Does dissociation further our understanding of PTSD?

Peritraumatic dissociation and posttraumatic stress symptoms: the moderating role of perceived threat

Background: Although peritraumatic dissociation (PD) is viewed as a risk factor for posttraumatic stress disorder (PTSD), prospective studies taking into account other well-known risk factors for PTSD have been scarce, and the exploration of potential moderators within the relations between PD and PTSD has been lacking.Objective: Filling this gap, this prospective study explored the moderating role of perceived threat within the relations between PD and PTSD, above and beyond age, gender, education, and early trauma-related symptoms.Method: A convenience sample of 200 Israeli civilians filled out self-report questionnaires during the peritraumatic phase (T1) and one to two months after the posttraumatic phase (T2) of being exposed to rocket attacks.Results: The results showed that perceived threat and PD were associated with early trauma-related symptoms and PTSD symptoms. Moreover, perceived threat moderated the relationship between PD and all PTSD symptom clusters apart from avoidance.Conclusions: The present results suggest that the implications of PD are shaped by levels of perceived threat, so that detriments of PD are evident when the trauma is appraised as being highly threatening. Therefore, early interventions that aim to decrease PD may be beneficial in preventing PTSD symptoms of intrusion, hyper arousal, and negative alterations in mood and cognition, for individuals who perceive traumatic events as highly threatening.

A Virtual Reality Courtroom for Survivors of Sexual Violence: A Mixed-Method Pilot Study on Application Possibilities

This mixed-method pilot study examined the application possibilities of a virtual courtroom to support survivors of sexual violence who may experience courtroom-associated distress. Female sexual violence survivors (n = 13) who had testified in court following victimization entered an interactive virtual courtroom replica. Their reactions were measured quantitatively and qualitatively. The virtual courtroom evoked both subjective and physiological stress. Participants perceived the virtual reality environment as similar to the real-life courtroom. Most reported negative experiences from interacting with the criminal justice system. The virtual courtroom is a possible future strategy to support survivors when reporting violence to the justice system.

[The roots of trauma: a review of the history of psychotrauma]

Perceptions of the importance of the role of psychological trauma in the origins of psychiatric problems have oscillated throughout the history of psychiatry. However, since the conception of post-traumatic stress disorder (PTSD), western societies have witnessed a marked expansion of the discourse of trauma in the interpretation of devastating human experiences like catastrophes, genocides, disasters, and epidemics. Through an integrative literature review, this article analyzes some of the historical and epistemological determinants behind the emergence of traumatic memory and the establishment of trauma as a semantic field that orients clinical responses and political strategies in the field of the humanities and the health sciences.

The Relationship between Lifetime Exposure to Potentially Traumatic Events, Peritraumatic Dissociation, and PTSD in a Sample of Sexually Assaulted Women in Sao Paulo, Brazil

Sexually assaulted women represent a particularly high-risk group for developing post-traumatic stress disorder (PTSD). Potentially traumatic events (PTEs) and peritraumatic dissociation (PD) are known risk factors for PTSD. However, little is known about how previous trauma affects PD and how this relationship affects PTSD. We aimed to investigate whether PD acts as a mediator between PTEs and PTSD severity in a sample of recently sexually assaulted women in Sao Paulo, Brazil. Seventy-four sexually assaulted women aged 18-44 completed questionnaires and structured interviews on PTSD, PD, and PTEs. We examined direct and indirect effects of variables using causal mediation analysis. Lifetime exposure to PTEs was a risk factor for PD, but PD was not a risk factor for PTSD symptom severity. Also, PD was not a mediator between PTEs and PTSD severity. We provided recommendations on how to further explore the relationship between lifetime traumatic exposure, PTSD, and peritraumatic dissociation.

Peri-Traumatic Dissociation and Tonic Immobility as Severity Predictors of Posttraumatic Stress Disorder After Rape

Some individuals show abnormal reactions to extreme fear and life-threatening situations, including tonic immobility (TI) and peri-traumatic dissociation (PTD). We aimed to investigate the association of TI and PTD with posttraumatic stress disorder (PTSD) in women who experienced sexual violence and the risk factors for PTD occurrence. We compared PTSD severity in 86 young adult women with PTSD after a sexual violence exposure grouped according to the presence of PTD and TI. In addition, we investigated whether PTD is associated with depression and anxiety symptoms and assessed potential risk factors for PTD reaction. We found a significant positive correlation between PTSD severity and PTD occurrence (R² = .132; p = .001). PTD was also positively correlated with all clusters of PTSD symptoms except the Clinician-Administered PTSD Scale avoidance cluster (p = .058). PTD was strongly correlated with anxiety (R² = .619; p < .001) and depressive symptoms (R² = .547; p < .001). Multiple logistic regression showed that history of physical abuse (odds ratio [OR]: 1.386; p = .011) and sexual abuse (OR: 1.947; p = .004) during childhood were associated with PTD occurrence. Other risk factors for PTD were having less years of study (OR: 0.216; p = .016) and lower income (OR: 7.403; p = .028). TI measures were available for a subsample of 29 women. We found no association between TI and PTSD severity. PTD, but not TI, is significantly associated with more severe PTSD, depressive, and anxiety symptoms. Less-educated women with a history of childhood abuse and a lower income are at risk of PTD occurrence during a sexual violence episode.

