Relations among peritraumatic dissociation and posttraumatic stress: a critical review

The relationship between tonic immobility and the development, severity, and course of posttraumatic stress disorder: Systematic and meta-analytic literature review

BACKGROUND

Tonic immobility (TI) is a reflexive, involuntary response that causes motor inhibition, vocal suppression, and analgesia. TI is elicited by extreme fear and perception of entrapment in a life-threatening situation. Research suggests that TI is a frequent peritraumatic response and may be related to subsequent posttraumatic stress disorder (PTSD). However, findings are mixed and, as of yet, no systematic or meta-analytic review examining associations between TI and PTSD has been published.

OBJECTIVE

We systematically and meta-analytically reviewed the literature and investigated whether TI is associated with the development, severity, and course of PTSD. Additionally, we evaluated whether different types of traumatic events are differentially associated with TI, and whether TI severity differs according to sex.

METHODS

A systematic literature search was conducted using Embase, PubMed, PsycINFO, and Scopus. Meta-analyses were performed on the included articles.

RESULTS

We identified 27 eligible articles. We found a significant association between TI and PTSD symptom severity (r = 0.39, 95% CI: 0.34-0.44; p < .0001). TI was more severe among females (Cohen's d=0.37, 95% CI: 0.25-0.48; p < .0001) and was more often elicited in situations involving interpersonal violence. We found limited longitudinal data to perform a meta-analysis of the association between TI and the development and/or course of PTSD. However, the literature available seems to support the role of TI in both the development and course of PTSD.

CONCLUSIONS

Peritraumatic TI is associated with PTSD symptom severity, occurs more often during interpersonal violence, and is more severe among females. More longitudinal research is needed to investigate the role of TI in psychopathology development and course.

Experimental induction of peritraumatic dissociation: The role of negative affect and pain and their psychophysiological and neural correlates

While research has elucidated processes underlying dissociative symptoms in patients with posttraumatic stress disorder, little is known about the circumstances under which trauma-related dissociation initially arises. To experimentally investigate causes and concomitants of peritraumatic dissociation, we subjected sixty-nine healthy women to aversive-audiovisual and painful-electrical stimulation in a 2(aversive/neutral film) x 2(pain/no pain) within-subject design while recording psychophysiological and fMRI-BOLD responses. Afterwards, participants rated negative-affect, pain, and dissociation for each condition. Using Bayesian multilevel regression models, we examined (1) whether aversive-audiovisual and painful-electrical stimulation elicit higher dissociation-levels than control conditions and (2) whether stronger negative-affect and pain responses (operationalized via self-report, psychophysiological, and neural markers) correlate with higher dissociation-levels. Several key findings emerged: Both aversive-audiovisual and painful-electrical stimulation elicited dissociation. Dissociation was linked to higher self-reported negative-affect, but we did not find enough evidence linking it to psychophysiological and neural negative-affect markers. However, dissociation was associated with higher levels of self-reported pain, a skin-conductance-response-based pain marker, and the fMRI-BOLD-based Neurologic-Pain-Signature. Results indicate that both aversive-audiovisual and painful stimuli can independently cause dissociation. Critically, pain responses captured via self-report, psychophysiological, and neural markers were consistently linked to higher dissociation-levels suggesting a specific, evolutionary meaningful, contribution of pain to the rise of dissociation.

Dissoziation: ein transdiagnostisches Phänomen

Der Begriff der Dissoziation wurde in frühen Anfängen der Neurosenlehre verwendet, hat sich seither gewandelt und ist Ausgangspunkt vieler Kontroversen. Unter Dissoziation wird i. Allg. die Abspaltung sonst integrierter Gedächtnis‑, Bewusstseins‑, Identitäts- und Wahrnehmungsfunktionen (eigene Person und Umwelt) verstanden. Dissoziation ist ein klinisches Kriterium von Belastungsstörungen und der emotional instabilen Persönlichkeitsstörung; dissoziative Symptome haben sind ebenfalls als Phänomene bei anderen Erkrankungen hochrelevant. Differenzialdiagnostisch ist Schizophrenie bedeutsam. Die Unterscheidung zwischen Dissoziation von Detachment- und Kompartmentalisationstyp sowie die Berücksichtigung möglicher Traumatatypen können die Entwicklung von Krankheitsmodellen unterstützen. Die Behandlung basiert auf akkurater Diagnostik, einschließlich Biografie und Beziehungen. Komplexe Dissoziationslagen erfordern eine komplexe Therapie, weil neben der psychischen Integration weitere psychosoziale Bedarfe zu bedienen sind.

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.

Late fetal demise, a risk factor for post-traumatic stress disorder

Late-term fetal demise including fetal death in utero, late miscarriage and late termination of pregnancy are relatively frequent occurrences. Post-traumatic stress disorder (PTSD) is a pathology that finds its roots in exposure to a life-threatening event or an event related to death. Exposure to fetal death during a late-term fetal demise is, therefore, a situation at risk of trauma. The objective of this study was to assess the prevalence of PTSD symptoms in the short term among patients faced with late fetal demise, and to identify potential risk factors. All women were assessed at 15 days, one month, and three months after late fetal demise using the Impact of Event Scale-Revised (IES-R) and the Peritraumatic Dissociative Experiences Questionnaire (PDEQ). At 15 days, 44.2% of patients presented a pathological score on the IES-R (≥ 33). At one month and three months, this figure was 34.1% and 9.1% respectively. Factor associated with PTSD symptoms were: peritraumatic dissociation (p = 0.014), seeing the fetus during hospitalization (p = 0.035), holding the fetus in one's arms (p = 0.046), and the organization of a funeral service (p = 0.025). Patients experiencing late fetal demise are at significant risk of trauma. Care providers should remain vigilant to identify high-risk situations to offer appropriate care.Clinical trials registration number: NCT03433989.

