Somatoform Dissociation,Psychological Dissociation,and Specific Forms of Trauma

Abstract

Background: Childhood trauma is clearly associated with psychological dissociation a failure to integrate cognitive, behavioural and emotional aspects of experience. However, there is also evidence that trauma results in somatoform dissociation, where the individual fails to process somatic experiences adequately. Somatoform dissociation is linked to a number of psychiatric disorders that are relatively resistant to treatment. The present study addresses the hypothesis that somatoform dissociation will be associated specifically with childhood trauma that involves physical contact, rather than with non-contact forms of trauma.

Methods: An unselected clinical group of 72 psychiatric patients completed standardized measures of childhood trauma, psychological dissociation, and somatoform dissociation.

Results: The findings supported the hypothesis, with a specific link between somatoform dissociation and the severity of reported childhood trauma involving physical contact or injury. In contrast, psychological dissociation was associated with a wider range of non-contact trauma.

Conclusions: Somatoform dissociation can be understood as a set of adaptive psychophysiologic responses to trauma where there is a threat of inescapable physical injury. Those responses are related to a range of psychiatric disorders, and are likely to interfere with treatment of those disorders. Clinicians may need to assess the nature and severity of childhood trauma and somatoform dissociation when there are high levels of somatic symptoms within psychiatric disorders that cannot be explained medically. Further research is needed to determine methods of treating somatoform dissociation, especially in the context of a history of trauma involving physical contact or injury.     

Somatoform Dissociation in Traumatized World War I Combat Soldiers

Abstract

The massive traumatization of World War I combat soldiers led to an unprecedented incidence of somatoform dissociative disorders and symptoms, usually diagnosed as hysterical disorders during the war years. Following a brief overview of the scope of the suffering during this Great War, attention is given to British army psychiatrist Charles S. Myers' (1940) observations of the alternation between a so-called “emotional” personality and an “apparently normal” personality in traumatized combat soldiers. Somatoform dissociation, further categorized into positive and negative symptoms, is related to this structural dissociation, and to fixation in the trauma and avoidance of the trauma, and may be part of a more encompassing symptomatology. Next, a short overview of diagnostic issues is given. We argue that the DSM-IV category of “conversion disorder” is incorrect. Rather, the findings revealed here support Janet's classic and Nijenhuis' more recent views on somatoform dissociation. Finally, treatment issues are briefly presented.     

The Development of the Somatoform Dissociation Index (SDI)

Abstract

The development of a new instrument for measuring dissociation, the Somatoform Dissociation Index (SDI), based on somatic items embedded in the MMPI is described. Logistic regression analyses revealed a set of 11 MMPI items that best optimized discrimination of dissociative and non-dissociative patients. The SDFs split-half reliabilities were .85 and .83 across studies. Cronbach's alpha scores were .82 and .86, respectively. Convergent validity was confirmed by significant correlations between the SDI and three commonly used measures of dissociation. A cutoff score of 6 was the SDI score with the highest accuracy of clinical classification when dissociation was quantified by summing salient responses to the individual items. The utility of the SDI and the Somatoform Dissociation Questionnaire as viable measures of dissociation was compared and discussed.     

Characteristics of Child Maltreatment,Psychological Dissociation,and Somatoform Dissociation of Canadian Inmates

ABSTRACT

Data are presented on childhood maltreatment characteristics, psychological dissociation, somatoform dissociation, and offense types with a sample of 93 Canadian inmates (62 males and 31 females), with a mean age of 34 years (SD = 9.5). The present study includes findings based on the Child Maltreatment Interview Schedule-Short Form (CMIS-SF), the Detailed Assessment of Posttraumatic States (DAPS), the Multidimensional Dissociation Inventory (MDI), the Somatoform Dissociation Questionnaire (SDQ-20), and indices of violent and sexual offending during adulthood. Chi-square, Cohen's d, and regression analyses were conducted with the data. Results showed that women reported more childhood sexual abuse (CSA) than men, and men committed more violent and sexual offenses than women. Mean comparisons using Cohen's d statistic showed that inmates (N = 62) reported more trauma-related dissociation (DAPS) and more MDI dissociation compared to normative data for these instruments; however, inmates had lower somatoform dissociation scores when compared to published means of dissociative disorder, somatoform disorder, and eating-disorder patients. Inmates with CSA histories had higher SDQ-20 scores than those who did not. No differences were found between sex offenders and non-sex offenders in terms of probable PTSD, probable DID, MDI scales, or the SDQ-20. CSA that involved penetration predicted MDI dissociation and also predicted later sexual offending. Of the MDI scales, derealization and memory disturbance predicted sexual offending. Neither MDI scales nor any of the CMIS-SF maltreatment types predicted violent offending. Results are discussed in terms of treatment implications for incarcerated individuals with histories of child maltreatment.     