PTSD Symptom dynamics after the great east japan earthquake: mapping the temporal structure using Dynamic Time Warping

Background: After the Great East Japan Earthquake [GEJE], approximately 70,000 Japan Ground Self Defense Force [JGSDF] personnel were deployed, risking Post-Traumatic Stress Disorder [PTSD]. The network approach to psychopathology suggests that symptoms may cause and exacerbate each other, resulting in the emergence and maintenance of disorders, including PTSD. It is therefore important to further explore the temporal interplay between symptoms. Most studies assessing the factor structure of the Impact of Event Scale-Revised [IES-R] have used cross-sectional designs. In this study, the structure of the IES-R was re-evaluated while incorporating the temporal interplay between symptoms.Methods: Using Dynamic Time Warping [DTW] the distances between PTSD symptoms on the IES-R were modelled in 1120 JGSDF personnel. Highly correlated symptoms were clustered at the group level using Distatis three-way principal component analyses of the distance matrices. The resulting clusters were compared to the original three subscales of the IES-R using a Confirmatory Factor Analysis (CFA).Results: The DTW analysis yielded four symptom clusters: Intrusion (five items), Hyperarousal (six items), Avoidance (six items), and Dissociation (five items). CFA yielded better fit estimates for this four-factor solution (RMSEA = 0.084, CFI = 0.918, TLI = 0.906), compared to the original three subscales of the IES-R (RMSEA = 0.103, CFI = 0.873, TLI = 0.858).Conclusions: DTW offers a new method of modelling the temporal relationships between symptoms. It yielded four IES-R symptom clusters, which may facilitate understanding of PTSD as a complex dynamic system.

Ebola virus disease, stigmatization, peritraumatic distress, and posttraumatic stress disorder in the Democratic Republic of the Congo: A moderated mediation model

BACKGROUND

Mechanisms worsening the development of Posttraumatic stress disorder (PTSD) symptoms among individuals affected by high-mortality epidemics are unclear. This study examined the prevalence of PTSD and related risk factors among populations affected by the Ebola virus disease (EVD) outbreak, and investigated whether peritraumatic distress mediates the impact of exposure level to EVD on PTSD symptoms, and the moderation role of stigmatization.

METHODS

The sample included 1614 participants (50% women) affected by EVD in Democratic Republic of the Congo (DRC). Participants completed the PTSD Check-List for DSM-5, Peritraumatic Distress Inventory, and measures evaluating levels of exposure and stigmatization related to EVD. Descriptive analyses and a moderated mediation model were computed.

RESULTS

A total of 58.81% participants (95% CI: 56.41%; 61.21%) met PTSD diagnostic criteria. Participants living in rural areas presented greater risk, while there is no significant difference between men and women. Peritraumatic distress mediated partially the association between exposure to EVD and PTSD symptoms. Moreover, this relationship was moderated by stigmatization related to EVD.

LIMITATIONS

As the design was cross-sectional, this study could not examine the causality of PTSD symptoms among communities affected by EVD.

CONCLUSIONS

This study shows high prevalence rates and important risk factors associated with PTSD in populations affected by EVD. It indicates elements that could help to develop and implement prevention and intervention programs in affected communities.

[Incidence and predictors of peri-traumatic reactions in an Algerian population faced with COVID-19]

Objectifs

La présente étude a été conçue pour explorer deux questions : (1) l’incidence de la détresse et de la dissociation péri-traumatique dans une population générale algérienne durant les phases initiales de l’épidémie COVID-19 ; (2) les prédicteurs sociodémographiques des réactions péri-traumatiques. L’objectif est de mieux comprendre le vécu péri-traumatique afin d’identifier les personnes vulnérables à qui une prise en charge psychologique pourrait être proposée.

Matériels et méthodes

Une enquête descriptive en ligne contenant trois questionnaires, un questionnaire démographique, le questionnaire de la détresse péri-traumatique et le questionnaire des expériences de dissociation péri-traumatique, a été menée en utilisant la technique d’échantillonnage boule de neige pour sélectionner 1 374 Algériens.

Résultats

Les résultats indiquent que 32,7 % des participants en confinement présentent une détresse péri-traumatique, et 61,8 % des participants présentent un niveau significatif de dissociation péri-traumatique durant les phases initiales de la pandémie COVID-19. Outre le confinement, le stress, le sexe féminin, la provenance d’une Wilaya particulièrement touchée, la situation économique moyenne et les antécédents de problèmes psychologiques prédisent la détresse péri-traumatique.

Conclusion

La COVID-19 a clairement un impact sur la population algérienne et la compréhension et l’évaluation des réactions péri-traumatiques durant les phases initiales sont essentielles pour prévenir le risque de développer un trouble de stress post-traumatique au cours des périodes ultérieures.

Psychological peritraumatic risk factors for post-traumatic stress disorder in children and adolescents: A meta-analytic review

BACKGROUND

Meta-analytic reviews concerning predictors of PTSD in children and adolescents have predominantly identified evidence relating to pre- and post-trauma risk factors; however, there is little evidence regarding peritraumatic risk factors. This paper comprised a systematic review and meta-analysis of studies exploring psychological peritraumatic risk factors for PTSD in youth.

METHODS

Thirty-two studies were identified. Random effects meta-analyses were undertaken, with meta-regressions to explore the moderating role of study characteristics (gender, sex, timing of assessment after trauma, study quality, design and trauma type) on the size of effect of predictive factors.

RESULTS

Peritraumatic subjective threat (k = 28; r = 0.37, 95% CI=0.31-0.42) yielded a medium effect size estimate, while dissociation (k = 5; r = 0.17, 95% CI=0.03-0.29) and data-driven processing (feeling muddled or confused during the trauma) (k = 2; r = 0.29, 95% CI=0.14-0.43) yielded smaller population effect size estimates for the relationship with PTSD symptoms. Perceived life threat yielded a medium sized effect (k = 12; r = 0.37, 95% CI=0.32-0.41). The relationship between subjective threat and PTSD symptoms was moderated by the percentage of female participants. Estimates of heterogeneity were high in studies assessing perceived threat and fear (I² = 95%), but moderate and low within studies assessing dissociation and data-driven processing (I² = 57% and 0%, respectively).

LIMITATIONS

Peritraumatic psychological processes were commonly assessed using single-item measures. Studies primarily concerned single-incident traumas, limiting generalisability.

CONCLUSIONS

Peritraumatic experiences, particularly relating to subjective threat, are important correlates of subsequent PTSD, which implicates timely assessment of these experiences in youth to inform identification of at-risk groups and implementation and design of intervention.