Beauty and Uncertainty as Transformative Factors: A Free Energy Principle Account of Aesthetic Diagnosis and Intervention in Gestalt Psychotherapy

Drawing from field theory, Gestalt therapy conceives psychological suffering and psychotherapy as two intentional field phenomena, where unprocessed and chaotic experiences seek the opportunity to emerge and be assimilated through the contact between the patient and the therapist (i.e., the intentionality of contacting). This therapeutic approach is based on the therapist’s aesthetic experience of his/her embodied presence in the flow of the healing process because (1) the perception of beauty can provide the therapist with feedback on the assimilation of unprocessed experiences; (2) the therapist’s attentional focus on intrinsic aesthetic diagnostic criteria can facilitate the modification of rigid psychopathological fields by supporting the openness to novel experiences. The aim of the present manuscript is to review recent evidence from psychophysiology, neuroaesthetic research, and neurocomputational models of cognition, such as the free energy principle (FEP), which support the notion of the therapeutic potential of aesthetic sensibility in Gestalt psychotherapy. Drawing from neuroimaging data, psychophysiology and recent neurocognitive accounts of aesthetic perception, we propose a novel interpretation of the sense of beauty as a self-generated reward motivating us to assimilate an ever-greater spectrum of sensory and affective states in our predictive representation of ourselves and the world and supporting the intentionality of contact. Expecting beauty, in the psychotherapeutic encounter, can help therapists tolerate uncertainty avoiding impulsive behaviours and to stay tuned to the process of change.

Stress Management Skills in the Physicians Practice of Primary Care Level

Current approaches to non-specialized help with stress are set out in this article and stress management tools are provided, which are developed by WHO in the stress management handbook “Doing What Matters in Times of Stress: An Illustrated Guide”. This knowledge is especially current in the giving of first aid in emergencies, and in giving psychosocial support to patients as well, by primary care physicians, who must have effective communication skills and mutual understanding, and have experience in supporting people in difficult situations too, as it is specified in numerous WHO recommendations on mental health, in such as : «mhGAP Intervention Guide for mental, neurological and substance use disorders in nonspecialized health settings», «IASC Guidelines for mental health and psychosocial support in emergency settings»,«mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies», «Support for Rehabilitation: Self-Management after COVID-19 Related Illness» and etc. Aim – to give the information for the distant self-learning of the primary care professionals to use the simple stress-management tools in difficult circumstances. Distance learning is built on the basis of the evidence based WHO documents and recommendations about low intensity psychological interventions. The WHO Guide has five sections, where five ideas and techniques for reducing stress are descibed, which are designed as the acquisition of five skills. The authors at the end of each section of the Guide developed algorithms of use the skills of such tools as: «Grounding», «Unhooking», «Acting according to own values», «Showing kindness», «Creating space». The psychosocial support provided by the primary care physician / facilitator / assistant lies in helping people to use guidance and apply strategies in their own lives, and it prevents the professional burnout of healthcare professionals as well. The short information about WHO guide and stress -management methods are described in sufficient details to enhance the awareness level of the primary care personnel about stress-management tools use. As the result of using the Guide will enhance the capacity of local helth care staff and non medical staff to provide the mental health services and psychosocial support during the current COVID-19 pandemic, and readiness for the future emergencies.

The shielding effect of not responding: Peritraumatic responses to child abuse and their links to posttraumatic symptomatology

BACKGROUND

Extensive literature focuses on peritraumatic responses to trauma and their link to subsequent posttraumatic symptomatology. However, although posttraumatic symptomatology following child abuse (CA) has been documented, research on peritraumatic responses to CA is sparse.

OBJECTIVE

The current study utilizes a new typology of peritraumatic responses to CA and tests whether automatic and behavioral peritraumatic responses to CA differ in their long-term implications for posttraumatic symptomatology, i.e., posttraumatic stress (PTS symptoms), deficiency in self-organization (DSO symptoms; complex posttraumatic symptoms), and dissociation.

PARTICIPANTS, SETTINGS AND METHODS

One-hundred and eighty adult CA survivors reported on CA, peritraumatic responses, PTS symptoms, DSO symptoms, and dissociation.

RESULTS

The tendency to freeze and dissociate, and utilize extensive behavioral methods to survive the abuse were implicated in higher posttraumatic symptomatology (F(2,178) > 4.26, p < 0.01). The absence of automatic and behavioral responses were found to be implicated in the lowest levels of posttraumatic symptomatology (p < 0.01) and to buffer the effect of CA severity on PTS and DSO posttraumatic symptoms (0.047 > effect>0.029, p < 0.001).

CONCLUSIONS

The findings uncovered a novel response pattern, reflected in a tendency to eradicate responses to CA, which was the most protective in regard to its link to later posttraumatic symptomatology. Contrarily, the most scarring peritraumatic responses to CA that arose from the findings were the tendency to freeze and dissociate and utilize various excessive behavioral methods to endure the abuse. These findings imply that CA generates several possible responses, some of which, although allowing for survival in childhood, have adverse effects in adulthood.

