predicted by psychoform dissociation (DIS-Q) and lower education, and lifetime diagnosis of major depression was predicted by somatoform dissociation (SDQ). Whereas childhood emotional neglect predicted somatoform dissociation, psychoform dissociation was predicted by childhood sexual abuse. Mental processing of anger seems to be 1 of the dimensions of psychodynamics in trauma-related depressive conditions. In the context of the perceived threat of loss of control due to expressed anger and mental disintegration, somatoform dissociation seems to contribute to overmodulation of emotions in dissociative depression. Among patients suffering from physical illness with possible psychosomatic dimensions, assessment of somatoform dissociation in addition to psychoform dissociation may be helpful to understand diverse psychopathological trajectories emerging in the aftermath of childhood adversities. The recently proposed category of “dissociative depression” (Sar, 2011) seems to be a promising concept for future research on psychosomatic aspects of traumatic stress.     

Dissociative Symptoms and Cortisol Responses to Recounting Traumatic Experiences Among Childhood Sexual Abuse Survivors with PTSD

ABSTRACT

This study examined dissociative symptoms in relation to changes in evening salivary cortisol levels after recounting traumatic experiences among 49 women with PTSD for child sexual abuse (CSA). Each woman was interviewed to describe her sexual abuse and was assessed on acute dissociative symptoms in response to a recent stressful event in the previous month. Salivary cortisol was assessed during the interview using saliva samples taken immediately before and after the interview. Changes in cortisol levels were measured at one hour, 24 hours, and 48 hours after the interview. Acute dissociative symptoms were related to salivary cortisol levels 24 hours after the interview, with high dissociators showing elevated levels compared to low dissociators. These results suggest that dissociative symptoms in response to recent life stress are associated with cortisol dysregulation among women with PTSD for CSA.     

Pathological Dissociative Taxon Membership,Absorption, and Reported Childhood Trauma in Women with Trauma-Related Disorders

Abstract

Employing a community sample, Irwin (1999) used the Childhood Trauma Questionnaire (CTQ; Bernstein et al, 1994) and Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986) to show that trauma predicts pathological dissociation as measured by Waller, Putnam, and Carlson's (1996) DES-T (dissociative “taxon”) scale but does not predict ostensibly non-pathological DES absorption. Yet Irwin merely studied DES-T scores as a continuous variable rather than classifying participants with respect to taxon membership, as the DES-T items were designed to do. The present study hypothesized that, in a traumatized clinical sample, trauma would be associated both with dissociative taxon membership and with absorption. An inpatient sample of 235 women were administered the CTQ and DES. Even in this relatively homogeneous trauma sample, taxon membership showed good discriminant validity with respect to clinical diagnosis and reported childhood abuse. Furthermore, whereas the effect of reported childhood sexual abuse on absorption was accounted for by taxon membership, reported childhood emotional abuse related to absorption independent of taxon membership. The authors discuss the diagnostic utility of computing taxon membership as well as the clinical significance of highly elevated absorption scores in a trauma population.     

The Role of Depression and Dissociation in the Link Between Childhood Sexual Abuse and Later Parental Practices

ABSTRACT

Research has yielded contradictory results on the relationship between childhood sexual abuse and later parental functioning. This study was undertaken to specify the link between childhood sexual abuse and maternal parenting, while taking into account mothers' childhood physical and emotional traumas and current depressive and dissociative symptoms. Data were collected through self-report measures completed by 93 French-speaking Canadian mothers of children aged 6 to 11 years referred to Youth Protection Services. Parental behaviors examined included involvement with the child, use of positive reinforcement, lack of monitoring and supervision of the child, inconsistency in applying discipline, and use of corporal punishment. Mothers' perception of the quality of the relationship with her child was also assessed. In addition, history of abuse and neglect, depression and dissociation were respectively measured with the Childhood Trauma Questionnaire, the Diagnostic Interview Schedule Simplified, and the Dissociative Experiences Scale. The short-form of the Marlowe-Crowne Social Desirability Scale was used to control for respondent bias aimed at minimizing their problems. Mothers' current depressive symptoms were not found to predict any of the parental dimensions measured. Results from multiple hierarchical regressions pointed to dissociative symptoms as the key predictor of parental practices and attitudes. More specifically, dissociative symptoms predicted the use of positive reinforcement, lack of monitoring and supervision of the child, inconsistency in applying discipline, and use of corporal punishment. Dissociation also mediated the association between childhood maltreatment (physical and emotional abuse and neglect) and inconsistency in applying discipline. Implications for research and practice are discussed.     