Psychoform and Somatoform Dissociation in a Clinical Sample of Australian Adolescents

Psychoform dissociation has been researched more than somatoform dissociation. The Somatoform Dissociation Questionnaire (SDQ-20), a commonly used adult measure of somatoform dissociation, is increasingly being used with adolescents internationally. We compared psychoform and somatoform dissociation in a mixed clinical adolescent sample. A total of 71 adolescents (12–18 years old) attending Australian community mental health and counseling services completed the SDQ-20 and the Adolescent Dissociative Experiences Scale, a commonly used measure of adolescent psychoform dissociation. The participants’ treating clinicians provided participants’ demographic details and mental health diagnoses. We found that 41% of participants reported high levels of psychoform dissociation and 21% reported high levels of somatoform dissociation. Both dissociation types were positively correlated. Neither was significantly related to participants’ age, gender, or mental health diagnoses. Participants with more than 1 Axis I mental health diagnosis had higher levels of somatoform dissociation than participants with only 1 or no Axis I mental health diagnosis. This study is the first to examine somatoform dissociation in Australian adolescents and enables initial international comparisons.     

What Mindfulness can learn about Dissociation and what Dissociation can learn from Mindfulness

Mindfulness based psychotherapeutic interventions have shown to be an effective intervention for quite some time now. These intervention, however, have not been that successful with individuals who experience dissociative disorders. There is a very clear disconnect between these two fields. In an attempt to close the gap, reviewing what mindfulness might be from an attachment and human developed lens, one can learn that there is a lot more occurring in a mindful state other than relaxation. There is a level of human development achievement that comes from a regular mindfulness practice that seems to play a role in raising our young and being part of a complex social group. Evidence suggests that the end product of mindfulness is likely deeply connected human relationships and balanced care-giving abilities. In knowing the benefits from a relational perspective of mindfulness those in the dissociative world can utilize adaptations of mindfulness so that their clients can eventually learn to developed mindfulness and, in turn, have the same deeply connected relationship that they often missed. Conversely those in the mindfulness based therapeutic world can learn a lot about dissociation and harmed people by understanding the real difficulties that individuals with dissociative disorders have in experiencing a mindful state. They can learn to understand the need to adapt mindfulness based practices to accommodate individuals who have a system that is phobic of awareness, terrified of being calm and who have no concept of what non-judgement means. Both fields would benefit greatly by knowing more about the other.     

The Multidimensional Inventory of Dissociation (MID): A Comprehensive Measure of Pathological Dissociation

ABSTRACT

This article describes the development and validation of the Multidimensional Inventory of Dissociation (MID). The MID is a 218-item, self-administered, multiscale instrument that comprehensively assesses the phenomenological domain of pathological dissociation and diagnoses the dissociative disorders. The MID measures 14 major facets of pathological dissociation; it has 23 dissociation diagnostic scales that simultaneously operationalize (1) the subjective/ phenomenological domain of pathological dissociation and (2) the hypothesized dissociative symptoms of dissociative identity disorder (Dell, 2001a). The MID was designed for clinical research and for diagnostic assessment of patients who present with a mixture of dissociative, posttraumatic, and borderline symptoms. The MID demonstrated internal reliability, temporal stability, convergent validity, discriminant validity, and construct validity. The MID also exhibited incremental validity over the Dissociative Experiences Scale (DES) by predicting an additional 18% of the variance in weighted abuse scores on the Traumatic Experiences Questionnaire (TEQ). Confirmatory factor analysis (CFA) did not support a one-factor model of the MID's clinical scales (i.e., the 14 facets and the 23 diagnostic symptoms). In contrast, however, CFA of the MID's factor scales (Dell & Lawson, 2005) has strongly supported a one-factor model. It was concluded that both the MID's 168 dissociation items and the construct of pathological dissociation have a second-order, unifactorial structure.     