Peritraumatic dissociation revisited: associations with autonomic activation, facial movements, staring, and intrusion formation

BACKGROUND

Peritraumatic dissociation is purported to emerge together with attenuated autonomic arousal, immobility, and staring. However, empirical evidence is scarce and heterogeneous. Moreover, it is still a matter of debate whether these responses predict intrusion formation.

OBJECTIVE

The present trauma-analogue study examined associations between peritraumatic dissociation, autonomic activation, facial movements, staring, and intrusion formation.

METHOD

Seventy-one healthy women watched a highly aversive film, while autonomic activation (heart rate, respiratory sinus arrhythmia, skin conductance level), facial movements (temporal variations in corrugator electromyography), and staring (fixation duration, tracklength) were assessed. Afterwards, participants rated the intensity of dissociation during film viewing and reported intrusions and associated distress in a smartphone application for 24 hours.

RESULTS

Peritraumatic dissociation was linked to higher autonomic arousal (higher heart rate and, on a trend-level, lower respiratory sinus arrhythmia), increased facial movements, and staring (lower tracklength). Peritraumatic dissociation, higher autonomic arousal (higher heart rate and lower respiratory sinus arrhythmia), staring (higher fixation duration), and, on a trend-level, more facial movements were linked to higher intrusion load (number x distress of intrusions) and together explained 59% of variance. Skin conductance level was neither linked to peritraumatic dissociation nor intrusion load.

CONCLUSIONS

Our results suggest that, at low-dissociation-levels observed in trauma-analogue studies, peritraumatic dissociation may occur together with heightened autonomic arousal and facial movements, indexing increased negative affect. Staring might, irrespectively of dissociation-levels, serve as objective marker for dissociation. Together, peritraumatic dissociation and its psychophysiological correlates might set the stage for later intrusion formation.

Dissociative symptoms predict risk for the development of PTSD: Results from the National Health and Resilience in Veterans Study (NHRVS)

Dissociative symptoms following trauma exposure, such as derealization (i.e., feeling that one's experience is strange and unreal) and depersonalization (i.e., feeling detached from oneself) have been implicated in the development and maintenance of posttraumatic stress disorder (PTSD). In the current study, we analyzed data from a 3-year prospective cohort study of a nationally representative sample of U.S. veterans to examine whether trait dissociative symptoms, which may impair adaptive emotion regulation following trauma exposure, predict risk for the development of PTSD in trauma-exposed veterans. Results revealed that derealization symptoms predicted a nearly 5-fold increase in relative risk of incident PTSD (relative risk ratio = 4.57, 95% confidence interval = 1.55-13.52), even after adjusting for relevant sociodemographic and trauma-related factors, and severity of PTSD symptoms at baseline. To our knowledge, this study is the first to suggest that trait dissociative symptoms-specifically derealization-may be an important population-based risk factor for the development of PTSD in trauma-exposed U.S. military veterans. These findings add to a body of literature on the prediction of PTSD that largely focuses on stable or immutable risk factors such as sociodemographic and trauma characteristics, or peritraumatic emotional reactions, and underscores the potential clinical utility of assessing, monitoring, and treating derealization symptoms in trauma-exposed U.S. military veterans at risk for PTSD.

Dissociation and disasters: A systematic review

BACKGROUND

Dissociation, which is defined as the failure to associate consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior into an integrated whole, has long been assumed to be generated by trauma. If dissociation is a product of trauma exposure, then dissociation would be a major mental health outcome observed in studies of disaster survivors. Although some studies have examined dissociation in disasters, no systematic literature reviews have been conducted to date on the topic.

AIM

To systematically evaluate the literature on the association between disaster and dissociation to determine the prevalence and incidence of dissociation after exposure to disaster and further examine their relationship.

METHODS

EMBASE, Medline, and PsychINFO were searched from inception to January 1, 2019 to identify studies examining dissociative disorders or symptoms related to a disaster in adult or child disaster survivors and disaster responders. Studies of military conflicts and war, articles not in English, and those with samples of 30 or more participants were excluded. Search terms used were “disaster*” and dissociation (“dissociat*,” “multiple personality,” “fugue,” “psychogenic amnesia,” “derealization,” and “depersonalization”). Reference lists of identified articles were scrutinized to identify studies for additional articles.

RESULTS

The final number of articles in the review was 53, including 36 articles with samples of adults aged 18 and above, 5 of children/adolescents under age 18, and 12 of disaster workers. Included articles studied several types of disasters that occurred between 1989 and 2017, more than one-third (38%) from the United States. Only two studies had a primary aim to investigate dissociation in relation to disaster and none reported data on dissociative disorders. All of the studies used self-report symptom scales; none used structured interviews providing full diagnostic assessment of dissociative disorders or other psychopathology. Several studies mixed exposed and unexposed samples or did not differentiate outcomes between exposure groups. Studies examining associations between dissociation and disaster exposure have been inconclusive. The majority (75%) of the studies compared dissociation with posttraumatic stress, with inconsistent findings. Dissociation was found to be associated with a wide range of other psychiatric disorders, symptoms, and negative emotional, cognitive, and functional states.

CONCLUSION

The studies reviewed had serious methodological limitations including problems with measurement of psychopathology, sampling, and generation of unwarranted conclusions, precluding conclusions that dissociation is an established outcome of disaster.