The Associations Of Maternal Emotion Dysregulation And Early Child Dissociative Behaviors

ABSTRACT

Although dissociation is believed to develop in early childhood, there is little research prospectively examining childhood dissociation or parental contributions related to its development. The current study sought to examine parent factors prospectively related to changes in dissociation symptoms in childhood. The current study sampled 68 mother-child dyads at two time points, when children were 3–4 and then 5–6 years, in which mothers with emotion dysregulation were oversampled. Maternal emotion dysregulation was assessed at both time points. Maternal dissociation was assessed only at time two. Child dissociation was assessed at each time point using a modified subscale of the Child Behavioral Checklist. Results showed moderate stability in childhood dissociation across time points. Further, maternal emotion dysregulation and dissociation were both significantly correlated with children’s dissociation. Accounting for several covariates, time one maternal emotion dysregulation was prospectively associated with preschoolers’ dissociative behaviors at 5–6 years old. The present work suggests that symptoms of dissociation can be observed early in childhood and that maternal factors play an early role in the development of dissociation in children.     

An examination of family adjustment among Operation Desert Storm veterans

This study examined interrelationships among combat exposure, symptoms of posttraumatic stress disorder (PTSD), and family adjustment in a sample of male and female Operation Desert Storm veterans (N = 1,512). In structural equation models for both male and female veterans, higher combat exposure was associated with higher PTSD symptoms, which in turn were associated with poorer family adjustment, although these indirect effects did not reach statistical significance. The model for female veterans evidenced a significant direct negative association between combat exposure and family adjustment when it statistically accounted for PTSD symptoms. When the relative impacts of separate PTSD symptom groupings were examined, those reflecting withdrawal/numbing symptoms and arousal/lack of control symptoms significantly and indirectly accounted for the negative effects of combat exposure on family adjustment. Study findings indicate a number of possible pathways through which war-zone deployments negatively impact military families and suggest several avenues for future research.     

Discriminating Dissociative Identity Disorder from Schizophrenia and Feigned Dissociation on Psychological Tests and Structured Interview

ABSTRACT

Objective: The purpose of this study was to evaluate the relative efficacy of a number of psychological tests and interviews in discriminating dissociative identity disorder (DID) from feigned dissociation and schizophrenia.

Method: Three measures of dissociation (SCID-D, DES, SDQ-5) two personality measures (MMPI-2, Millon-III) and a brief measure of hypnotic susceptibility (Spiegel & Spiegel's Eye-Roll Sign) were assessed for their ability to differentiate these diagnostic groups.

Results: Results indicate that the SCID-D was clearly the most efficacious instrument in discriminating DID from schizophrenia and from feigned dissociation. The DES-Taxon and the SDQ-5 were adequate in screening pathological dissociation from schizophrenia but were less discriminative of feigned dissociation. The commonly used personality inventories were unable to detect feigned dissociation and the DID group tended to have higher elevations on scales measuring psychotic symptoms than did the schizophrenic group. The Eye-Roll Sign discriminated feigned dissociation from those with dissociative disorders.

Conclusions: Structured interviews such as the SCID-D, although resource consuming, are essential in comprehensive assessment of dissociative disorders. Comprehensive assessment of psychotic disorders should include some measure of dissociation.     

Depressive Symptoms and Sleep Disturbance in Adults with Histories of Childhood Abuse

Abstract

Depressive symptoms including sleep disturbance are clinically apparent in many patients with histories of childhood abuse. This study investigated the nature and severity of depressive symptoms, sleep disturbance, and trauma-related symptoms in a group of female participants with abuse histories, as compared to a non-abused group of female participants with major depression. Sixty (60) participants with a history of childhood abuse and 13 participants with major depression completed several self-report instruments which examine past life experiences, depressive symptoms, post-traumatic symptoms, dissociative symptoms, and sleep problems. To control for differences in background characteristics, a subset of participants with abuse histories were matched to and compared with the 13 depressed participants. Both the abused and depressed groups showed high levels of depressive symptoms, but there were no significant differences between the groups. The abused group had significantly more intrusive post-traumatic symptoms, more dissociative symptoms, and were more likely to be afraid of falling asleep and more anxious upon mid-sleep awakening. Severity of depressive symptoms in the abused group was correlated with severity of intrusive post-traumatic symptomatology. The investigators conclude that symptoms of major depression in some patients with abuse histories may have a post-traumatic etiology, especially since intrusive reexperi-encing of past trauma may produce severe dysphoria and hopelessness. The nature of sleep disturbance in patients with abuse histories may be a clinical tool to identify patients whose depressive symptoms may be post-traumatic in origin.     