Relationships Between CSA Characteristics, Waiting Time, and Psychotherapy Treatment Response

Child sexual abuse (CSA) can cause negative outcomes on cognitive, emotional, physical, and social development of the victims. A significant amount of symptoms related to CSA can be minimized or even treated with professional interventions. Thereby, it is important to examine factors related to treatment response. This article aimed to identify the relationships between CSA characteristics (abuse form, age, relationship with the offender, context, and frequency), waiting time for psychotherapy, and treatment response. Zero-order correlation analysis and network analysis were performed. The analyses called the attention to two important aspects: victims' perception of guilt and waiting time for treatment. In conclusion, these results show that it is crucial to prioritize the development of guilt-related interventions on the treatment of CSA victims. Additionally, it also demonstrates that the immediate psychological care after the disclosure of the abuse can contribute for impact minimization of this experience on children and adolescents.

Gender Differences in the Prediction of Acute Stress Disorder From Peritraumatic Dissociation and Distress Among Victims of Violent Crimes

Peritraumatic dissociation and distress are strong predictors of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) development. However, there is limited data concerning gender differences in these relations, particularly among victims of violent crimes (VVC). The objective of this study is to examine whether peritraumatic dissociation and distress predict the number of ASD symptoms differently for men and women VVC. In all, 162 adults (97 women, M age = 39.6 years), 63% of whom experienced physical assaults, completed the Acute Stress Disorder Interview, the Peritraumatic Dissociative Experience Questionnaire, and the Peritraumatic Distress Inventory. Analyses included t tests and multiple hierarchical regressions models controlling for known PTSD risk factors. The regression model showed dissociation and distress to be significant predictors of ASD for both men and women (β = .349 and β =.312 respectively; all p < .001). A significant three-way interaction was also observed between peritraumatic distress (PDI), past potentially traumatic experiences, and gender. In simple slopes analyses, the combination of high levels of PDI and of a high number of past potentially traumatic events were associated with greater risk of ASD in men only (b = 3.78, p < .001). However, women experienced greater PDI, t(157) = 5.844, p = .005, than men, and elevated distress was associated with more ASD symptoms independently of past traumatic events. Gender differences were revealed as a function of past potentially traumatic experiences. There is a cumulative impact of past potential traumas and current distress that predicts ASD in men, while in women, it contributes to ASD via increased distress.

Do acute dissociation reactions predict subsequent posttraumatic stress and growth? A prospective experience sampling method study

While peritraumatic dissociation has been identified as a predictor of posttraumatic stress disorder, it may also have some protective aspect. The study uses experience sampling methods to assess acute dissociation reactions during conflict, and to investigate these reactions as predictors of subsequent posttraumatic stress symptoms (PTSS) and posttraumatic growth (PTG). During the 2014 Israel-Gaza conflict, Israeli civilians (n = 96) exposed to rocket fire gave twice-daily experience sampling method (ESM) reports of dissociation symptoms for 30 days via mobile phone. PTSS and PTG were assessed two months later. A mixed effects random intercepts and slopes model estimated acute dissociation reactions. Individual slope coefficients for acute dissociative reactivity were entered as predictors of subsequent PTSS and PTG in regression analyses investigating linear and curvilinear associations. Exposure to sirens elicited acute dissociation reactions. Dissociative reactivity gradually reduced over the conflict. Higher acute dissociative reactivity during conflict predicted PTSS in a curvilinear manner (inverted U) and PTG in a positive linear manner two months later. The current study provides an important and novel contribution to the field by using ESM methods to assess peritraumatic dissociation, and in demonstrating that peritraumatic dissociation may be both adaptive and maladaptive, which has implications for risk assessment and clinical practice.

Trauma-related altered states of consciousness in post-traumatic stress disorder patients with or without comorbid dissociative disorders

Background: The four-dimensional ('4-D') model has been proposed as a theoretical framework to understand and delineate trauma-related dissociative experiences, categorizing symptoms into trauma-related altered states of consciousness (TRASC) and normal waking consciousness (NWC), which occur along four dimensions: time, thought, body and emotion. Objective: The main aim of the present study was to evaluate the validity of this model in patients with post-traumatic stress disorder (PTSD), with and without comorbid dissociative disorders. Method: The predictions of the 4-D model were tested in 142 patients with PTSD, with (N = 46) and without (N = 96) comorbid dissociative disorders. Results: As predicted by the 4-D model, experiences of TRASC were less frequent and more specifically related to other measures of dissociation, dissociative disorder comorbidity and a history of childhood sexual abuse compared to experiences of NWC. The predicted lower intercorrelation of TRASC was not supported. Conclusion: The 4-D model represents a promising framework for understanding dissociation across trauma-related disorders.

Pre-deployment dissociation and personality as risk factors for post-deployment post-traumatic stress disorder in Danish soldiers deployed to Afghanistan

Objective: This study investigated whether pre-deployment dissociation was associated with previously identified post-traumatic stress disorder (PTSD) symptom trajectories from before to 2.5 years after military deployment. Furthermore, it examined whether the tendency to dissociate, pre-deployment personality factors, conceptualized by the Big Five model, and previous trauma represented independent risk factors for post-deployment PTSD symptoms. Method: This prospective study included the entire team of 743 soldiers from the Danish Contingent of the International Security Assistance Force 7 deployed to Afghanistan in 2009. Data consisted of self-report measures and were collected six times: before deployment; during deployment; and 1-3 weeks, 2 months, 7 months and 2.5 years after homecoming. Results: The findings indicate significant associations between pre-deployment dissociation and six PTSD trajectories (p < 0.001, η² = 0.120). Based on mean differences in dissociation for the six trajectories, two main groups emerged: a group with high dissociation scores at pre-deployment, which had moderate PTSD symptom levels at pre-deployment and fluctuated over time; and a group with low dissociation scores at pre-deployment, which had low initial PTSD symptom levels and diverged over time. Our study also confirmed previous findings of a positive association between neuroticism and dissociation (r = 0.31, p < 0.001). This suggests that negative emotionality may be a vulnerability that enhances dissociative experiences, although a causal link cannot be concluded from the findings. Finally, pre-deployment dissociation, pre-deployment neuroticism and a history of traumatic events, as independent factors, were significant predictors of post-deployment PTSD (p < 0.001, R² = 0.158). Conclusions: The study emphasizes the multiplicity of factors involved in the development of PTSD, and group differences in dissociative symptoms support the heterogeneity in PTSD. Further, this study points to specific aspects of personality that may be targeted in a clinical setting and in pre-deployment assessments in the military.