A study of dissociation in survivors of 5 disasters

This study examined dissociation as an outcome to disaster in dissociative data collected from 423 highly-exposed survivors of 5 different disasters using consistent methodology. Ten items selected for conceptual relevance to disaster experience were administered from the Dissociative Disorders Interview Schedule, a structured interview for lifetime dissociative disorders. Structured psychiatric interviews provided data on incident somatization symptoms, disaster-related PTSD, and lifetime predisaster psychopathology. The Temperament and Character Inventory assessed personality. Observed levels of dissociation were low and not usually postdisaster. Dissociation level was associated with female sex, number of incident somatization symptoms, personality (underdeveloped executive functioning), PTSD, and predisaster psychopathology in bivariate analyses. In multiple linear regression models, dissociation was associated with the low number of incident somatoform symptoms observed independent of the effects of PTSD, hyperarousal specifically (but not intrusion or avoidance/numbing), personality, predisaster psychopathology, and demographic variables which were not independently associated with dissociation. The low levels of dissociation found in this study and the lack of association between dissociation and indicators of psychopathology point to a largely nonpathological nature of the dissociative phenomena measured. These findings do not indicate the development of dissociative psychopathology as a prevalent mental health outcome of disasters.

The effects of trauma on brain and body: A unifying role for the midbrain periaqueductal gray

Post-traumatic stress disorder (PTSD), a diagnosis that may follow the experience of trauma, has multiple symptomatic phenotypes. Generally, individuals with PTSD display symptoms of hyperarousal and of hyperemotionality in the presence of fearful stimuli. A subset of individuals with PTSD; however, elicit dissociative symptomatology (i.e., depersonalization, derealization) in the wake of a perceived threat. This pattern of response characterizes the dissociative subtype of the disorder, which is often associated with emotional numbing and hypoarousal. Both symptomatic phenotypes exhibit attentional threat biases, where threat stimuli are processed preferentially leading to a hypervigilant state that is thought to promote defensive behaviors during threat processing. Accordingly, PTSD and its dissociative subtype are thought to differ in their proclivity to elicit active (i.e., fight, flight) versus passive (i.e., tonic immobility, emotional shutdown) defensive responses, which are characterized by the increased and the decreased expression of the sympathetic nervous system, respectively. Moreover, active and passive defenses are accompanied by primarily endocannabinoid- and opioid-mediated analgesics, respectively. Through critical review of the literature, we apply the defense cascade model to better understand the pathological presentation of defensive responses in PTSD with a focus on the functioning of lower-level midbrain and extended brainstem systems.

Trauma Memory Processing in Posttraumatic Stress Disorder Psychotherapy: A Unifying Framework

Trauma memory processing (TMP) is an empirically supported approach to psychotherapy for posttraumatic stress disorder (PTSD). However, TMP is not a single, uniform intervention but instead a paradigm that can be operationalized through a variety of component procedures that have not been systematically elucidated and formally tested. Based on findings from phenomenological/structural and neuroimaging research, a central feature of PTSD is theorized to be the involuntary immersion in trauma memories with diminished awareness or negative appraisals of self and current context. Such intrusive reexperiencing-which is epitomized by, but not limited to, flashbacks-is postulated to underlie PTSD's avoidance, altered emotions and cognitions, dissociative, and hyperarousal/hypervigilance symptoms; it is thus a logical target for TMP. The varied approaches to TMP for PTSD are conceptualized as having the common goal of activation of the neural networks in the brain that underlie two key capacities disrupted by intrusive reexperiencing in PTSD: intentional self-referential retrieval of memories and suppression of memory retrieval. Therefore, TMP is postulated to involve two core functions (purposeful reflective remembering and memory awareness in situ) and three essential types (in vivo, imaginal, and cognitive reappraisal). Several implications of this framework for clinical practice and research on TMP for PTSD are discussed.

What was once essential, may become detrimental: The mediating role of depersonalization in the relationship between childhood emotional maltreatment and psychological distress in adults

Depersonalization (DP) is a dissociative phenomenon, characterized by feeling "unreal" or detached from one's own emotions, thoughts, and behavior (APA, 2013). It is considered to be a defense mechanism, employed in response to overwhelming events, whereby thoughts and emotions are suppressed in order to enhance the individual's capacity to function in traumatic environments. DP has been found to co-occur with anxiety and depressive disorders, and childhood emotional maltreatment (EM) has been identified as an important predisposing factor. The study's primary aim was to investigate the mediating role of DP in the relationship between childhood EM and psychological distress in young adults. Additionally, it aimed to confirm that a history of childhood EM (emotional abuse and emotional neglect) predicted current levels of DP and to explore how both a person's attitude towards experiencing and expressing emotions (with an emphasis on the affect phobia model) and their current attachment security are related to current DP. A cross-sectional design was employed, which included young adults (N = 761) aged between 18 and 25 years. Participants completed an online survey that comprised of several self-report measures. Regression and mediation analyses were conducted. The results indicated that: (1) DP significantly mediated the relationship between childhood EM and current psychological distress; (2) that a history of EM, but no other forms of childhood abuse, significantly predicted current DP experiences; and (3) EM, attachment-related anxiety, and negative attitudes toward emotions predicted clinical cutoff levels of DP. The results are discussed in detail, including clinical implications and direction for future research.

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.

Current Understanding of the Neural Mechanisms of Dissociation in Borderline Personality Disorder

Purpose of Review

In this article, we aim to give an overview over recent neuroimaging research on dissociation in borderline personality disorder (BPD). Stress-related dissociation is highly prevalent in BPD, while so far only little is known about its neural underpinnings.

