The dissociative subtype of PTSD: a replication and extension

The Dissociative Subtype of Post-Traumatic Stress Disorder: A Systematic Review of the Literature using the Latent Profile Analysis

A PTSD subtype with dissociative symptoms (D-PTSD) was included in the DSM-5 recognizing the existence of a more severe form of PTSD, associated to past trauma, high comorbidity, and complex clinical management. As research is rapidly growing and results are inconsistent, a better investigation of this subtype is of primary importance. We conducted a systematic review of studies using Latent Profile Analysis to investigate the existence of a D-PTSD subtype. Covariates of D-PTSD were included, to understand additional symptoms, risk factors and comorbidities. The search was performed on PubMed, EBSCOHost, and PTSDPubs according to 2020 PRISMA guidelines. Eligible articles assessed trauma exposure, PTSD symptoms and diagnosis, and dissociation, in adult samples. 13 of 165 articles met the inclusion criteria. All identified a dissociative subtype of PTSD, mainly characterized by higher levels of depersonalization and derealization. D-PTSD profile sometimes presented other dissociative symptoms, such as gaps in awareness and memory, other comorbid disorders, and a history of abuse. Despite some limitations, this review supports the existence of a dissociative subgroup of individuals among those with PTSD. More rigorous studies are needed to clarify these findings and their clinical implications.

Disentangling the Link Between Mindfulness and Dissociation in PTSD: The Mediating Role of Attention and Emotional Acceptance

INTRODUCTION

A number of studies have investigated the relationship between mindfulness and dissociation and suggested that mindfulness-based interventions could be effective in the treatment of dissociative symptoms. A recent study in healthy volunteers found that attention and emotional acceptance mediates this relationship. However, no study has yet been performed among a clinical sample to assess this association.

METHOD

We recruited 90 patients (76 women) suffering from Posttraumatic Stress Disorder (PTSD). They completed self-report questionnaires to measure PTSD, dissociation, emotion regulation difficulties, childhood trauma, mindfulness abilities and cognitive abilities.

RESULTS

We found that mindfulness abilities, emotional difficulties, dissociation and attention-concentration were all related to each other. Using a step-by-step approach and bootstrapping techniques, we found a significant indirect effect of mindfulness abilities on dissociation through non-acceptance (confidence interval 95%=-.14 to -.01) and attentional difficulties (confidence interval 95%=-.23 to -.05).

CONCLUSION

Patients with higher levels of dissociative symptoms have less capacity for mindfulness. Our results support Bishop et al.'s model proposing that attention and emotional acceptance are the two active components of mindfulness. To extend our findings, clinical trials are required to evaluate a causal relationship and the effectiveness of mindfulness-based interventions for patients suffering from dissociation.

Neurophysiological changes associated with vibroacoustically-augmented breath-focused mindfulness for dissociation: targeting interoception and attention

BACKGROUND

Dissociative symptoms can emerge after trauma and interfere with attentional control and interoception; disruptions to these processes are barriers to mind-body interventions such as breath-focused mindfulness (BFM). To overcome these barriers, we tested the use of an exteroceptive augmentation to BFM, using vibrations equivalent to the amplitude of the auditory waveform of the actual breath, delivered via a wearable subwoofer in real time (VBFM). We tested whether this device enhanced interoceptive processes, attentional control and autonomic regulation in trauma-exposed women with dissociative symptoms.

METHODS

65 women, majority (82%) Black American, aged 18-65 completed self-report measures of interoception and 6 BFM sessions, during which electrocardiographic recordings were taken to derive high-frequency heart rate variability (HRV) estimates. A subset (n = 31) of participants completed functional MRI at pre- and post-intervention, during which they were administered an affective attentional control task.

RESULTS

Compared to those who received BFM only, women who received VBFM demonstrated greater increases in interoception, particularly their ability to trust body signals, increased sustained attention, as well as increased connectivity between nodes of emotion processing and interoceptive networks. Intervention condition moderated the relationship between interoception change and dissociation change, as well as the relationship between dissociation and HRV change.

CONCLUSIONS

Vibration feedback during breath focus yielded greater improvements in interoception, sustained attention and increased connectivity of emotion processing and interoceptive networks. Augmenting BFM with vibration appears to have considerable effects on interoception, attention and autonomic regulation; it could be used as a monotherapy or to address trauma treatment barriers.

Inhibition, Attentional Control and Binding Abilities in Relation to Dissociative Symptoms Among PTSD Patients

INTRODUCTION

The relationship between dissociation and cognitive abilities remains controversial. Empirical studies have reported positive, negative and non-existent associations between dissociation and cognition. These inconsistent results may be due to the fact that the studies focused mainly on trait dissociation, while dissociation is not stable but transient. After validating the French version of the Clinician Administered Dissociative States Scale (CADSS), the aim of the present study was to evaluate the relationship between state dissociation and cognitive abilities.

METHOD

We recruited 83 patients suffering from post-traumatic stress disorder (PTSD) and assessed them twice. At T1, they performed a neutral Stroop task and a neutral binding task. At T2 (one to three weeks later), after a script-driven dissociative induction, they performed an emotional Stroop task and an emotional binding task. Between the two sessions, they completed questionnaires at home evaluating PTSD severity, trait dissociation and cognitive difficulties. State dissociation was assessed at T1 and T2 using the Clinician-Administered Dissociative States Scale (CADSS).

RESULTS

We found good psychometric properties of the French version of the CADSS. After inducing dissociation, significantly lower attentional performance was found among patients with than without dissociative reactions. We found a significant positive correlation between state dissociation and increased attention and memory difficulties after induction.

CONCLUSION

The French version of the CADSS is a reliable and valid tool to assess state dissociation, which is correlated with attentional difficulties. Attentional training is recommended to help patients control dissociative symptoms.

Moral injury appraisals and dissociation: Associations in a sample of trauma-exposed community members

Appraisal of trauma is a critical factor in the development of impairing post-traumatic stress symptoms, such as dissociation. Individuals may appraise trauma as morally injurious (i.e., moral injury exposure [MIE]) and experience subsequent moral distress related to this exposure (i.e., moral injury distress [MID]). To date, however, investigation into the relations between moral injury appraisals and dissociation has been limited, particularly within community populations. This study investigated MIE and MID in relation to six facets of dissociation (disengagement, depersonalization, derealization, memory disturbances, emotional constriction, identity dissociation) in a sample of trauma-exposed community members (n = 177, 58.2% Black, 89.3% female) recruited from a public hospital and/or community advertisements. Participants completed measures assessing trauma exposure, MIE, MID, dissociation, and posttraumatic stress disorder (PTSD) symptoms. Partial correlation analyses revealed that after controlling for PTSD symptoms, MIE was correlated with disengagement, r = .23, p ≤ .025, and depersonalization, r = .25, p ≤ .001, and MID was correlated with depersonalization, r = .19, p ≤ .025. Sex moderated each association, with stronger associations observed for female participants. Findings suggest that moral injury appraisals are linked to more severe dissociative symptoms among female civilians, and as such, may need to be specifically targeted in empirically supported treatments.