The Impact of Experiential Avoidance and Event Centrality in Trauma-Related Rumination and Posttraumatic Stress

Cognitive control strategies like rumination often increase posttraumatic stress disorder (PTSD) symptoms. However, extant research has provided equivocal results when attempting to explain why this phenomenon occurs. The current study explored several mechanisms that may clarify such findings. For this study, 193 trauma-exposed community members completed measures of PTSD, rumination, experiential avoidance, and event centrality. Elevated reports of rumination were associated with greater PTSD symptomology, experiential avoidance, and event centrality. Results suggest that rumination indirectly influenced PTSD symptom severity through experiential avoidance. This pattern held true regardless of whether a trauma survivor viewed their reported trauma as central or peripheral to their personal identity. These data suggest that the link between ruminating about a traumatic experience and enhanced PTSD symptomology may be partially explained by increasingly restrictive cognitive patterns and enhanced avoidance of aversive internal stimuli. Furthermore, they provide preliminary evidence to suggest that rumination and experiential avoidance are strongly associated with one another (and subsequent PTSD symptomology) among trauma survivors, regardless of how central a traumatic event is to an individual’s personal narrative. Such findings support clinical interventions like exposure, which progressively support new learning in response to feared or unwanted experiences in service of expanding an individual’s cognitive and behavioral repertoires.

The Mediating Role of Integration of Loss in the Relationship Between Dissociation and Prolonged Grief Disorder

OBJECTIVE

Findings from the field of trauma have shown that there is a negative relationship between dissociation and integration of loss into the self-narrative. At the same time, an increasing amount of literature on grief has stressed the importance of an integrated self-narrative in the grieving process. Accordingly, the current study examined the possible mediating role played by the extent to which individuals have integrated their loss into their self-narrative in the relationship between dissociation and symptoms of prolonged grief disorder (PGD).

METHOD

The Prolonged Grief Disorder Scale (PGD-13), the Outcome Questionnaire, the Integration of Stressful Life Experiences Scale, the Dissociative Experiences Scale, and a sociodemographic questionnaire were administered to 66 individuals who had lost a loved one.

RESULTS

The hypothesized mediation model of integration was confirmed.

CONCLUSION

The effect of people's dissociative tendencies on their PGD symptoms seems to occur via the impairment of their ability to integrate the memory of their loss into their general autobiographical memory. Empirical and clinical implications are discussed.

Association of peritraumatic dissociation with symptoms of depression and posttraumatic stress disorder

AIM

In this study, we evaluated whether peritraumatic dissociation (PD) was associated with symptoms of depression and posttraumatic stress disorder (PTSD), and whether this association was modified by trauma prior to police work.

METHOD

Symptoms of depression, PTSD, peritraumatic dissociative experience (PDE), and trauma prior to police work were measured using the Center for Epidemiologic Studies Depression scale, PTSD Checklist-Civilian, PDE questionnaire, and the Brief Trauma questionnaire, respectively, in 328 police officers. Separate regression models were used to assess if either symptoms of depression or PTSD were associated with PD stratified by prior trauma. Means were adjusted for race, number of drinks per week, and smoking.

RESULTS

PD was associated with symptoms of PTSD and depression (β = 0.65, p < .001 and β = 0.27, p < .001, respectively). PD was positively associated with symptoms of PTSD regardless of prior trauma (β = 0.61, p < .001(without prior trauma), 0.75, p < .001 (with prior trauma). In contrast to PTSD, depression symptoms were significantly associated with PD scores in individuals with prior trauma (β = 0.47, p < .001), but not in individuals without prior trauma (β = 0.13, p = .165).

LIMITATIONS

This is a cross-sectional study. Outcomes were obtained via self-report and were not clinically diagnosed. Aspects of both the trauma event as well as the symptoms and severity of PD may have introduced recall bias.

CONCLUSION

These results add to the literature indicating that PD plays a role in symptoms of PTSD and depression and how prior trauma may modify this relationship. (PsycINFO Database Record

Dissociation mediates the association between intimate partner violence and posttraumatic stress among treatment-seeking incarcerated women

OBJECTIVE

Women in prison experience high rates of interpersonal trauma as well as elevated rates of posttraumatic stress disorder (PTSD) relative to women in the general population. The present study examined the relationship between recent intimate partner violence (IPV), additional forms of lifetime trauma exposure, trait dissociation, and posttraumatic stress among a sample of incarcerated female survivors of IPV.

METHOD

Participants were 186 treatment-seeking incarcerated women who reported experiences of IPV in the year prior to incarceration. Participants completed self-report measures of IPV, nonpartner-perpetrated lifetime trauma exposure, trait dissociation, and PTSD symptomatology. Associations among study variables were evaluated using sequential multiple regression.

RESULTS

Participants reported experiencing several forms of interpersonal trauma. More than half of respondents (i.e., 53%) fell beyond a conservative cutoff score on the PTSD Checklist-Civilian Version, indicating clinically significant symptoms of PTSD. Trait dissociation partially mediated the association between IPV and PTSD symptoms above and beyond history of nonpartner-perpetrated violence. Trait dissociation emerged as the strongest independent predictor of PTSD symptoms and explained approximately 15% of the variance in PTSD symptoms.

CONCLUSION

This finding highlights the need for additional research concerning dissociation among women in prison and warrants consideration in future research and intervention efforts focused on trauma recovery among incarcerated women.