Recent Findings

Based on research in depersonalization and the dissociative subtype of posttraumatic stress disorder, it has been proposed that dissociation involves alterations in a cortico-limbic network. In BPD, neuroimaging research explicitly focusing on dissociation is still scarce.

Summary

Functional neuroimaging studies have provided preliminary evidence for an altered recruitment and interplay of fronto-limbic regions (amygdala, anterior cingulate, inferior frontal gyrus, medial and dorsolateral prefrontal cortices) and temporoparietal areas (superior temporal gyrus, inferior parietal lobule, fusiform gyrus), which may underlie disrupted affective-cognitive processing during dissociation in BPD. More neuroimaging research with larger samples, clinical control groups, and repeated measurements is needed to deepen the understanding of dissociation in BPD.

Screaming Body and Silent Healthcare Providers: A Case Study with a Childhood Sexual Abuse Survivor

Stressful early life experiences cause immune dysregulation across the lifespan. Despite the fact that studies have identified childhood sexual abuse (CSA) survivors as a particularly vulnerable group, only a few attempts have been made to study their lived-experience of the physical health consequences of CSA. The aim of this study was to explore a female CSA survivor’s lived-experience of the physical health consequences of CSA and how she experienced the reactions of healthcare providers. Seven interviews were conducted with this 40-year-old woman, Anne, using a phenomenological research approach. Anne was still a young child (two to three years old) when her father started to rape her. Since her childhood, she has experienced complex and widespread physical health consequences such as repeated vaginal and abdominal infections, widespread and chronic pain, sleeping problems, digestive problems, chronic back problems, fibromyalgia, musculoskeletal problems, repeated urinary tract infections, cervical dysplasia, inflammation of the Fallopian tubes, menorrhagia, endometrial hyperplasia, chlamydia, ovarian cysts, ectopic pregnancies, uterus problems, severe adhesions, and ovarian cancer. Anne disclosed her CSA experience to several healthcare providers but they were silent and failed to provide trauma-informed care. Anne’s situation, albeit unique, might reflect similar problems in other female CSA survivors.

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.

Parallel-Distinct Structures of Internal World and External Reality: Disavowing and Re-Claiming the Self-Identity in the Aftermath of Trauma-Generated Dissociation

The nature of consciousness and the autonomy of the individual's mind have been a focus of interest throughout the past century and inspired many theories and models. Revival of studies on psychological trauma and dissociation, which remained outside mainstream psychiatry, psychology, and psychoanalysis for the most part of the past century, has provided a new opportunity to revisit this intellectual and scientific endeavor. This paper attempts to integrate a series of empirical and theoretical studies on psychological consequences of developmental traumatization, which may yield further insight into factors which threaten the integrity of human consciousness. The paper proposes that an individual's experience of distorted reality and betrayal precipitates a cyclical dynamic between the individual and the external world by disrupting the developmental function of mutuality which is essential for maintenance of the integrity of the internal world while this inner world is in turn regulated vis-à-vis external reality. Dissociation -the common factor in all types of post-traumatic syndromes- is facilitated by violation of boundaries by relational omission and intrusion as represented by distinct effects and consequences of childhood neglect and abuse. Recent research conducted on clinical and non-clinical populations shows both bimodal (undermodulation and overmodulation) and bipolar (intrusion and avoidance) neurobiological and phenomenological characteristics of post-traumatic response. These seem to reflect "parallel-distinct structures" that control separate networks covering sensori-motor and cognitive-emotional systems. This understanding provides a conceptual framework to assist explanation of diverse post-traumatic mental trajectories which culminate in a common final pathway comprised of partly overlapping clinical syndromes such as complex PTSD, dissociative depression, dissociative identity disorder (DID), or "borderline" phenomena. Of crucial theoretical and clinical importance is that these maladaptive post-traumatic psychological formations are regarded as processes in their own right rather than as a personality disorder innate to the individual. Such mental division may perform in that internal detachment can serve to preserve the genuine aspects of the subject until such time as they can be reclaimed via psychotherapy. The paper attempts to integrate these ideas with reference to the previously proposed theory of the "Functional Dissociation of Self" (Şar and Öztürk, 2007).

Dissociation and Alterations in Brain Function and Structure: Implications for Borderline Personality Disorder

Dissociation involves disruptions of usually integrated functions of consciousness, perception, memory, identity, and affect (e.g., depersonalization, derealization, numbing, amnesia, and analgesia). While the precise neurobiological underpinnings of dissociation remain elusive, neuroimaging studies in disorders, characterized by high dissociation (e.g., depersonalization/derealization disorder (DDD), dissociative identity disorder (DID), dissociative subtype of posttraumatic stress disorder (D-PTSD)), have provided valuable insight into brain alterations possibly underlying dissociation. Neuroimaging studies in borderline personality disorder (BPD), investigating links between altered brain function/structure and dissociation, are still relatively rare. In this article, we provide an overview of neurobiological models of dissociation, primarily based on research in DDD, DID, and D-PTSD. Based on this background, we review recent neuroimaging studies on associations between dissociation and altered brain function and structure in BPD. These studies are discussed in the context of earlier findings regarding methodological differences and limitations and concerning possible implications for future research and the clinical setting.

Biological and psychological predictors of posttraumatic stress disorder onset and chronicity. A one-year prospective study

BACKGROUND

Few studies have prospectively examined risk factors for posttraumatic stress disorder (PTSD) in the aftermath of a traumatic exposure. The aim of this study is to identify the concurrent influence of psychological and biological diatheses on PTSD onset and maintenance, taking into account socio-demographic factors and psychiatric antecedents.