To Trust is to Survive: Toward a Developmental Model of Moral Injury

Research on trauma- and stressor-related disorders has recently expanded to consider moral injury, or the harmful psychological impact of profound moral transgressions, betrayals, and acts of perpetration. Largely studied among military populations, this construct has rarely been empirically extended to children and adolescents despite its relevance in the early years, as well as youths' potentially heightened susceptibility to moral injury due to ongoing moral development and limited social resources relative to adults. Application of the construct to young persons, however, requires theoretical reconceptualization from a developmental perspective. The present paper brings together theory and research on developmentally-oriented constructs involving morally injurious events, including attachment trauma, betrayal trauma, and perpetration-induced traumatic stress, and describes how they may be integrated and extended to inform a developmentally-informed model of moral injury. Features of such a model include identification of potentially morally injurious events, maladaptive developmental meaning-making processes that underlie moral injury, as well as behavioral and emotional indicators of moral injury among youth. Thus, this review summarizes the currently available developmental literatures, identifies the major implications of each to a developmentally-informed construct of moral injury, and presents a conceptual developmental model of moral injury for children and adolescents to guide future empirical research.

Differing associations of depersonalization with physiological response during rest and breath-focused mindfulness in a trauma-exposed female population

BACKGROUND

Dissociative and posttraumatic stress disorder (PTSD) symptoms are commonly co-occurring responses to psychological trauma. Yet, these two groups of symptoms appear to be related to diverging patterns of physiological response. To date, few studies have examined how specific dissociative symptoms, namely, depersonalization and derealization, relate to skin conductance response (SCR), a marker of autonomic function, within the context of PTSD symptoms. We examined associations among depersonalization, derealization, and SCR during two conditions - resting control and breath-focused mindfulness - in the context of current PTSD symptoms.

METHODS

Sixty-eight trauma-exposed women (82.4% Black; Mage = 42.5, SDage = 12.1) were recruited from the community for a breath-focused mindfulness study. SCR data were collected during alternating resting control and breath-focused mindfulness conditions. Moderation analyses were conducted to examine relations among dissociative symptoms, SCR, and PTSD for these different conditions.

RESULTS

Moderation analyses revealed that depersonalization was linked to lower SCR during resting control, B = 0.0005, SE = 0.0002, p = .006, in participants low-to-moderate PTSD symptoms; however, depersonalization was associated with higher SCR during breath-focused mindfulness, B = -0.0006, SE = 0.0003, p = .029, in individuals with similar levels of PTSD symptoms. No significant interaction between derealization and PTSD symptoms on SCR was observed.

CONCLUSIONS

Depersonalization symptoms may associate with physiological withdrawal during rest, but greater physiological arousal during effortful emotion regulation in individuals with low-to moderate levels of PTSD, which has significant implications for barriers to treatment engagement as well as treatment selection in this population.

Neurobiological and genetic correlates of the dissociative subtype of posttraumatic stress disorder

Approximately 10%-30% of individuals with posttraumatic stress disorder (PTSD) exhibit a dissociative subtype of the condition defined by symptoms of depersonalization and derealization. This study examined the psychometric evidence for the dissociative subtype of PTSD in a sample of young, primarily male post-9/11-era Veterans (n = 374 at baseline and n = 163 at follow-up) and evaluated its biological correlates with respect to resting state functional connectivity (default mode network [DMN]; n = 275), brain morphology (hippocampal subfield volume and cortical thickness; n = 280), neurocognitive functioning (n = 337), and genetic variation (n = 193). Multivariate analyses of PTSD and dissociation items suggested a class structure was superior to dimensional and hybrid ones, with 7.5% of the sample comprising the dissociative class; this group showed stability over 1.5 years. Covarying for age, sex, and PTSD severity, linear regression models revealed that derealization/depersonalization severity was associated with: decreased DMN connectivity between bilateral posterior cingulate cortex and right isthmus (p = .015; adjusted-p [padj] = .097); increased bilateral whole hippocampal, hippocampal head, and molecular layer head volume (p = .010-.034; padj = .032-.053); worse self-monitoring (p = .018; padj = .079); and a candidate genetic variant (rs263232) in the adenylyl cyclase 8 gene (p = .026), previously associated with dissociation. Results converged on biological structures and systems implicated in sensory integration, the neural representation of spatial awareness, and stress-related spatial learning and memory, suggesting possible mechanisms underlying the dissociative subtype of PTSD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prevalence, Clinical Features, and Psychological Characteristics of Dissociative Subtype of Posttraumatic Stress Disorder in Chinese Prisoners

This study aimed to examine prevalence, clinical symptoms, and psychological characteristics of D-PTSD in a sample of Chinese prisoners with probable PTSD. A total of 1458 male prisoners were recruited from a large prison in Guangdong, China. Participants completed self-administrated questionnaires that assessed PTSD and dissociative symptoms, psychopathology, emotion regulation, emotional expressivity, social pleasure, traumatic events, and social support. According to DSM-5 criteria, participants were classified into four groups: D-PTSD, PTSD only, derealization/depersonalization (DD) only, and neither. The proportions of D-PTSD, PTSD only, DD only and neither were 2.5%, 4.7%, 2.4%, and 92.2%, respectively. PTSD symptoms and emotion regulation difficulties were distinguishing for the four groups: PTSD symptoms declined gradually in the order of D-PTSD, PTSD only, DD only, and neither, while emotion regulation difficulties declined in an order from D-PTSD, DD only, and PTSD only to neither, all ps < .001. D-PTSD and DD only had higher depressive and dissociative symptoms than PTSD only and the neither groups, all ps < .001. D-PTSD also had more borderline personality symptoms, emotion regulation difficulties, and more negative emotional expressivity than PTSD only and DD only, all ps < .05. Logistic regressions indicated that D-PTSD reported lower social support compared to PTSD only (OR = 0.95, p < .01), DD only (OR = 0.96, p < .05) and neither (OR = 0.93, p < .001). D-PTSD is common in probable PTSD in prisoners and is associated with complex clinical presentations as well as emotional processing. Social support is an important protective factor of D-PTSD.

Unravelling psychiatric heterogeneity and predicting suicide attempts in women with trauma-related dissociation using artificial intelligence

Background: Suicide is a leading cause of death, and rates of attempted suicide have increased during the COVID-19 pandemic. The under-diagnosed psychiatric phenotype of dissociation is associated with elevated suicidal self-injury; however, it has largely been left out of attempts to predict and prevent suicide.Objective: We designed an artificial intelligence approach to identify dissociative patients and predict prior suicide attempts in an unbiased, data-driven manner.Method: Participants were 30 controls and 93 treatment-seeking female patients with posttraumatic stress disorder (PTSD) and various levels of dissociation, including some with the PTSD dissociative subtype and some with dissociative identity disorder (DID).Results: Unsupervised learning models identified patients along a spectrum of dissociation. Moreover, supervised learning models accurately predicted prior suicide attempts with an F1 score up to 0.83. DID had the highest risk of prior suicide attempts, and distinct subtypes of dissociation predicted suicide attempts in PTSD and DID.Conclusions: These findings expand our understanding of the dissociative phenotype and underscore the urgent need to assess for dissociation to identify individuals at high-risk of suicidal self-injury.