Acute stress disorder as a predictor of posttraumatic stress: A longitudinal study of Chinese children exposed to the Lushan earthquake

This study examined the prevalence of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) in children who experienced the Lushan earthquake in Sichuan, China, and assessed the ability of ASD to predict PTSD. The Acute Stress Disorder Scale (ASDS) was used to assess acute stress reaction within weeks of the trauma. The University of California at Los Angeles Post-Traumatic Stress Disorder Reaction Index (UCLA-PTSD) for children was administered at intervals of 2, 6, and 12 months after the earthquake to 197 students who experienced the Lushan earthquake at the Longxing Middle School. The results demonstrated that 28.4% of the children suffered from ASD, but only a small percentage of the population went on to develop PTSD. Among all of the students, 35.0% of those who met the criteria for ASD were diagnosed with PTSD at the 12-month interval. The severity of ASD symptoms correlated with later PTSD symptoms.

Attachment in detachment: The positive role of caregivers in POWs' dissociative hallucinations

Humans are social creatures and therefore exhibit a pervasive need for others. Hence, when benevolent human contact is scarce, this dearth may be compensated imaginatively. War captivity is an extreme example of such deprivation and one wherein dissociative hallucinations have been exhibited. Although hallucinations may serve to virtually summon benevolent others and thus provide the prisoner of war (POW) with a platform for compensation, the contents of such hallucinations have yet to be investigated. The current qualitative study is the first to examine whether the content of such hallucinations may harbor positive effects. Guided by the notion that people search for compensation in lack of companionship, we scrutinized testimonies of former POWs for accounts of hallucinatory experiences. A narrative analysis was utilized in an attempt to understand the meaning of the hallucinations for the POW. Findings reveal that benevolent figures and concomitant acts of care are exhibited in war captivity hallucinatory experiences. Thus, it is argued that the content of such hallucinations may be protective. These findings are discussed in light of the literature concerning peritraumatic dissociative experiences. In addition, attachment theory is suggested as a plausible framework for understanding these findings. Finally, limitations of the study are discussed, and future researched is suggested.

Peritraumatic Distress and Dissociation in Prolonged Grief and Posttraumatic Stress Following Violent and Unexpected Deaths

This study examined associations between the violence of a loss and the suddenness of a loss and symptom levels of prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) after the death of a loved one. A further aim was to investigate whether peritraumatic distress (i.e., fear, helplessness, and horror) and peritraumatic dissociation mediate the emotional impact of violent losses and unexpected losses. We obtained self-reported data from 265 individuals bereaved in the previous 3 years by losses due to violent causes (17%) or illness (83%). Outcomes showed that participants who experienced violent losses (due to homicide, suicide, or accident) reported more PGD symptoms and PTSD symptoms compared to those confronted with illness loss. In this latter group, greater perceived unexpectedness was positively associated with PGD severity and PTSD severity. Multiple mediation analyses showed that the impact of violent loss and unexpectedness of the loss on PGD severity and PTSD severity was fully mediated by peritraumatic distress and dissociation; peritraumatic helplessness and peritraumatic dissociation (but not peritraumatic fear and horror) emerged as unique mediators. Findings suggest that both violent and unexpected losses exacerbate postloss psychopathology, which is at least partially because of such losses yielding more intense acute helplessness and dissociative responses.

Trauma-related dissociation and altered states of consciousness: a call for clinical, treatment, and neuroscience research

The primary aim of this commentary is to describe trauma-related dissociation and altered states of consciousness in the context of a four-dimensional model that has recently been proposed (Frewen & Lanius, 2015). This model categorizes symptoms of trauma-related psychopathology into (1) those that occur within normal waking consciousness and (2) those that are dissociative and are associated with trauma-related altered states of consciousness (TRASC) along four dimensions: (1) time; (2) thought; (3) body; and (4) emotion. Clinical applications and future research directions relevant to each dimension are discussed. Conceptualizing TRASC across the dimensions of time, thought, body, and emotion has transdiagnostic implications for trauma-related disorders described in both the Diagnostic Statistical Manual and the International Classifications of Diseases. The four-dimensional model provides a framework, guided by existing models of dissociation, for future research examining the phenomenological, neurobiological, and physiological underpinnings of trauma-related dissociation.

Posttraumatic stress in intensive care unit survivors - a prospective study

Aims: This study aimed to estimate the prevalence of severe Posttraumatic Stress Disorder (PTSD) symptoms and to identify factors associated with PTSD in survivors of intensive care unit (ICU) treatment following traumatic injury. Methods: Fifty-two patients who were admitted to an ICU through the emergency ward following traumatic injury were prospectively followed. Information on injury severity and ICU treatment were obtained through medical records. Demographic information and measures of acute stress symptoms, experienced social support, coping style, sense of coherence (SOC) and locus of control were assessed within one-month post-accident (T1). At the six months follow-up (T2), PTSD was assessed with the Harvard Trauma Questionnaire (HTQ). Results: In the six months follow-up, 10 respondents (19.2%) had HTQ total scores reaching a level suggestive of PTSD (N = 52), and 11 respondents (21%) had symptom levels indicating subclinical PTSD. Female, five illness factors: coma time, mechanical ventilation, sedation, benzodiazepine, pain relieving medication, and four psychological factors: symptoms of acute stress (T1), fear of death and/or feeling completely helpless and powerless in relation to the accident and/or ICU (T1), SOC (T1) and more external locus of control (T1) correlated significantly with PTSD symptoms at T2. In the linear regression analysis, female, length of sedation, dissociation (T1), hypervigilance (T1), and external locus of control predicted 58% of the variation of PTSD. Conclusions: High levels of PTSD symptoms occurred in 19.2% of respondents in six months following traumatic injury requiring ICU admission. Screening for the variables gender, length of sedation, dissociation, hypervigilance, and locus of control after ICU admission following traumatic injuries may help to predict who will develop PTSD.