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.     

Emotion Regulation Processes and Psychoform and Somatoform Dissociation in Adolescents and Young Adults with Cumulative Maltreatment

The relationship between childhood trauma and dissociative experiences is widely acknowledged. However, the association between emotion regulation difficulties (ERD), anxiety/depression and dissociation in adolescents and young adults with cumulative maltreatment (CM) remains unclear. The present study examined the role of ERD at both intrapersonal and interpersonal levels and anxiety/depression symptoms in the development of psychoform or somatoform dissociation in adolescents and young adults with CM. We assessed 58 participants with CM and 55 participants without childhood trauma history between the age of 12 and 22 years old. Participants completed self-reports of ERD, anxiety/depression, psychoform dissociation and somatoform dissociation. The results revealed that adolescents and young adults exposed to CM displayed high levels of psychoform and somatoform dissociation, ERD and anxiety/depression symptoms. It was also found that intrapersonal and interpersonal ERD predicted psychoform dissociation, whereas anxiety/depression predicted somatoform dissociation in adolescents and young adults with CM. Intrapersonal and interpersonal ERD and anxiety/depression are therapy targets for clinical interventions in adolescents and young adults with CM and dissociative symptoms.     

Development of Dissociation: Examining the Relationship Between Parenting,Maternal Trauma and Child Dissociation

SUMMARY

While many studies have demonstrated relationships between trauma and dissociation, relatively little is known about other factors that may increase children's risk for developing dissociative symptoms. Drawing on betrayal trauma theory and Discrete Behavioral States frameworks, the current study examined the contributions of maternal factors (including mothers' dissociation, betrayal trauma experiences, and inconsistent parenting) to children's dissociation. Seventy-two mother-child dyads completed self-report questionnaires. Maternal dissociation was found to relate positively to maternal betrayal trauma history. Additionally, both mothers' and children's betrayal trauma history were found to significantly predict children's dissociation. Implications for the intergenerational transmission of betrayal trauma and dissociation are discussed.     

The Language of Dissociation

ABSTRACT

Three case studies of inner-city elementary school children illustrate the connection between speech-language disorders and dissociative disorders in children who have known or suspected trauma histories. The role of speech language pathologists in identifying and responding to dissociative symptoms in children is explored. Lack of adequate training concerning the impact of trauma and scarce literature on the communication profiles of dissociative children contributes and greatly impacts the diagnosis, referral, and treatment of these children. The case studies demonstrate how unusual speech and language symptoms and awareness of dissociative features may aid in identifying trauma-related problems and instituting effective treatment. Grounding techniques and specific language interventions can assist children in acquiring the vocabulary needed for communicating both their daily experiences and traumatic histories. The nature of the relationship between dissociation and communication disorders is explored, and the importance of future research, interdisciplinary collaboration, and trauma training in the speech-language curriculum is emphasized.     

Dissociation and Schizophrenia

ABSTRACT

The authors administered the Dissociative Experiences Scale (DES), the Dissociative Disorders Interview Schedule (DDIS), the Scale for the Assessment of Positive Symptoms, and the Scale for Assessment of Negative Symptoms to 60 participants with schizophrenia. Participants were divided into two groups: those with scores below 10 on the DES and no dissociative disorder on the DDIS; and those with scores above 25 on the DES and/or a dissociative disorder on the DDIS. The dissociative participants had more severe trauma histories, more comorbidity and higher scores for both positive and negative symptoms. The authors interpret their findings as evidence in support of a trauma-dissociation subgroup within schizophrenia.     

Somatoform and psychoform dissociation among students

Recent evidence suggests a relationship between psychoform and somatoform dissociation both in clinical and non clinical samples. The aim of the study was to investigate the association between the two forms of dissociation among 947 university students who completed two self-administered questionnaires, the Somatoform Dissociation Questionnaire (SDQ-20) and the Dissociative Experience Scale (DES). The main result of the study was that the association between somatoform and psychoform dissociation was strong for individuals with moderate level of DES scores (O.R.=7.0), but much stronger for individuals with high level of DES scores (O.R.=18.9).     