The brain-body disconnect: A somatic sensory basis for trauma-related disorders

Although the manifestation of trauma in the body is a phenomenon well-endorsed by clinicians and traumatized individuals, the neurobiological underpinnings of this manifestation remain unclear. The notion of somatic sensory processing, which encompasses vestibular and somatosensory processing and relates to the sensory systems concerned with how the physical body exists in and relates to physical space, is introduced as a major contributor to overall regulatory, social-emotional, and self-referential functioning. From a phylogenetically and ontogenetically informed perspective, trauma-related symptomology is conceptualized to be grounded in brainstem-level somatic sensory processing dysfunction and its cascading influences on physiological arousal modulation, affect regulation, and higher-order capacities. Lastly, we introduce a novel hierarchical model bridging somatic sensory processes with limbic and neocortical mechanisms regulating an individual's emotional experience and sense of a relational, agentive self. This model provides a working framework for the neurobiologically informed assessment and treatment of trauma-related conditions from a somatic sensory processing perspective.

Anxiety sensitivity predicts depression severity in individuals with dissociative identity disorder

BACKGROUND

Anxiety sensitivity involves the fear of anxiety-related symptoms and can exacerbate both major depressive disorder and posttraumatic stress disorder (PTSD) symptoms. However, it is unclear if anxiety sensitivity plays a similar role in dissociative identity disorder (DID) where symptoms of depression and PTSD commonly co-occur. We examined the association between anxiety sensitivity, depression, PTSD and dissociative symptoms in DID, hypothesizing a positive association between all symptoms and anxiety sensitivity.

METHOD

Participants were 21 treatment-seeking adult females with histories of childhood trauma, current PTSD, and DID. Participants completed the Anxiety Sensitivity Index (ASI), Beck Depression Inventory-II, Childhood Trauma Questionnaire, Multidimensional Inventory of Dissociation, and PTSD Checklist for DSM-5. The ASI included subscales that assessed anxiety sensitivity in cognitive, physical, and social domains.

RESULTS

Participants reported high levels of anxiety sensitivity. A multiple regression analysis demonstrated that the ASI cognitive subscale was the strongest predictor of depressive symptoms. No direct associations were identified between anxiety sensitivity and PTSD or dissociative symptoms. We conducted a mediation analysis to test an indirect relationship between cognitive anxiety sensitivity and dissociative symptoms, and found a significant indirect effect through depressive symptoms.

CONCLUSIONS

Our results suggest that cognitive anxiety sensitivity or the fear of cognitive dyscontrol is linked with symptom severity in DID. These findings emphasize the need to assess for and utilize interventions that target anxiety sensitivity, which may in turn alleviate symptoms of depression and dissociation in DID.

Prevalence of the dissociative subtype of post-traumatic stress disorder: a systematic review and meta-analysis

The dissociative subtype of post-traumatic stress disorder (PTSD-DS) was introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and is characterised by symptoms of either depersonalisation or derealisation, in addition to a diagnosis of post-traumatic stress disorder (PTSD). This systematic review and meta-analysis sought to estimate the point prevalence of current PTSD-DS, and the extent to which method of assessment, demographic and trauma variables moderate this estimate, across different methods of prevalence estimation. Studies included were identified by searching MEDLINE (EBSCO), PsycInfo, CINAHL, Academic Search Complete and PTSDpubs, yielding 49 studies that met the inclusion criteria (N = 8214 participants). A random-effects meta-analysis estimated the prevalence of PTSD-DS as 38.1% (95% CI 31.5-45.0%) across all samples, 45.5% (95% CI 37.7-53.4%) across all diagnosis-based and clinical cut-off samples, 22.8% (95% CI 14.8-32.0%) across all latent class analysis (LCA) and latent profile analysis (LPA) samples and 48.1% (95% CI 35.0-61.3%) across samples which strictly used the DSM-5 PTSD criteria; all as a proportion of those already with a diagnosis of PTSD. All results were characterised by high levels of heterogeneity, limiting generalisability. Moderator analyses mostly failed to identify sources of heterogeneity. PTSD-DS was more prevalent in children compared to adults, and in diagnosis-based and clinical cut-off samples compared to LCA and LPA samples. Risk of bias was not significantly related to prevalence estimates. The implications of these results are discussed further.

Conceptualizing traumatic stress and the structure of posttraumatic psychopathology through the lenses of RDoC and HiTOP

Trauma-related psychopathology, most notably posttraumatic stress disorder (PTSD), poses unique challenges for psychiatric nosology due to the wide range of symptoms and diagnoses associated with trauma and challenges representing the impact of trauma exposure on psychopathology. In this paper, we review the literature on categorical (i.e., Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases systems) versus dimensional conceptualizations of trauma-related symptoms with an emphasis on the Research Domain Criteria (RDoC) and the Hierarchical Taxonomy of Psychopathology (HiTOP) frameworks. We identify strengths of each approach and challenges in accommodating the full range of trauma-related psychopathology and the clinical implications thereof. We discuss several potential approaches for improving the representation of traumatic stress, including the use of PTSD subtypes, trauma-related specifiers for psychiatric diagnoses, and the development of a dimension that we call the traumatic stress spectrum, which spans both adaptive and adverse reactions to trauma. These approaches to representing traumatic stress can be evaluated empirically and further refined. We also discuss how the use of an integrated RDoC-HiTOP approach to reconceptualize traumatic stress might maximize the ability to model valid and reliable trauma-related phenotypes, which would aid in the investigation of clinically relevant biological correlates.

Contrasting Associations Between Heart Rate Variability and Brainstem-Limbic Connectivity in Posttraumatic Stress Disorder and Its Dissociative Subtype: A Pilot Study

Background

Increasing evidence points toward the need to extend the neurobiological conceptualization of posttraumatic stress disorder (PTSD) to include evolutionarily conserved neurocircuitries centered on the brainstem and the midbrain. The reticular activating system (RAS) helps to shape the arousal state of the brain, acting as a bridge between brain and body. To modulate arousal, the RAS is closely tied to the autonomic nervous system (ANS). Individuals with PTSD often reveal altered arousal patterns, ranging from hyper- to blunted arousal states, as well as altered functional connectivity profiles of key arousal-related brain structures that receive direct projections from the RAS. Accordingly, the present study aims to explore resting state functional connectivity of the RAS and its interaction with the ANS in participants with PTSD and its dissociative subtype.

Methods

Individuals with PTSD (n = 57), its dissociative subtype (PTSD + DS, n = 32) and healthy controls (n = 40) underwent a 6-min resting functional magnetic resonance imaging and pulse data recording. Resting state functional connectivity (rsFC) of a central node of the RAS – the pedunculopontine nuclei (PPN) – was investigated along with its relation to ANS functioning as indexed by heart rate variability (HRV). HRV is a prominent marker indexing the flexibility of an organism to react adaptively to environmental needs, with higher HRV representing greater effective adaptation.

Results

Both PTSD and PTSD + DS demonstrated reduced HRV as compared to controls. HRV measures were then correlated with rsFC of the PPN. Critically, participants with PTSD and participants with PTSD + DS displayed inverse correlations between HRV and rsFC between the PPN and key limbic structures, including the amygdala. Whereas participants with PTSD displayed a positive relationship between HRV and PPN rsFC with the amygdala, participants with PTSD + DS demonstrated a negative relationship between HRV and PPN rsFC with the amygdala.

Conclusion

The present exploratory investigation reveals contrasting patterns of arousal-related circuitry among participants with PTSD and PTSD + DS, providing a neurobiological lens to interpret hyper- and more blunted arousal states in PTSD and PTSD + DS, respectively.