METHODS

A total of 123 civilians (61.8% of women) recruited in emergency units, were assessed using validated instruments during the first week and then at 1, 4, and 12 months post-trauma. Baseline assessment included evaluation of the psychological diathesis (i.e. psychiatric history and peritraumatic distress and dissociation), and the biological diathesis [i.e. cortisol, norepinephrine, epinephrine, c-reactive protein, total cholesterol, HDL cholesterol, glycosylated haemoglobin, waist-to-hip ratio (WHR), body mass index, diastolic and systolic blood pressure (SBP), and heart rate].

RESULTS

Multivariate logistic regression analyses demonstrated both psychological and biological diatheses to be independent risk factors for PTSD. Peritraumatic distress and dissociation predicted onset (1-month) and mid-term PTSD (4-months), respectively. PTSD risk was associated positively with SBP and negatively with WHR, throughout the follow-up. In addition, a higher level of 12 h-overnight urinary norepinephrine independently predicted mid-term PTSD (4-months).

CONCLUSIONS

This prospective study shows that peritraumatic psychological and biological markers are independent predictors of PTSD onset with specificities according to the stage of PTSD development; the psychological diathesis, i.e. peritraumatic distress and dissociation, being a better predictor of short-term dysfunction whereas biological diathesis was also predictive of development and maintenance of PTSD.

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.

Trauma-Related Altered States of Consciousness (TRASC) and Functional Impairment I: Prospective Study in Acutely Traumatized Persons

A theoretical framework referred to as a 4-D model has been described for classifying posttraumatic stress symptoms into those potentially occurring within normal waking consciousness (NWC) versus those thought to intrinsically exemplify dissociative experiences, specifically, trauma-related altered states of consciousness (TRASC). As a further test of this theoretical distinction, this prospective study evaluated whether TRASC and NWC forms of distress incrementally and prospectively predicted functional impairment at 6 and 12 weeks following presentation at hospital emergency departments in the acute aftermath of traumatic events in 180 persons. Establishing the clinical significance of both TRASC and NWC-distress symptoms, we found that 6-week markers of TRASC and NWC-distress independently predicted 12-week self-reported levels of social and occupational impairment. We also observed broad support for various predictions of the 4-D model except that, in contrast with hypotheses, childhood trauma history was generally more strongly correlated with symptoms of NWC-distress than with TRASC. Future research directions are discussed.

The co-occurrence of PTSD and dissociation: differentiating severe PTSD from dissociative-PTSD

PURPOSE

A dissociative-posttraumatic stress disorder (PTSD) subtype has been included in the DSM-5. However, it is not yet clear whether certain socio-demographic characteristics or psychological/clinical constructs such as comorbid psychopathology differentiate between severe PTSD and dissociative-PTSD. The current study investigated the existence of a dissociative-PTSD subtype and explored whether a number of trauma and clinical covariates could differentiate between severe PTSD alone and dissociative-PTSD.

METHODS

The current study utilized a sample of 432 treatment seeking Canadian military veterans. Participants were assessed with the Clinician Administered PTSD Scale (CAPS) and self-report measures of traumatic life events, depression, and anxiety. CAPS severity scores were created reflecting the sum of the frequency and intensity items from each of the 17 PTSD and 3 dissociation items. The CAPS severity scores were used as indicators in a latent profile analysis (LPA) to investigate the existence of a dissociative-PTSD subtype. Subsequently, several covariates were added to the model to explore differences between severe PTSD alone and dissociative-PTSD.

RESULTS

The LPA identified five classes: one of which constituted a severe PTSD group (30.5 %), and one of which constituted a dissociative-PTSD group (13.7 %). None of the included, demographic, trauma, or clinical covariates were significantly predictive of membership in the dissociative-PTSD group compared to the severe PTSD group.

CONCLUSIONS

In conclusion, a significant proportion of individuals report high levels of dissociation alongside their PTSD, which constitutes a dissociative-PTSD subtype. Further investigation is needed to identify which factors may increase or decrease the likelihood of membership in a dissociative-PTSD subtype group compared to a severe PTSD only group.

The DSM-5 dissociative-PTSD subtype: can levels of depression, anxiety, hostility, and sleeping difficulties differentiate between dissociative-PTSD and PTSD in rape and sexual assault victims?

The DSM-5 currently includes a dissociative-PTSD subtype within its nomenclature. Several studies have confirmed the dissociative-PTSD subtype in both American Veteran and American civilian samples. Studies have begun to assess specific factors which differentiate between dissociative vs. non-dissociative PTSD. The current study takes a novel approach to investigating the presence of a dissociative-PTSD subtype in its use of European victims of sexual assault and rape (N=351). Utilizing Latent Profile Analyses, we hypothesized that a discrete group of individuals would represent a dissociative-PTSD subtype. We additionally hypothesized that levels of depression, anger, hostility, and sleeping difficulties would differentiate dissociative-PTSD from a similarly severe form of PTSD in the absence of dissociation. Results concluded that there were four discrete groups termed baseline, moderate PTSD, high PTSD, and dissociative-PTSD. The dissociative-PTSD group encompassed 13.1% of the sample and evidenced significantly higher mean scores on measures of depression, anxiety, hostility, and sleeping difficulties. Implications are discussed in relation to both treatment planning and the newly published DSM-5.

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.