Acute peritraumatic dissociation: in favor of a phenomenological inquiry

Fundamental aspects of trauma--among them dissociation during trauma, which is considered one of the strongest predictors of posttraumatic stress disorder-are not fully understood. This article argues that the application of the phenomenological structure of time and the phenomenological description of the self (minimal self, sense of ownership, sense of agency, sense of self) to dissociation during trauma can improve our understanding of this phenomenon-at its occurrence and during any possible ensuing symptoms. In addition, it is argued that the phenomenological approach, as a method that focuses on the bodily level of experience, in particular the body as it is experienced from within, enables us to penetrate the traumatic experience. Thus, by applying the phenomenological approach we may be able to improve our understanding of the traumatic experience and enable the development of better treatment.

Alterations of consciousness in psychogenic nonepileptic seizures: emotion, emotion regulation and dissociation

Impairment of consciousness and reduced self-control are key features of most psychogenic nonepileptic seizures (PNESs), although, compared with patients with epilepsy, those with PNESs demonstrate greater conscious awareness during their seizures. The neurobiological underpinnings of PNESs and of alterations of awareness associated with PNESs remain relatively unknown. We suggest that an understanding of conscious experiences and discrepancies between subjective impairment of consciousness and the lack of objectifiable neurobiological changes in PNESs may benefit from an examination of emotion processing, including understanding sensory, situational, and emotional triggers of PNESs; emotional and physiological changes during the attacks; and styles of emotional reactivity and regulatory capacity. We also suggest that in addition to the typical comparisons between patients with PNESs and those with epilepsy, studies of PNESs would benefit from the inclusion of comparison groups such as those with PTSD, dissociation, and other forms of psychopathology where dissociative and emotion regulatory mechanisms have been explored more fully. We conclude that current evidence and theory suggest that impairment of consciousness in PNESs is only "dissociative" in one subgroup of these seizures, when consciousness is suppressed as a collateral effect of the excessive inhibition of emotion processing. We propose that PNES behaviors and experiences of reduced control or awareness may also represent direct behavioral manifestation of overwhelming emotions, or that minor emotional fluctuations or relatively neutral stimuli may trigger PNESs through conditioning or other preconscious processes. Future studies exploring the neurobiological mechanisms underpinning PNESs are likely to be more fruitful if researchers bear in mind that it is unlikely that all PNESs result from the same processes in the brain.

Psychological distress after physical injury: a one-year follow-up study of conscious hospitalised patients

BACKGROUND

Acute physical injury may lead to psychological distress. The relationship between peritraumatic responses, injury severity, the personality trait of optimism/pessimism and psychological distress is not fully understood. In addition, the development of post-traumatic stress symptoms may differ in subgroups.

METHODS

One hundred and eighty-one patients (18-65 years) completed questionnaires 1 (baseline), 3 and 12 months after first admission for acute physical injury. All patients were conscious on arrival. Scores on the Casualty Chain Inventory (CCI) for peritraumatic responses, the Impact of Event Scale (IES), the Hospital Anxiety and Depression Scale (HADS), the Life Orientation Test-Revised (LOT-R), trauma-related variables (ISS, Abbreviated Injury Scale [AIS], Glasgow Coma Scale [GCS]), and background variables were assessed.

RESULTS

Mean IES scores were 21.5 (95% CI: 19.0-24.0) at baseline and 15.8 (13.5-18.1) at 12 months (p<0.001). One subgroup (delayed onset, 12.2%) had an increase of at least 10 points in the IES score and another subgroup (chronic, 13.3%) had high and persistent post-traumatic stress symptoms during the follow-up period. At baseline, 45.3% had an IES score ≥ 20, indicating possible clinical case levels, compared with 33.1% at 12 months. Accordingly, 14% had anxiety symptoms and 10.8% had depression symptoms at a case level (HADS ≥ 8) at one-year follow-up. Mutually independent predictors of post-traumatic stress symptoms at 12 months were dissociation (OR 1.3, 95% CI: 1.1-1.6) and perception (OR 1.1, 95% CI: 1.0-1.3) measured by the CCI. Being in work before injury (OR 0.1, 95% CI: 0.02-0.4) and higher educational level (OR 0.3, 95% CI: 0.1-0.7) were associated with fewer IES symptoms. Dissociation and having a pessimistic trait predicted anxiety and depression at 12 months. Previous psychiatric problems predicted anxiety symptoms, and high educational level predicted less depression symptoms.

CONCLUSION

One-third of conscious physical injured patients had post-traumatic stress symptoms at a possible clinical case level one year after the traumatic event, and one-third of these had delayed onset. Symptoms of peritraumatic dissociation and perception were mutually independent predictors of psychological distress.

Gray matter volume alterations related to trait dissociation in PTSD and traumatized controls

OBJECTIVE

This study used voxel-based morphometry (VBM) to investigate brain structural alterations related to trait dissociation and its relationship with post-traumatic stress disorder (PTSD).

METHOD

Thirty-two subjects either developing (N = 15) or non-developing (N = 17) PTSD underwent MRI scanning and were assessed with the Dissociative Experience Scale (DES), subscales for pathological (DES-T) and non-pathological trait (DES-A) dissociation, and other clinical measures. Gray matter volume (GMV) was analyzed using VBM as implemented in SPM. PTSD and non-PTSD subjects were compared to assess brain alterations related to PTSD pathology, whereas correlation analyses between dissociation measures and GMV were performed on the whole sample (N = 32), irrespective of PTSD diagnosis, to identify alterations related to trait dissociation.

RESULTS

As compared to traumatized controls, PTSD subjects showed reduced GMV in the prefrontal cortex, hippocampus and lingual gyrus. Correlations with dissociation measures (DES, DES-T, and DES-A) consistently showed increased GMV in the medial and lateral prefrontal, orbitofrontal, parahippocampal, temporal polar, and inferior parietal cortices.

CONCLUSION

PTSD and dissociation seem to be associated with opposite volumetric patterns in the prefrontal cortex. Trait dissociation appears to involve increased GMV in prefrontal, paralimbic, and parietal cortices, with negligible differences between pathological and non-pathological dissociation.