The Role of the Insula in Classical and Dissociative PTSD: A Double Case Study

Two service members were diagnosed with PTSD due to military trauma exposure. One presented with the classical manifestation; the other presented with the dissociative subtype. A statistical map revealed anterior localization of insula connectivity in the classical PTSD patient and posterior localization in the dissociative PTSD patient. These differences suggest that dissociative PTSD may be identified, understood, and treated as a disorder related to increased posterior insula connectivity. This double case study provides preliminary evidence for a concrete neuroanatomical discrepancy between insula function in classical and dissociative PTSD that may help explain the emergence of different coping strategies.

Posttraumatic stress disorder symptom expression in racially and ethnically diverse women veterans

The number of racial/ethnic and women minorities entering the military continues to grow and more research is needed to properly assess, conceptualize, and treat posttraumatic stress disorder (PTSD) in diverse women. Recently, typological approaches have been useful in revealing distinct PTSD symptom presentations; however, existing research has not examined racial/ethnic differences among women veterans. We examined PTSD symptom expression and whether it differed by race/ethnicity in a sample of 407 women veterans that were recruited as part of a larger study on veterans' health. We conducted a series of model-based cluster analyses by race/ethnicity. Most racial/ethnic groups had between two- and four-group typologies that differed primarily in symptom severity. Latina veterans were found to have a unique eight-group PTSD typology differing not only in overall symptom severity but also in elevations of avoidance and hyperarousal symptoms. Racial and ethnic minority trauma survivors may present with a variety of posttraumatic symptom expressions. Better understanding these varying PTSD typologies will allow us to provide more tailored assessment and treatment for diverse women veterans with PTSD.

Autonomic nervous system correlates of posttraumatic stress symptoms in youth: Meta-analysis and qualitative review

Physiological dysregulation is a key diagnostic criterion for posttraumatic stress disorder (PTSD). While PTSD is defined by trauma exposure, symptom presentations are varied. Similarly, findings of autonomic nervous system (ANS), including parasympathetic (PNS) and sympathetic nervous system (SNS), function in youth exposed to trauma are mixed (e.g., hyporeactivity and hyperreactivity). The present meta-analysis quantitatively assesses the relation between ANS measures broadly, and PNS- and SNS-specific measures, and posttraumatic stress symptoms (PTSS) in youth (ages 4.98 to 19.55 years) across 38 cross-sectional and longitudinal studies (N = 3488). Findings demonstrate that heightened ANS activity is related to increased PTSS during stress tasks (r = 0.07), while decreased SNS activity at rest corresponded to increased PTSS (r = -0.09). The correlation between PNS measures and PTSS was non-significant. The moderation effect of age on the relation between PNS activity measured during stress tasks and PTSS approached significance, such that younger children showed a stronger negative relation between symptoms and PNS activity compared to older youth. Qualitative review of included studies revealed significant variability across sample and stressor characteristics and study methodology. Findings indicate the importance of autonomic dysregulation in youth with PTSS. Additional considerations for future research are discussed.

The dissociative subtype of PTSD in trauma-exposed individuals: a latent class analysis and examination of clinical covariates

BACKGROUND

A dissociative subtype of posttraumatic stress disorder (D-PTSD) was introduced into the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) but latent profiles and clinical correlates of D-PTSD remain controversial.

OBJECTIVE

The aims of our study were to identify subgroups of individuals with distinct patterns of PTSD symptoms, including dissociative symptoms, by means of latent class analyses (LCA), to compare these results with the categorization of D-PTSD vs. PTSD without dissociative features according to the CAPS-5 interview, and to explore whether D-PTSD is associated with higher PTSD severity, difficulties in emotion regulation, and depressive symptoms.

METHOD

A German sample of treatment-seeking individuals was investigated (N = 352). We conducted an LCA on the basis of symptoms of PTSD and dissociation as assessed by the CAPS-5. Moreover, severity of PTSD (PCL-5), difficulties in emotion regulation (DERS), and depressive symptoms (BDI-II) were compared between patients with D-PTSD according to the CAPS-5 interview and patients without dissociative symptoms.

RESULTS

LCA results suggested a 5-class model with one subgroup showing the highest probability to fulfill criteria for the dissociative subtype and high scores on both BDI and DERS. Significantly higher scores on the DERS, BDI and PCL-5 were found in the D-PTSD group diagnosed with the CAPS-5 (n = 75; 35.7%). Sexual trauma was also reported more often by this subgroup. When comparing the dissociative subtype to the LCA results, only a partial overlap could be found.

CONCLUSIONS

Our findings suggest that patients with D-PTSD have significantly more problems with emotion regulation, more depressive symptoms, and more severe PTSD-symptoms. Given the results of our LCA, we conclude that the dissociative subtype seems to be more complex than D-PTSD as diagnosed by means of the CAPS-5.

Dissociation as a Transdiagnostic Indicator of Self-Injurious Behavior and Suicide Attempts: A Focus on Posttraumatic Stress Disorder and Borderline Personality Disorder

Dissociative symptoms and suicidality are transdiagnostic features of posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). The primary objective of this study was to examine associations between dissociation (i.e., depersonalization and derealization) and suicidality (i.e., self-harm and suicide attempts) among individuals with PTSD and BPD. We analyzed data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; N = 36,309). The Alcohol Use Disorder and Associated Disabilities Interview Schedule for DSM-5 was used to assess lifetime PTSD and BPD. Estimated rates of self-harm among individuals who endorsed dissociation were 15.5%-26.2% for those with PTSD and 13.7%-23.5% for those with BPD, and estimates of suicide attempts among individuals who endorsed dissociation were 34.5%-38.1% for those with PTSD and 28.3%-33.1% for those with BPD. Multiple logistic regressions were conducted to examine the associations between dissociation (derealization, depersonalization, and both) and both self-harm and suicide attempts among respondents with PTSD and BPD. The results indicated that dissociation was associated with self-harm and suicide attempts, especially among individuals with BPD, aORs = 1.39-2.66; however, this association may be driven in part by a third variable, such as other symptoms of PTSD or BPD (e.g., mood disturbance, PTSD or BPD symptom severity). These results may inform risk assessments and targeted interventions for vulnerable individuals with PTSD, BPD, or both aimed at mitigating the risk of self-harm and suicide.

A Network Analysis to Identify Associations between PTSD and Dissociation among Teenagers

We conducted a network analysis of measures of dissociation and posttraumatic symptoms (PTS) with a varied sample of adolescents (N = 312), some of them previously exposed to war scenarios. The global measure of dissociation (A-DES) was uniquely linked to the arousal PTS symptom cluster (CRIES-13), in particular sleep problems, but not to the reexperiencing and avoidance clusters. Three of four (i.e., depersonalization/derealization, amnesia, mental partition/compartmentalization) dissociation clusters were uniquely linked to PTS severity, but not absorption. The results with the pooled groups were generally representative of both groups. The DP/DR relation to PTS was based on data from both samples, whereas the link between amnesia and partition/parts might have been driven by the normative group, although the refugee sample had significantly higher scores in those variables. The results replicate some previous findings with adult samples and suggest new paths for research and theory.