Relationships among childhood trauma, posttraumatic stress disorder, and dissociation in men living with HIV/AIDS

This study examined the relationships among dissociation, childhood trauma and sexual abuse, and posttraumatic stress disorder (PTSD) symptoms in HIV-positive men. Data were collected from 167 men enrolled in a randomized clinical trial that examined a group therapy intervention to decrease HIV-related risk behavior and trauma-related stress symptoms. Participants completed the Trauma History Questionnaire, the Impact of Events Scale-Revised, and the Stanford Acute Stress Reaction Questionnaire. Overall, 35.3% of the participants reported having experienced childhood sexual abuse. A total of 55.7% of the sample met diagnostic criteria for PTSD. The intensity of dissociative symptoms that participants endorsed was positively associated with experience of childhood sexual abuse (r?=?.20, p < .01). Dissociative symptoms were also positively associated with specific PTSD symptoms, notably hyperarousal (r?=?.69, p < .001). Hierarchical regression indicated that hyperarousal symptoms accounted for more of the variance in dissociation than childhood sexual abuse. These results suggest that childhood sexual abuse may be involved in the development of dissociative symptoms in the context of adulthood stress reactions. Furthermore, the pattern of the association between dissociation and PTSD is consistent with the possibility of a dissociative PTSD subtype among HIV-positive men.     

Carcinogenicity and teratogenicity vs. psychogenicity: psychological characteristics associated with self-reported Agent Orange exposure among Vietnam combat veterans who seek treatment for substance abuse

This study asked, "What are the psychological characteristics of Vietnam combat veterans who claim Agent Orange exposure when compared with combat-experienced cohorts who do not report such contamination?" The question was researched among 153 heroin addicts, polydrug abusers, and chronic alcoholics who were seeking treatment: 58 reported moderate to high defoliant exposure while in combat; 95 reported minimal to no exposure while in Vietnam. The null hypothesis was accepted for measures of childhood and present family social climate, premilitary backgrounds, reasons for seeking treatment, patterns and types of illicit drug and alcohol use, interpersonal problems, intellectual functioning, and short-term memory. The null hypothesis was rejected for personality differences, however, those who self-reported high Agent Orange exposure scored significantly higher on MMPI scales F, Hypochondriasis, Depression, Paranoia, Psychasthenia, Schizophrenia, Mania, and Social interoversion. The results suggest that clinicians carefully assess attributional processing of those who report traumatic experience.     

Trauma and Dissociation

Abstract

The inauguration of this journal is the fruit of 20 years of modern study of trauma and dissociation that began with the publication of DSM III. Beginning with Janet and Freud, this editorial traces the growth of research, teaching and treatment in these fields and examines their close link to historic waves of social recognition and denial of child abuse in Western societies. Beginning with the women's movement of the 1960s that publicized rape and incest, followed by the undeniable traumas of American Vietnam veterans, we trace the blossoming progress of research, theory and treatment techniques in the fields of trauma and dissociation, of which this journal is one of the fruits. We note three generations of trauma treatment theory that have focused successively on abreaction, on the three-stage model of trauma treatment, and finally on integration of trauma-focused work with other theoretical models in the emerging post-memory-backlash era. As this journal is launched, our field stands at a point of unprecedented theoretical sophistication and burgeoning research on memory, trauma and dissociation to assist therapists in helping trauma survivors put their victimization in the past.     

The interaction of exposure to adverse childhood and combat experiences on the current mental health of new post-9/11 veterans

Military veterans have greater exposure to adverse childhood experiences (ACEs) than civilians and many also encounter warfare exposures, which can increase the likelihood of mental health problems. The purpose of this study was to test an interaction between childhood traumas and warfare exposures on the mental health of a sample of nearly 10,000 new post-9/11 veterans. Results revealed that male veterans exposed to one or two ACEs, but no warfare, were more likely to experience anxiety, depression, suicidal thinking, and angry outbursts than the reference group (i.e., no ACEs and no warfare exposure). Female veterans exposed to one or two ACEs, but no warfare, were only more likely to experience suicidal thinking. Male and female veterans exposed to three or more ACEs and no warfare were more likely to experience probable posttraumatic stress disorder (PTSD), anxiety, depression, suicidality, and angry outbursts. Among those veterans who experienced corollaries of combat only (e.g., seeing someone killed or seriously wounded), male, but not female veterans were more likely to have probable PTSD, anxiety, and depression. Veterans exposed to warfare (i.e., combat and the corollaries of combat), irrespective of ACEs exposure, were the most likely to report mental health symptoms. Implications for community-based mental health services are discussed.