Risk factors for posttraumatic stress disorder in persons with spinal cord injury

PURPOSE

Many of the events that cause spinal cord injury (SCI) are traumatic events that can result in posttraumatic stress disorder (PTSD). It therefore appears that most persons with SCI are at risk for developing PTSD. This study retrospectively examined risk factors for PTSD symptoms in a sample of 71 persons with SCI.

METHOD

The Structured Clinical Interview for DSM-IV was used to assess full and partial PTSD diagnoses. Self-administered questionnaires were used to measure potential risk factors.

RESULTS

Results indicated that 11% of the participants met the criteria for full PTSD, and an additional 20% met the criteria for partial PTSD at some point after their SCI. Hierarchical linear regression analyses revealed that trauma history, peritraumatic reactions, and intolerance of uncertainty predicted the number of PTSD symptoms.

CONCLUSION

This study highlights the importance of trauma history, peritraumatic reactions, and intolerance of uncertainty in the development of PTSD symptoms. Patients at risk for PTSD should be identified early in the rehabilitation process and could benefit from psychological interventions with the aim of preventing PTSD development.

Current status on behavioral and biological markers of PTSD: a search for clarity in a conflicting literature

Extensive research has identified stereotypic behavioral and biological abnormalities in post-traumatic stress disorder (PTSD), such as heightened autonomic activity, an exaggerated startle response, reduced basal cortisol levels and cognitive impairments. We have reviewed primary research in this area, noting that factors involved in the susceptibility and expression of PTSD symptoms are more complex and heterogeneous than is commonly stated, with extensive findings which are inconsistent with the stereotypic behavioral and biological profile of the PTSD patient. A thorough assessment of the literature indicates that interactions among myriad susceptibility factors, including social support, early life stress, sex, age, peri- and post-traumatic dissociation, cognitive appraisal of trauma, neuroendocrine abnormalities and gene polymorphisms, in conjunction with the inconsistent expression of the disorder across studies, confounds attempts to characterize PTSD as a monolithic disorder. Overall, our assessment of the literature addresses the great challenge in developing a behavioral and biomarker-based diagnosis of PTSD.

Depersonalization/derealization during acute social stress in social phobia

The present study aimed at investigating how frequently and intensely depersonalization/derealization symptoms occur during a stressful performance situation in social phobia patients vs. healthy controls, as well as testing hypotheses about the psychological predictors and consequences of such symptoms. N=54 patients with social phobia and N=34 control participants without mental disorders were examined prior to, during, and after a standardized social performance situation (Trier Social Stress Test, TSST). An adapted version of the Cambridge Depersonalization Scale was applied along with measures of social anxiety, depression, personality, participants' subjective appraisal, safety behaviours, and post-event processing. Depersonalization symptoms were more frequent in social phobia patients (92%) than in controls (52%). Specifically in patients, they were highly positively correlated with safety behaviours and post-event-processing, even after controlling for social anxiety. The role of depersonalization/derealization in the maintenance of social anxiety should be more thoroughly recognized and explored.

Dissociation in posttraumatic stress disorder: evidence from the world mental health surveys

BACKGROUND

Although the proposal for a dissociative subtype of posttraumatic stress disorder (PTSD) in DSM-5 is supported by considerable clinical and neurobiological evidence, this evidence comes mostly from referred samples in Western countries. Cross-national population epidemiologic surveys were analyzed to evaluate generalizability of the subtype in more diverse samples.

METHODS

Interviews were administered to 25,018 respondents in 16 countries in the World Health Organization World Mental Health Surveys. The Composite International Diagnostic Interview was used to assess 12-month DSM-IV PTSD and other common DSM-IV disorders. Items from a checklist of past-month nonspecific psychological distress were used to assess dissociative symptoms of depersonalization and derealization. Differences between PTSD with and without these dissociative symptoms were examined across a variety of domains, including index trauma characteristics, prior trauma history, childhood adversity, sociodemographic characteristics, psychiatric comorbidity, functional impairment, and treatment seeking.

RESULTS

Dissociative symptoms were present in 14.4% of respondents with 12-month DSM-IV/Composite International Diagnostic Interview PTSD and did not differ between high and low/middle income countries. Symptoms of dissociation in PTSD were associated with high counts of re-experiencing symptoms and net of these symptom counts with male sex, childhood onset of PTSD, high exposure to prior (to the onset of PTSD) traumatic events and childhood adversities, prior histories of separation anxiety disorder and specific phobia, severe role impairment, and suicidality.

CONCLUSION

These results provide community epidemiologic data documenting the value of the dissociative subtype in distinguishing a meaningful proportion of severe and impairing cases of PTSD that have distinct correlates across a diverse set of countries.

The expectancy of threat and peritraumatic dissociation

BACKGROUND

Peritraumatic dissociation is one of the most critical acute responses to a traumatic experience, partly because it predicts subsequent posttraumatic stress disorder. Despite this, there is little understanding about the factors that influence peritraumatic dissociation. This study investigated the extent to which peritraumatic dissociation is predicted by the amount of perceived warning that participants had of the impact of the trauma.

METHOD

Randomized eligible admissions to four major trauma hospitals (N=243) were assessed during hospital admission with the Peritraumatic Dissociation Experiences Questionnaire (PDEQ) and the perceived warning that participants had before the trauma impact occurred.

RESULTS

Whereas female gender predicted both Awareness and Derealization subscale scores on the PDEQ, perceived warning also predicted scores on the Derealization subscale.

CONCLUSIONS

This finding suggests that the degree of anticipated threat may contribute to peritraumatic dissociation.

The psychological reactions after witnessing a killing in public in a Danish high school

BACKGROUND

School killings attract immense media and public attention but psychological studies surrounding these events are rare.

OBJECTIVE

To examine the prevalence of posttraumatic stress disorder (PTSD) and possible risk factors of PTSD in 320 Danish high school students (mean age 18 years) 7 months after witnessing a young man killing his former girlfriend in front of a large audience.