Neural contributors to trauma resilience: a review of longitudinal neuroimaging studies

Resilience in the face of major life stressors is changeable over time and with experience. Accordingly, differing sets of neurobiological factors may contribute to an adaptive stress response before, during, and after the stressor. Longitudinal studies are therefore particularly effective in answering questions about the determinants of resilience. Here we provide an overview of the rapidly-growing body of longitudinal neuroimaging research on stress resilience. Despite lingering gaps and limitations, these studies are beginning to reveal individual differences in neural circuit structure and function that appear protective against the emergence of future psychopathology following a major life stressor. Here we outline a neural circuit model of resilience to trauma. Specifically, pre-trauma biomarkers of resilience show that an ability to modulate activity within threat and salience networks predicts fewer stress-related symptoms. In contrast, early post-trauma biomarkers of subsequent resilience or recovery show a more complex pattern, spanning a number of major circuits including attention and cognitive control networks as well as primary sensory cortices. This novel synthesis suggests stress resilience may be scaffolded by stable individual differences in the processing of threat cues, and further buttressed by post-trauma adaptations to the stressor that encompass multiple mechanisms and circuits. More attention and resources supporting this work will inform the targets and timing of mechanistic resilience-boosting interventions.

Depression in post-traumatic stress disorder

Major depressive disorder (MDD) symptoms commonly occur after trauma-exposure, both alone and in combination with post-traumatic stress disorder (PTSD). This article reviews recent research on comorbidity between these disorders, including its implications for symptom severity and response to treatment. Despite considerable symptom overlap, the two disorders represent distinct constructs and depend, at least in part, on separate biological mechanisms. Both, however, are also clearly related to stress psychopathology. We recommend that more research focus specifically on the study of individual differences in symptom expression in order to identify distinct subgroups of individuals and develop targeted treatments. However, a barrier to this line of inquiry is the trend of excluding particular patients from clinical trials of new interventions based on symptom severity or comorbidity. Another obstacle is the overreliance on self-report measures in human research. We argue that developing computer-based behavioral measures in order to supplement self-report can help address this challenge. Furthermore, we propose that these measures can help tie findings from human and non-human animal research. A number of paradigms have been used to model MDD-and PTSD-like behavior in animals. These models remain valuable for understanding the biological basis of these disorders in humans and for identifying potential interventions, but they have been underused for the study of comorbidity. Although the interpretation of animal behavior remains a concern, we propose that this can also be overcome through the development of close human analogs to animal paradigms.

Altered basal forebrain BOLD signal variability at rest in posttraumatic stress disorder: A potential candidate vulnerability mechanism for neurodegeneration in PTSD

Individuals with posttraumatic stress disorder (PTSD) are at increased risk for the development of various forms of dementia. Nevertheless, the neuropathological link between PTSD and neurodegeneration remains unclear. Degeneration of the human basal forebrain constitutes a pathological hallmark of neurodegenerative diseases, such as Alzheimer's and Parkinson's disease. In this seed-based resting-state (rs-)fMRI study identifying as outcome measure the temporal BOLD signal fluctuation magnitude, a seed-to-voxel analyses assessed temporal correlations between the average BOLD signal within a bilateral whole basal forebrain region-of-interest and each whole-brain voxel among individuals with PTSD (n = 65), its dissociative subtype (PTSD+DS) (n = 38) and healthy controls (n = 46). We found that compared both with the PTSD and healthy controls groups, the PTSD+DS group exhibited increased BOLD signal variability within two nuclei of the seed region, specifically in its extended amygdaloid region: the nucleus accumbens and the sublenticular extended amygdala. This finding is provocative, because it mimics staging models of neurodegenerative diseases reporting allocation of neuropathology in early disease stages circumscribed to the basal forebrain. Here, underlying candidate etiopathogenetic mechanisms are neurovascular uncoupling, decreased connectivity in local- and large-scale neural networks, or disrupted mesolimbic dopaminergic circuitry, acting indirectly upon the basal forebrain cholinergic pathways. These abnormalities may underpin reward-related deficits representing a putative link between persistent traumatic memory in PTSD and anterograde memory deficits in neurodegeneration. Observed alterations of the basal forebrain in the dissociative subtype of PTSD point towards the urgent need for further exploration of this region as a potential candidate vulnerability mechanism for neurodegeneration in PTSD.

Complex PTSD and borderline personality disorder

BACKGROUND

This article builds on a previous review (Ford and Courtois, Borderline Personal Disord Emot Dysregul 1:9, 2014) which concluded that complex posttraumatic stress disorder (cPTSD) could not be conceptualized as a sub-type of either PTSD or BPD. Recent research is reviewed that extends and clarifies the still nascent understanding of the relationship between cPTSD and BPD.

MAIN BODY

The circumscribed formulation of adult cPTSD that has been developed, validated, and included in the 11th Edition of the International Classification of Diseases has spurred research aimed at differentiating cPTSD and BPD both descriptively and empirically. A newly validated Developmental Trauma Disorder (DTD) syndrome for children and adolescents provides a basis for systematic research on the developmental course and origins of adult cPTSD and BPD. This review summarizes recent empirical findings regarding BPD, PTSD, and cPTSD in terms of: (1) prevalence and comorbidity; (2) clinical phenomenology; (3) traumatic antecedents; (4) psychobiology; (5) emotion dysregulation; (6) dissociation; and (7) empirically supported approaches to clinical assessment and psychotherapeutic treatment.

CONCLUSION

The evidence suggests that PTSD, cPTSD, and BPD are potentially comorbid but distinct syndromes. A hypothesis is advanced to stimulate scientific research and clinical innovation defining and differentiating the disorders, positing that they may represent a continuum paralleling the classic conceptualization of the stress response, with dissociation potentially involved in each disorder.

How Processing of Sensory Information From the Internal and External Worlds Shape the Perception and Engagement With the World in the Aftermath of Trauma: Implications for PTSD

Post-traumatic stress disorder (PTSD) is triggered by an individual experiencing or witnessing a traumatic event, often precipitating persistent flashbacks and severe anxiety that are associated with a fearful and hypervigilant presentation. Approximately 14–30% of traumatized individuals present with the dissociative subtype of PTSD, which is often associated with repeated or childhood trauma. This presentation includes symptoms of depersonalization and derealization, where individuals may feel as if the world or self is “dream-like” and not real and/or describe “out-of-body” experiences. Here, we review putative neural alterations that may underlie how sensations are experienced among traumatized individuals with PTSD and its dissociative subtype, including those from the outside world (e.g., touch, auditory, and visual sensations) and the internal world of the body (e.g., visceral sensations, physical sensations associated with feeling states). We postulate that alterations in the neural pathways important for the processing of sensations originating in the outer and inner worlds may have cascading effects on the performance of higher-order cognitive functions, including emotion regulation, social cognition, and goal-oriented action, thereby shaping the perception of and engagement with the world. Finally, we introduce a theoretical neurobiological framework to account for altered sensory processing among traumatized individuals with and without the dissociative subtype of PTSD.