Early Traumatized Inpatients High in Psychoform and Somatoform Dissociation: Characteristics and Treatment Response

This study examined the clinical relevance of differences in psychoform and somatoform dissociative symptoms in 55 early traumatized inpatients. The high psychoform and somatoform dissociative group (n = 18), somatoform dissociative group (n = 22), and nondissociative group (n = 15) did not differ on abuse severity, depressive symptoms, interpersonal problems, Axis I or II comorbidity, or deterioration rates. Compared to the other 2 groups, the highly dissociative group was characterized by younger age, living alone, higher levels of posttraumatic and general distress, more frequent reports of suicidality, self-mutilation, eating problems, and less favorable treatment response. The results highlight the clinical relevance of using dissociation measures for identifying subgroups of patients with severe psychopathology who may be more treatment resistant.     

综合医院躯体形式障碍临床特点的初步研究

目的：了解综合医院门诊病人中符合ＩＣＤ－１０躯体形式障碍的比率及其临床症状特点。方法：采用躯体形式障碍筛选表和躯体形式障碍评定表检查内科和神经科门诊病人。结果：共筛查了３３４６位综合医院的门诊病人,ＩＣＤ－１０躯体形式障碍的估计比率为１８２％。躯体形式障碍各亚型之间重叠较多。１３５例患者在过去一年平均就医１３１次;经过治疗６０％的自感无变化或恶化。躯体化障碍患者的症状中以“对医生的诊断和治疗不信任”最为突出。结论：躯体形式障碍在综合医院内科、神经科门诊有较高的比率。其就医次数较多而治疗效果较差。ＩＣＤ－１０躯体形式障碍各亚型的诊断标准缺乏特异性     

帕罗西汀治疗持续的躯体形式疼痛障碍的疗效观察

目的　研究帕罗西汀对持续的躯体形式疼痛障碍 (以下简称持续疼痛障碍 )的疗效。方法　用帕罗西汀治疗 60例持续疼痛障碍患者 6周 ,剂量为 2 0 mg/d,应用疼痛量表 ( MOSPM)及汉密尔顿抑郁量表 ( HAMD) ,在治疗前及治疗后的第 2 ,4,6周末进行评定。结果　经 MOSPM及 HAMD评定 ,帕罗西汀治疗的有效率均随治疗时间延长而增加 ,在治疗第 6周末 ,有效率分别达到 76%和 79%。结论　帕罗西汀可缓解该类患者的疼痛症状和抑郁症状 ,服药依从性好。     

Phase-Oriented Treatment of Structural Dissociation in Complex Traumatization: Overcoming Trauma-Related Phobias

ABSTRACT

The theory of structural dissociation of the personality proposes that patients with complex trauma-related disorders are characterized by a division of their personality into different prototypical parts, each with its own psychobiological underpinnings. As one or more “apparently normal” parts (ANPs), patients have a propensity toward engaging in evolutionary prepared action systems for adaptation to daily living to guide their actions. Two or more “emotional” parts (EPs) are fixated in traumatic experience. As EPs, patients predominantly engage action systems related to physical defense and attachment cry. ANP and EP are insufficiently integrated, but interact and share a number of dispositions of the personality (e.g., speaking). All parts are stuck in maladaptive action tendencies that maintain dissociation, including a range of phobias, which is a major focus of this article. Phase-oriented treatment helps patients gradually develop adaptive mental and behavioral actions, thus overcoming their phobias and structural dissociation. Phase 1, “symptom reduction and stabilization,” is geared toward overcoming phobias of mental contents, dissociative parts, and attachment and attachment loss with the therapist. Phase 2, “treatment of traumatic memories,” is directed toward overcoming the phobia of traumatic memories, and phobias related to insecure attachment to the perpetrator(s), particularly in EPs. In Phase 3, “integration and rehabilitation,” treatment is focused on overcoming phobias of normal life, healthy risk-taking and change, and intimacy. To the degree that the theory of structural dissociation serves as an integrative heuristic for treatment, it should be compatible with other theories that guide effective treatment of patients with complex dissociative disorders.     