Periloss dissociation, symptom severity, and treatment response in complicated grief

BACKGROUND

Complicated grief (CG) is a bereavement-specific syndrome characterized by traumatic and separation distress lasting over 6 months. Little is known about the role of dissociation experienced during or immediately after the loss of a loved one (i.e., periloss dissociation [PLD]) in CG. The present study aimed to examine the psychometric properties of the PLD-adapted Peritraumatic Dissociative Experiences Questionnaire and its association with symptom severity, treatment response, and drop-out rate.

METHODS

PLD data collected as part of a randomized controlled trial of two loss-focused psychotherapy approaches for CG were examined. Treatment-seeking individuals with primary CG (n = 193) were assessed for PLD at the initial visit, 95 of whom were randomized and completed at least one treatment session.

RESULTS

The PLD-adapted Peritraumatic Dissociative Experiences Questionnaire was found to be internally consistent (α = 0.91) with good convergent and divergent validity. After controlling for age, gender, time since loss, and current comorbid psychiatric diagnosis, self-reported PLD was associated with greater CG symptom severity (P < .01). However, contrary to our hypotheses, after controlling for age, baseline symptoms severity, psychiatric comorbidity, and treatment arm, PLD was predictive of better treatment response (P < .05) and lower study discontinuation (P < .01).

CONCLUSIONS

PLD may be useful in identifying individuals at risk for CG and those who might respond to psychotherapy. Additional research should investigate the relationship of PLD with treatment outcome for different treatment approaches, and whether PLD prospectively predicts the development of CG.

Psychological responses after a major, fatal earthquake: the effect of peritraumatic dissociation and posttraumatic stress symptoms on anxiety and depression

Following trauma, most people with initial symptoms of stress recover, but it is important to identify those at risk for continuing difficulties so resources are allocated appropriately. There has been limited investigation of predictors of posttraumatic stress disorder following natural disasters. This study assessed psychological difficulties experienced in 101 adult treatment seekers following exposure to a significant earthquake. Peritraumatic dissociation, posttraumatic stress symptoms, anxiety, depression, and emotional support were assessed. Path analysis was used to determine whether the experience of some psychological difficulties predicted the experience of other difficulties. As hypothesized, peritraumatic dissociation was found to predict posttraumatic stress symptoms and anxiety. Posttraumatic stress symptoms then predicted anxiety and depression. Depression and anxiety were highly correlated. Contrary to expectations, emotional support was not significantly related to other psychological variables. These findings justify the provision of psychological support following a natural disaster and suggest the benefit of assessing peritraumatic dissociation and posttraumatic stress symptoms soon after the event to identify people in need of monitoring and intervention.

Peritraumatic and persistent dissociation as predictors of PTSD symptoms in a female cohort

Recent research has investigated peritraumatic and persistent dissociation as a possible predictive factor for posttraumatic stress disorder (PTSD). The current study aimed to add to this literature by examining dissociative responses in female assault survivors (N = 92 at initial assessment; n = 62 at follow-up). Dissociative symptoms experienced at 3 time points were assessed: peritraumatic dissociation (PD), persistent dissociation-initial (M = 28.2 days posttrauma) and follow-up (M = 224.9 days posttrauma), as well as initial and follow-up PTSD symptoms. We hypothesized that PD and persistent dissociative symptoms would predict chronic PTSD symptoms at the follow-up assessment with initial PTSD symptoms and assault type in the model. Hierarchical regression resulted in a significant model predicting 39% of the variance in follow-up PTSD symptom scores (p < .001). Both peritraumatic and follow-up persistent dissociative symptoms significantly and uniquely added to the variance explained in follow-up PTSD symptom score contributing 4% (p = .05) and 8% (p = .008) of the variance, respectively. Results support the predictive value of peritraumatic and persistent dissociative symptoms, and the findings suggest that persistent dissociation may contribute to the development and continuation of PTSD symptoms. We discuss the implications for assessment and possible treatment of PTSD as well as future directions.

Posttraumatic stress symptoms after exposure to two fire disasters: comparative study

This study investigated traumatic stress symptoms in severely burned survivors of two fire disasters and two comparison groups of patients with "non-disaster" burn injuries, as well as risk factors associated with acute and chronic stress symptoms. Patients were admitted to one out of eight burn centers in The Netherlands or Belgium. The Impact of Event Scale (IES) was administered to 61 and 33 survivors respectively of two fire disasters and 54 and 57 patients with "non-disaster" burn etiologies at 2 weeks, 3, 6, 12 and 24 months after the event. We used latent growth modeling (LGM) analyses to investigate the stress trajectories and predictors in the two disaster and two comparison groups. The results showed that initial traumatic stress reactions in disaster survivors with severe burns are more intense and prolonged during several months relative to survivors of "non-disaster" burn injuries. Excluding the industrial fire group, all participants' symptoms on average decreased over the two year period. Burn severity, peritraumatic anxiety and dissociation predicted the long-term negative outcomes only in the industrial fire group. In conclusion, fire disaster survivors appear to experience higher levels of traumatic stress symptoms on the short term, but the long-term outcome appears dependent on factors different from the first response. Likely, the younger age, and several beneficial post-disaster factors such as psychosocial aftercare and social support, along with swift judicial procedures, contributed to the positive outcome in one disaster cohort.