Latent classes of posttraumatic psychiatric comorbidity in the general population

Some narrow patterns of posttraumatic psychiatric comorbidity are well-established (e.g., posttraumatic stress disorder and substance use). However, broad multi-diagnosis profiles of posttraumatic comorbidity are poorly characterized. The goal of the current study was to use latent class analysis (LCA) to identify profiles of posttraumatic psychopathology from 11 International Classification of Diseases (ICD-10) diagnostic categories (e.g., stress, substance, depressive, psychosis, personality). Danish national registries were used to identify 166,539 individuals (median age = 41 years, range = <1 to >100) who experienced a traumatic event between 1994 and 2016 and were diagnosed with one or more mental disorders within 5 years. Two through 14-class LCA solutions were evaluated. A 13-class solution (a) provided the best fit, with the Bayes and Akaike Information Criteria reaching a minimum, (b) was broadly consistent with prior LCA studies, and (c) included several novel classes reflecting differential patterns of posttraumatic psychopathology. Three classes were characterized by high comorbidity: broad high comorbidity (M # diagnoses = 4.3), depression with stress/substance use/personality/neurotic disorders (M# diagnoses = 3.8), and substance use with personality/stress/psychotic disorders (M # diagnoses = 3.1). The other 10 classes were characterized by distinct patterns of mild comorbidity or negligible comorbidity. Compared to the mild and negligible comorbidity classes, individuals in high comorbidity classes were younger, had lower income, and had more pre-event psychiatric disorders. Results suggest that several different comorbidity patterns should be assessed when studying and treating posttraumatic psychopathology.

Dissociative symptoms predict severe illness presentation in Canadian public safety personnel with presumptive post-traumatic stress disorder (PTSD)

BACKGROUND

Post-traumatic stress disorder affects 9% of individuals across their lifetime and increases nearly fourfold to 35% in Canadian public safety personnel (PSP). On-the-job experiences of PSP frequently meet criteria for traumatic events, making these individuals highly vulnerable to exposures of trauma and the negative consequences of PTSD. Few studies have reported on the clinical characteristics of Canadian samples of PSP and even fewer have examined the dissociative subtype of PTSD, which is associated with more severe, chronic traumatic experiences, and worse outcomes.

OBJECTIVE

This study aimed to characterize dissociative symptoms, PTSD symptom severity, and other clinical variables among Canadian PSP with presumptive PTSD.

METHODS

We sampled current and past PSP in Canada from both inpatient and outpatient populations (N = 50) that were enrolled in a psychological intervention. Only baseline testing data (prior to any intervention) were analysed in this study, such as PTSD symptom severity, dissociative symptoms, emotion dysregulation, and functional impairment.

RESULTS

In our sample, 24.4% self-reported elevated levels of dissociation, specifically symptoms of depersonalization and derealization. Depersonalization and derealization symptoms were associated with more severe PTSD symptoms, greater emotion dysregulation, and functional impairment.

CONCLUSIONS

Nearly a quarter of this sample of Canadian PSP reported experiencing elevated levels of PTSD-related dissociation (depersonalization and derealization). These high levels of depersonalization and derealization were consistently positively associated with greater illness severity across clinical measures. It is imperative that dissociative symptoms be better recognized in patient populations that are exposed to chronic traumatic events such as PSP, so that treatment interventions can be designed to target a more severe illness presentation.

Animal models for the discovery of novel drugs for post-traumatic stress disorder

INTRODUCTION

Existing pharmacological treatments for PTSD are limited and have been used primarily because of their effectiveness in other psychiatric conditions. To generate novel, PTSD specific pharmacotherapy, researchers must utilize animal models to assess the efficacy of experimental drugs.

AREAS COVERED

This review includes a discussion of factors that should be considered when developing an animal model of PTSD, as well as descriptions of the most commonly used models. Researchers have utilized physical stressors, psychological stressors, or a combination of the two to induce PTSD-like physiological and behavioral sequelae in animals. Such models have provided researchers with a valuable tool to examine the neurobiological mechanisms underlying the condition.

EXPERT OPINION

PTSD is a heterogeneous disorder that manifests as different symptom clusters in different individuals. Thus, there cannot be a one-size-fits-all approach to modeling the disorder in animals. Preclinical investigators must adopt a concentrated effort aimed at modeling specific PTSD subtypes and the distinct symptom profiles that result from specific types of human trauma. Moreover, researchers have focused so much on modeling a single PTSD syndrome in animals that studies examining only specific facets of the disorder are largely ignored. Future research employing animal models of PTSD requires greater focus on the nuances of PTSD.

A network analysis of posttraumatic stress disorder and dissociation in trauma-exposed adolescents

Posttraumatic stress disorder (PTSD) and dissociation have long been recognized to co-occur, leading the DSM-5 to introduce a dissociative subtype of PTSD into its nomenclature. Most research to date on the dissociative subtype has focused on adults. The current study aimed to extend this research to an adolescent sample and to examine symptom-level associations between PTSD and dissociation using network analysis. The analysis was conducted with 448 trauma-exposed detained US adolescents (24.55% female; mean age 15.98 ± 1.25 years). A network consisting of 20 DSM-5 PTSD symptoms was constructed, followed by a network consisting of 20 PTSD symptoms and five dissociative items. Expected influence bridge centrality was estimated to examine items with the most/strongest cross-construct connections (i.e. between PTSD and dissociation). The PTSD symptoms concentration problems, amnesia and recurrent memories and the dissociative items depersonalization, derealisation and can't remember things that happened had the highest bridge centrality values. These symptom-level associations extend our understanding of the PTSD-dissociation relationship by pointing to specific symptoms of PTSD and dissociation that may drive the co-morbidity between the two constructs. These findings may inform future intervention efforts.

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

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 ICD-11 PTSD, complex PTSD and dissociative experiences

Debate exists in the trauma literature regarding the role of dissociation in traumatic stress disorders. With the release of the new ICD-11 diagnostic guideline for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD), this issue warrants further attention. In the current study, we provide a preliminary assessment of the associations between ICD-11 CPTSD and dissociative experiences. This study is based on a sample (N = 106) of highly traumatized clinical patients from the United Kingdom who completed measures of traumatic stress and dissociative experiences. The majority of participants met the diagnostic criteria for CPTSD (69.1%, n = 67), with few patients qualifying for a diagnosis of PTSD (9.3%, n = 9). Those with CPTSD had significantly higher levels of dissociative experiences compared to those with PTSD (Cohen's d = 1.04) and those with no diagnosis (Cohen's d = 1.44). Three CPTSD symptom clusters were multivariately associated with dissociation: Affective Dysregulation (β = .33), Re-experiencing in the here and now (β = .24), and Disturbed Relationships (β = .22). These findings indicate that dissociative experiences are particularly relevant for clinical patients with CPTSD. Future longitudinal work will be needed to determine if dissociation is a risk factor for, or outcome of, CPTSD.

Identifying clusters of health symptoms in deployed military personnel and their relationship with probable PTSD

OBJECTIVE

Among military personnel posttraumatic stress disorder is strongly associated with non-specific health symptoms and can have poor treatment outcomes. This study aimed to use machine learning to identify and describe clusters of self-report health symptoms and examine their association with probable PTSD, other psychopathology, traumatic deployment exposures, and demographic factors.

METHOD

Data were from a large sample of military personnel who deployed to the Middle East (n = 12,566) between 2001 and 2009. Participants completed self-report measures including health symptoms and deployment trauma checklists, and several mental health symptom scales. The data driven machine learning technique of self-organised maps identified health symptom clusters and logistic regression examined their correlates.