METHOD

The students answered the Harvard Trauma Questionnaire (HTQ), the Crisis Support Scale (CSS), and the Trauma Symptom Checklist (TSC).

RESULTS

Prevalence of PTSD 7 months after the incident was 9.5%. Furthermore, 25% had PTSD at a subclinical level. Intimacy with the deceased girl; feeling fear, helplessness, or horror during the killing; lack of expressive ability; feeling let down by others; negative affectivity; and dissociation predicted 78% of the variance of the HTQ total scores.

CONCLUSION

It is possible to identify students who are most likely to suffer from PTSD. This knowledge could be used to intervene early on to reduce adversities.

A Preliminary Evaluation of Repeated Exposure for Depersonalization and Derealization

Dissociative symptoms including depersonalization and derealization are commonly experienced by individuals suffering from panic disorder or posttraumatic stress disorder (PTSD). Few studies have been published investigating the specific treatment of these symptoms in individuals diagnosed with panic disorder or PTSD, despite evidence that the subset of individuals with panic disorder who experience depersonalization and derealization report more panic attacks as well as greater panic severity and functional impairment. Furthermore, it has been shown that these symptoms can impede treatment and recovery in PTSD. Finally, recent research has shown that interoceptive exposure generally enhances the efficacy of treatment outcome for PTSD and PTSD with comorbid panic. This study investigated the use of a novel interoceptive exposure technique for treatment of depersonalization and derealization in individuals with high anxiety sensitivity and/or symptoms of PTSD. Results indicated significant reductions on six of seven items as well as total score on an outcome measure of depersonalization and derealization. Thus, this technique appears to hold promise for utilization as a form of interoceptive exposure in the treatment of these symptoms.

The impact of dissociation on PTSD treatment with cognitive processing therapy

BACKGROUND

This secondary analysis of data from a randomized controlled trial of cognitive processing therapy (CPT) and its constituent components investigated whether dissociation decreased over the course of treatment primarily targeting symptoms of posttraumatic stress disorder (PTSD) and explored whether levels of dissociation predicted treatment outcome differentially by treatment condition.

METHODS

An intention to treat sample of 150 women were randomized to CPT, cognitive therapy only (CPT-C) or written trauma accounts only (WA). Dissociation was measured by the dissociation subscale of the Traumatic Stress Inventory and the Multiscale Dissociation Inventory.

RESULTS

Multilevel regression analyses revealed significant decreases in dissociation that did not vary as a function of treatment condition. Growth curve modeling revealed significant treatment condition by dissociation interactions such that the impact of pretreatment levels of dissociation impacted the treatment conditions differently.

CONCLUSIONS

Women who endorsed low pretreatment levels of dissociation responded most efficiently to CPT-C, whereas women with the highest levels of dissociation, in particular high levels of depersonalization, responded better to CPT.

The dissociative subtype of posttraumatic stress disorder: rationale, clinical and neurobiological evidence, and implications

BACKGROUND

Clinical and neurobiological evidence for a dissociative subtype of posttraumatic stress disorder (PTSD) has recently been documented. A dissociative subtype of PTSD is being considered for inclusion in the forthcoming Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) to address the symptoms of depersonalization and derealization found among a subset of patients with PTSD. This article reviews research related to the dissociative subtype including antecedent, concurrent, and predictive validators as well as the rationale for recommending the dissociative subtype.

METHODS

The relevant literature pertaining to the dissociative subtype of PTSD was reviewed.

RESULTS

Latent class analyses point toward a specific subtype of PTSD consisting of symptoms of depersonalization and derealization in both veteran and civilian samples of PTSD. Compared to individuals with PTSD, those with the dissociative subtype of PTSD also exhibit a different pattern of neurobiological response to symptom provocation as well as a differential response to current cognitive behavioral treatment designed for PTSD.

CONCLUSIONS

We recommend that consideration be given to adding a dissociative subtype of PTSD in the revision of the DSM. This facilitates more accurate analysis of different phenotypes of PTSD, assist in treatment planning that is informed by considering the degree of patients' dissociativity, will improve treatment outcome, and will lead to much-needed research about the prevalence, symptomatology, neurobiology, and treatment of individuals with the dissociative subtype of PTSD.

Pre-Traumatic Vaccination Intervention: Can Dissociative Symptoms be Reduced?

The Pre-Traumatic Vaccination Intervention (PTV) has been developed in an attempt to help rescue personnel cope with anticipated and non-anticipated disasters, and to prevent trauma-related mental disorders during and after a traumatogenic exposure. Contrary to the generally accepted approach of treating trauma after it has occurred, the PTV has been designed to be administered prior to the potentially traumatic event. Based on empirical findings, the PTV training techniques were designed to prepare the participants for distressful situations. Trainees were gradually exposed to increasingly severe sights using cognitive-behavioral techniques along with foreseen situations relating to their profession. Various interventions were aimed at normalizing using personal resources and implementing relaxation techniques. The PTV was administrated as part of the Israeli Defense Forces rescue personnel's and military police training courses. The results of an uncontrolled, preliminary study suggest that the intervention reduced the level of dissociation leading to more awareness to the traumatic event's details, less suffering, lower probability of making mistakes, and increased likelihood of returning to normal functioning. Lower dissociation may suggest a lower probability to be diagnosed with post-traumatic stress disorder among rescue personnel.

Cognitive behavioral hypnotherapy for dissociative disorders

Dissociative disorders (DD) prevail as sequelae to overwhelming experiences in childhood. These readily formed post-traumatic responses and trance states develop in high hypnotizable subjects whose dysregulations become organized into ego states. A cognitive behavioral hypnotherapeutic treatment model will effectively contain, explore, metabolize, and resolve these life-endangering conditions. This article will detail the cognitive hypnotic world of DD patients, the relational spaces of the ego states, and the triphasic treatment mode to successfully resolve the dissociative pathology. Structured and phase appropriate hypnotic interventions will be described.