Dissociation in sexually abused Puerto Rican children: a replication utilizing social workers as informers

This study explores dissociative symptoms in 3 different groups of Puerto Rican children. Data were collected on 40 children with documented sexual abuse history, 39 children with psychiatric disorders but without a history of sexual abuse, and 40 community control children. Dissociative symptoms were assessed with the child using the Trauma Symptom Checklist for Children (TSCC); a social worker answered the Child Dissociative Checklist (CDC). Results indicated that children with sexual abuse obtained significantly different scores on both the TSCC and the CDC. Further analysis indicated that child and social worker reports of dissociative symptoms were highly correlated (r = .73). Furthermore, 30% of the children in the sexual abuse group scored at or above the cutoff point of 12 on the CDC, which is indicative of a dissociative disorder. None of the children in the other 2 groups obtained such a score. The results suggest that children with documented sexual abuse victimization demonstrate a significant number of dissociative phenomena that not only are subjectively experienced but also can be observed by a non-family member. Finally, as nearly a third of the abused children obtained a score of 12 or higher on the CDC, the next step is to prepare clinicians to conduct a proper and formal diagnosis assessment of dissociative disorders.

Prior peritraumatic dissociative experiences affect autonomic reactivity during trauma recall

To better understand the psychophysiological correlates of peritraumatic dissociation (PD), the present study examined the relationship between reports of prior PD and sympathetic and parasympathetic functioning in response to a laboratory stress paradigm in 39 traumatized female undergraduates. Participants were asked to talk about their most distressing traumatizing experience while continuous measures of heart rate, pre-ejection period, and respiratory sinus arrhythmia were taken. Overall, high dissociators had significantly larger increases in heart rate and larger decreases in pre-ejection period and respiratory sinus arrhythmia during trauma recall. In opposition to our hypothesis, these results suggest that female trauma victims reporting high levels of PD during a prior trauma may be more reactive to traumatic reminders than victims who report lower levels of PD.

Recalled peritraumatic reactions, self-reported PTSD, and the impact of malingering and fantasy proneness in victims of interpersonal violence who have applied for state compensation

The present study explores the associations between three types of peritraumatic reactions (dissociation, distress, and tonic immobility) and posttraumatic stress disorder (PTSD) symptoms in a sample of 125 victims of interpersonal violence who had applied for compensation with the Dutch Victim Compensation Fund (DCVF). In addition, the confounding roles of malingering and fantasy proneness are examined. Results indicate that tonic immobility did not predict PTSD symptom levels when adjusting for other forms of peritraumatic reactions, whereas peritraumatic dissociation and distress did. However, after the effects of malingering and fantasy proneness had been controlled for, malingering is the only factor associated with increased PTSD symptomatology. Implications for policy practice as well as study strengths and limitations are discussed.

An examination of structural dissociation of the personality and the implications for cognitive behavioural therapy

The aim of this review was to ascertain whether an examination of the theory of structural dissociation of the personality (TSDP) and its treatment may lead to recommendations in the treatment of dissociative identity disorder (DID) and other trauma-related disorders utilizing CBT. An analysis of the neurobiology of trauma will aid this process. The literature review considers a variety of literature on TSDP. Several themes were identified which suggested that dissociation refers to a structural dividedness of the personality and that there is a psychobiological pathway for all trauma-related disorders. Additionally the role of bottom-up vs. top-down processing was explored. Recommendations for the treatment of trauma-related disorders using CBT have been made.

Dissociation in trauma: a new definition and comparison with previous formulations

Amid controversy regarding the psychobiological construct of dissociation, efforts to formulate a precise definition of dissociation are rare. Some understandings of dissociation are so broad that a host of common psychobiological phenomena would qualify as dissociative. Overly narrow conceptualizations of dissociation exclude phenomena that originally, and for good reasons, have been regarded as dissociative. A common lack of conceptual distinctions between dissociation as process, organization, deficit, psychological defense, and symptom adds to the current confusion. In previous publications, we criticized many of these perspectives and proposed a detailed psychobiological theory of dissociation in trauma. However, what has remained missing is a precise definition of dissociation in trauma. This article first presents such a definition and elucidates its various components. Next the new definition is compared with several other major definitions of the concept. The strengths of the new formulation are highlighted and discussed.

Validation of the Peritraumatic Dissociative Experiences Questionnaire and Peritraumatic Distress Inventory in school-aged victims of road traffic accidents

BACKGROUND

Although the reliable and valid Peritraumatic Distress Inventory (PDI-C) and Peritraumatic Dissociative Experiences Questionnaire (PDEQ) are useful for identifying adults at risk of developing acute and chronic posttraumatic stress disorder (PTSD), they have not been validated in school-aged children and their predictive values remain unknown in this population. This study aims to assess the psychometric properties of the children versions of these two measures (PDI-C and PDEQ-C) in a sample of French-speaking school-children.

METHODS

One-hundred and thirty-three consecutive victims of road traffic accidents, aged 8-15 years, were recruited into this longitudinal study via the emergency room. The peritraumatic reactions were assessed at baseline and PTSD symptoms were assessed 1 month later.

RESULTS

Cronbach's alpha coefficients were 0.8 and 0.77 for the PDI-C and PDEQ-C, respectively. The 1-month test-retest correlation coefficient (n=33) was 0.77 for both measures. The PDI-C demonstrated a two-factor structure while the PDEQ-C displayed a one-factor structure. As with adults, the two measures were intercorrelated (r=0.52) and correlated with subsequent PTSD symptoms and diagnosis (r=0.21-0.56; P<0.05).

CONCLUSIONS

The children versions of the PDI and PDEQ are reliable and valid in children.