RESULTS

Two clusters differentiated by number and severity of health symptoms were identified: a small 'high health symptom cluster' (HHSC; n = 366) and a large 'low health symptom cluster' (LHSC; n = 12,200). The HHSC had significantly higher proportions of (Gates et al., 2012 [1]) scaled scores indicative of PTSD (69% compared with 2% of LHSC members), Unwin et al. (1999a) [2] scores on other psychological scales that were indicative of psychopathology, and (Graham et al., n.d. [3]) deployment trauma. HHSC members with probable PTSD had a stronger relationship with subjective (OR 1.25; 95% CI 1.12, 1.40) and environmental (OR 1.08; 95% CI 1.03, 1.13) traumatic deployment exposures than LHSC members with probable PTSD.

CONCLUSION

These findings highlights that health symptoms are not rare in military veterans, and that PTSD is strongly associated with health symptoms. Results suggest that there may be subtypes of PTSD, differentiated by health symptoms.

The Dissociative Subtype of PTSD Interview (DSP-I): Development and Psychometric Properties

The inclusion of the dissociative subtype of post-traumatic stress disorder (PTSD-DS) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reflects the importance of assessing PTSD-DS. We developed the Dissociative Subtype of PTSD Interview (DSP-I). This clinician-administered instrument assesses the presence and severity of PTSD-DS (i.e., symptoms of depersonalization or derealization) and contains a supplementary checklist that enables assessment and differentiation of other trauma-related dissociative symptoms (i.e., blanking out, emotional numbing, alterations in sensory perception, amnesia, and identity confusion). The psychometric properties were tested in 131 treatment-seeking individuals with PTSD and histories of multiple trauma, 17.6 % of whom met criteria for PTSD-DS in accordance with the DSP-I. The checklist was tested in 275 treatment-seeking individuals. Results showed the DSP-I to have high internal consistency, good convergent validity with PTSD-DS items of the CAPS-5, and good divergent validity with scales of somatization, anxiety and depression. The depersonalization and derealization scales were highly associated. Moreover, the DSP-I accounted for an additional variance in PTSD severity scores of 8% over and above the CAPS-5 and number of traumatic experiences. The dissociative experiences of the checklist were more strongly associated with scales of overall distress, somatization, depression, and anxiety than scales of depersonalization and derealization. In conclusion, the DSP-I appears to be a clinically relevant and psychometrically sound instrument that is valuable for use in clinical and research settings.

Psychometric Properties of the Dissociative Subtype of PTSD Scale: Replication and Extension in a Clinical Sample of Trauma-Exposed Veterans

The addition of the dissociative subtype of posttraumatic stress disorder (PTSD) to the DSM-5 has spurred investigation of its genetic, neurobiological, and treatment response correlates. In order to reliably assess the subtype, we developed the Dissociative Subtype of PTSD Scale (DSPS; Wolf et al., 2017), a 15-item index of dissociative features. Our initial investigation of the dichotomous DSPS lifetime items in a veteran epidemiological sample demonstrated its ability to identify the subtype, supported a three-factor measurement structure, distinguished the three subscales from the normal-range trait of absorption, and demonstrated the greater contribution of derealization and depersonalization symptoms relative to other dissociative symptomatology. In this study, we replicated and extended these findings by administering self-report and interview versions of the DSPS, and assessing personality and PTSD in a sample of 209 trauma-exposed veterans (83.73% male, 57.9% with probable current PTSD). Results replicated the three-factor structure using confirmatory factor analysis of current symptom severity interview items, and the identification of the dissociative subtype (via latent profile analysis). Associations with personality supported the discriminant validity of the DSPS and suggested the subtype was marked by tendencies towards odd and unusual cognitive experiences and low positive affect. Receiver operating characteristic curves identified diagnostic cut-points on the DSPS to inform subtype classification, which differed across the interview and self-report versions. Overall, the DSPS performed well in psychometric analyses, and results support the utility of the measure in identifying this important component of posttraumatic psychopathology.

Management of post-traumatic stress disorder: A protocol for a multiple treatment comparison meta-analysis of randomized controlled trials

BACKGROUND

Most systematic reviews have explored the efficacy of treatments on symptoms associated with post-traumatic stress disorder (PTSD), which is a chronic and often disabling condition. Previous network meta-analysis (NMA) had limitations such as focusing on pharmacological or psychotherapies. Our review is aims to explore the relative effectiveness of both pharmacological and psychotherapies and we will establish the differential efficacy of interventions for PTSD in consideration of both symptom reduction and functional recovery.

METHODS

We will conduct a network meta-analysis of randomized controlled trials evaluating treatment interventions for PTSD. We will systematically search Medline, PILOT, Embase, CINHAL, AMED, Psychinfo, Health Star, DARE and CENTRAL to identify trials that: (1) enroll adult patients with PTSD, and (2) randomize them to alternative interventions or an intervention and a placebo/sham arm. Independent reviewers will screen trials for eligibility, assess risk of bias using a modified Cochrane instrument, and extract data. Our outcomes of interest include PTSD symptom reduction, quality of life, functional recovery, social and occupational impairment, return to work and all-cause drop outs.

RESULTS

We will conduct frequentist random-effects network meta-analysis to assess relative effects of competing interventions. We will use a priori hypotheses to explore heterogeneity between studies, and assess the certainty of evidence using the GRADE approach.

CONCLUSION

This network meta-analysis will determine the comparative effectiveness of therapeutic options for PTSD on both symptom reduction and functional recovery. Our results will be helpful to clinicians and patients with PTSD, by providing a high-quality evidence synthesis to guide shared-care decision making.

Exploring evidence of a dissociative subtype in PTSD: Baseline symptom structure, etiology, and treatment efficacy for those who dissociate

OBJECTIVE

With the inclusion of a dissociative subtype, recent changes to the DSM-5 diagnosis of posttraumatic stress disorder (PTSD) have emphasized the role of dissociation in the experience and treatment of the disorder. However, there is a lack of research exploring the clinical impact for highly dissociative groups receiving treatment for PTSD. The current study examined the presence and clinical impact of a dissociative subtype in a sample of individuals receiving treatment for chronic PTSD.

METHOD

This study used latent transition analyses (LTA), an expanded form of latent profile analyses (LPA), to examine latent profiles of PTSD and dissociation symptoms before and after treatment for individuals (N = 200) receiving prolonged exposure (PE) or sertraline treatment for chronic PTSD.

RESULTS

The best fitting LTA model was one with a 4-class solution at both pretreatment and posttreatment. There was a latent class at pretreatment with higher levels of dissociative symptoms. However, this class was also marked by higher reexperiencing symptoms, and membership was not predicted by chronic child abuse. Further, although those in the class were less likely to transition to the responder class overall, this was not the case for exposure-based treatment specifically.