The Interrelatedness of Disconnection: The Relationship Between Dissociative Tendencies and Alexithymia

ABSTRACT

This study explored the extent to which alexithymia can be seen as a dissociative phenomenon, examining three facets of dissociation in relationship to the five dimensions of alexithymia. The dissociative facets were: pathological psychoform dissociation (amnesia and derealization/depersonalization), non-pathological psychoform dissociation (absorption) and somatoform dissociation. The alexithymia facets were: difficulties emotionalizing, fantasizing, identifying, verbalizing and analyzing emotions. Various self-report measures were used including the latest developed measure of alexithymia, the Bermond Vorst Alexithymia Questionnaire (BVAQ). Canonical correlation results indicated that somatoform dissociation was the strongest predictor of alexithymia. For younger males, somatoform dissociation was directly related to all facets of alexithymia except for fantasizing. Males with somatoform dissociation, irrespective of age, appeared to have the highest difficulties emotionalizing and identifying emotions. Whilst somatoform and pathological psychoform dissociation were related to difficulties identifying emotions for younger females, no type of dissociation directly influenced the development of any alexithymia dimension for women.     

Dissociation,Depression and Trauma in Psychiatric Inpatients in Puerto Rico

ABSTRACT

This study investigated the frequency of self-reported childhood abuse experiences of psychiatric inpatients, and the presence of dissociative and depressive symptoms. A total of 100 Puerto Rican in-patients who were hospitalized during a two month period were included in the study. The participants' dissociative and depressive symptoms were assessed using the Dissociative Experiences Scale and a subset of its items (DES-Taxon), the Questionnaire of Experiences in Dissociation and the Beck Depression Inventory. We also used a self-report instrument to assess the frequency and severity of a variety of abusive experiences. Seventy-eight percent (78%) of the participants reported some type of abusive experiences, 38% reported extreme and frequent abuse, and 40% reported being sexually abused during childhood. The findings showed a correlation between greater frequency of the abusive experiences and higher levels of dissociative and depressive symptoms. When the variable of child sexual abuse was used, only the Dissociative Experiences Scale was able to detect differences between those patients who reported such abusive experiences and those who reported none. We conclude that the level of abusive experiences reported by psychiatric in-patients in Puerto Rico is very similar to the rate in other investigations in the international literature. The data demonstrate that the participants who report frequent and intense abuse endorse a wide variety of dissociative experiences, and, to a lesser extent, depressive symptoms. As more than 95% of our inpatients had never been screened or assessed for the possibility of a dissociative disorder, we suggest that clinicians in psychiatric units in Latin America should be more sensitive and attentive to the presence of such disorders.     

加用完形心理治疗及奥氮平对躯体形式障碍的作用

目的：研究单一药物、联合用药、联合用药加完形心理治疗三种治疗方式对躯体形式障碍的疗效。方法：将96例躯体形式障碍患者分为三组，分别采用单一药物5一羟色胺再摄取抑制剂（SSRI）、联合用药（SSRI加小剂量非典型抗精神病药物），以及联合用药加完形心理治疗三种治疗方式。治疗前和治疗3个月后采用汉密尔顿抑郁量表（HAMD）进行测查，评定三种治疗方式的减分率和有效率。结果：（1）三种治疗方式的有效率分别为53．1％、61．8％和96．7％，以联合用药加完形心理治疗组最高，联合用药组次之（82．4％）（X^2=15．5，P〈0．05）；（2）治疗后三组患者的HAMD总分减分率均值，以联合用药加完形心理治疗组最高（82．4％），联合用药组次之（57．9％），单一药物组最低（45．2％），方差分析组问差异显著，Welch统计量为20．92，P〈0．001；Tamhane方法多重比较，联合用药加完形心理治疗组与氟西汀组、联合用药组均有显著性差异；氟西汀组与联合用药组仅躯体化、睡眠、绝望感三因子分有显著性差异。结论：三种治疗方式对躯体形式障碍均有明显疗效；联合用药加完形心理治疗对躯体形式障碍的疗效优于单纯药物治疗。