CONCLUSION

These findings are not in line with the dissociative-subtype theoretical literature that proposes those who dissociate represent a clinically distinct group that may respond worse to exposure-based treatments for PTSD. (PsycINFO Database Record

The Dissociative Subtype of Post-traumatic Stress Disorder: Research Update on Clinical and Neurobiological Features

Recently, a dissociative subtype of post-traumatic stress disorder (PTSD) has been included in the DSM-5. This review focuses on the clinical and neurobiological features that distinguish the dissociative subtype of PTSD from non-dissociative PTSD. Clinically, the dissociative subtype of PTSD is associated with high PTSD severity, predominance of derealization and depersonalization symptoms, a more significant history of early life trauma, and higher levels of comorbid psychiatric disorders. Furthermore, PTSD patients with dissociative symptoms exhibit different psychophysiological and neural responses to the recall of traumatic memories. While individuals with non-dissociative PTSD exhibit an increased heart rate, decreased activation of prefrontal regions, and increased activation of the amygdala in response to traumatic reminders, individuals with the dissociative subtype of PTSD show an opposite pattern. It has been proposed that dissociation is a regulatory strategy to restrain extreme arousal in PTSD through hyperinhibition of limbic regions. In this research update, promises and pitfalls in current research studies on the dissociative subtype of PTSD are listed. Inclusion of the dissociative subtype of PTSD in the DSM-5 stimulates research on the prevalence, symptomatology, and neurobiology of the dissociative subtype of PTSD and poses a challenge to improve treatment outcome in PTSD patients with dissociative symptoms.

PTSD symptom profiles among Louisiana women affected by the 2010 Deepwater Horizon Oil Spill: A latent profile analysis

BACKGROUND

Few prior studies have investigated the latent class structure of PTSD using DSM-5 symptoms.

METHODS

To describe latent PTSD profiles among women who resided in Deepwater Horizon Oil Spill (DHOS)-affected coastal Louisiana communities, we used data from women enrolled in The Women and Their Children's Health (WaTCH) Study. Latent profile analysis was performed on the 20-item PTSD Checklist for DSM-5 (PCL-5) and model fit statistics for 2-class through 6-class solutions were compared. The pseudo-class draws method was employed on the best class solution to compare key covariates (including demographics, mental health indicators, DHOS exposure indicators, and trauma exposures) across classes.

RESULTS

Among 1997 women (mean age 46.63 ± 12.14 years, 56.8% white, mean trauma categories 6.09 ± 2.98, 9.55% previously diagnosed with PTSD), model fit statistics supported a five-class solution: low symptoms (mean PCL-5 = 4.10), moderate without mood alterations (mean = 19.73), moderate with mood alterations (mean = 34.24), severe without risk-taking (mean = 55.75), and severe with risk-taking (mean = 53.80). Women in the low-symptom class were significantly more likely to be white, have finished high school, have an income of at least $40,001 per year, be married or living with a partner, and endorse fewer trauma categories than women in the four symptomatic classes. Women with moderate to severe symptoms often had co-morbid depressive symptoms and no prior PTSD diagnosis.

LIMITATIONS

This study was limited by use of self-reported data and one-time assessment of PTSD symptoms.

DISCUSSION

Five distinct latent profiles of DSM-5 PTSD symptoms consisted of notably different individuals. Most affected women did not report prior PTSD diagnosis. Future research and practice identifying and addressing barriers to care for trauma-affected women in these communities is warranted.

Relationships Between Maltreatment, Posttraumatic Symptomatology, and the Dissociative Subtype of PTSD Among Adolescents

The purpose of this study was to explore relationships between maltreatment, posttraumatic stress disorder, and the dissociative subtype of posttraumatic stress disorder among adolescents. This descriptive study used secondary data from the National Child Traumatic Stress Network Core Data Set. A clinical sample of adolescents exposed to potentially traumatizing events ages 12 to 16 was selected (N = 3081) to explore associations between trauma history characteristics, sociodemographic factors, posttraumatic stress disorder, and the dissociative subtype of PTSD which includes depersonalization and derealization. More than half of adolescents who met criteria for posttraumatic stress disorder also met criteria for the posttraumatic stress disorder dissociative subtype with significant depersonalization/derealization symptoms. No particular maltreatment type was associated with increased odds of posttraumatic stress disorder, with or without the dissociative subtype. All posttraumatic stress disorder-affected adolescents, with or without the dissociative subtype, experienced more overall potentially traumatizing events and maltreatment events than those without a posttraumatic stress disorder diagnosis. Girls and adolescents in residential treatment were more likely to have posttraumatic stress disorder with the dissociative subtype. This study provides evidence about the dissociative subtype of posttraumatic stress disorder among adolescents and provides new directions for research on trauma and dissociation. Future research studies should explore the co-occurrence of posttraumatic stress disorder and dissociation with broader range of dissociative symptoms than only depersonalization/derealization to further understand how to diagnose and treat traumatic stress disorders among adolescents.

Are PTSD and autistic traits related? An examination among typically developing Israeli adults

BACKGROUND AND OBJECTIVES

Previous research indicates that individuals with Autism Spectrum Disorder (ASD) face an increased risk of experiencing traumatic events. Autistic Traits (AT), characteristic of ASD, are continuously distributed across the general population. Our main objective was to examine the association between AT and PTSD (Post Traumatic Stress Disorder), a topic rarely assessed before.

METHODS

One hundred and three college students from 3 academic areas, previously found to be associated with different degrees of AT, completed self-report questionnaires tapping PTSD (the PCL-5; PTSD Checklist for DSM-5), AT (AQ; the Autism Spectrum Quotient), and traumatic life events.

RESULTS

AT were positively associated with all PTSD symptom clusters, except for avoidance. The association between imagination difficulties and PTSD was moderated by gender. Among participants meeting the PTSD cutoff, those with the highest AT levels reported a PTSD symptomatic profile with an increased dominance of hyper-arousal symptoms.

CONCLUSIONS

The AT-PTSD association reported here may be attributed to several factors, including increased victimization associated with AT, as well as shared vulnerability factors for both conditions, including impairments in social cognition. Further research is needed in order to understand the associations between these two conditions, considering gender differences, and possible shared underlying mechanisms.

The dissociative subtype of PTSD in women with substance use disorders: Exploring symptom and exposure profiles

The dissociative subtype of posttraumatic stress disorder (PTSD) was officially introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In accordance with this new classification, prior studies using Latent Class Analysis (LCA) empirically identified a subgroup of patients that were characterized by a high severity of dissociative symptoms. Despite the high prevalence of PTSD in patients with substance use disorders (SUD), however, no LCA studies on the dissociative subtype of PTSD exist in this population so far. Therefore, the current study aimed to identify subgroups of patients with different symptom and exposure profiles in patients with SUD and PTSD. It was assumed that one symptom and exposure profile could be identified that would be characterized by higher dissociative symptoms, higher additional psychopathology and a higher burden of childhood trauma, as compared to other subgroups. In N = 258 female patients with SUD and PTSD, clinical characteristics of dissociative symptoms, PTSD severity, borderline personality disorder (BPD), depression, childhood trauma and substance abuse were assessed. To identify symptom and exposure profiles, Latent Class Analysis was applied. A three-class solution indicated the best model fit to our data. One class was characterized by a high probability of dissociative symptoms (D-PTSD class), whereas the other two classes were characterized by lower probabilities of dissociative symptoms. The D-PTSD class encompassed 18.7% of the patients. In accordance with our hypothesis, the D-PTSD class showed higher probabilities of PTSD severity, borderline personality disorder symptoms, depressive symptoms, childhood emotional and sexual abuse, childhood emotional neglect, and drug abuse. Our results indicate that the dissociative subtype of PTSD could also be identified in a sample of female patients with SUD. Patients with SUD and PTSD characterized by the dissociative subtype showed more severe psychopathological symptoms than the remaining patients, indicating enhanced clinical needs for this vulnerable group.