The dissociative post-traumatic stress disorder (PTSD) subtype: A treatment outcome cohort study in veterans with PTSD

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

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

Efficacy of traumatic memory reactivation with or without propranolol in PTSD with high dissociative experiences

Background: Post-traumatic stress disorder (PTSD) with dissociative symptoms is now a full-fledged subtype of this disorder. The dissociative subtype is associated with a greater number of psychiatric comorbidities. To date, the impact of dissociation on the efficacy of PTSD treatment remains unclear.Objective: The aim of this study was to compare the efficacy of a traumatic memory reactivation procedure with the administration of propranolol or a placebo once a week for six consecutive weeks in reducing PTSD and MDE symptoms between PTSD subjects with or without high dissociative symptoms.Method: For that, we conducted a randomized clinical trial in 66 adults diagnosed with longstanding PTSD and measured the SCID PTSD module, the PTSD Checklist (PCL-S), Beck's Depression Inventory-II (BDI-II), and the Dissociative Experiences Scale (DES).Results: Patients with and without high dissociative experience had significant improvement in their PCL-S scores over the 6 treatment sessions, and PCL-S scores continued to decline in all patients during the post-treatment period. However, there was no correlation between the presence/absence of high dissociative experiences and no specific effect of propranolol treatment. We found exactly the same results for MDE symptoms. Interestingly, patients with high dissociative experiences before treatment exhibited very significant improvement in their DES scores after the 6 treatment sessions, and patients maintained this improvement 3 months post-treatment.Conclusions: The traumatic memory reactivation procedure is an effective way to treat dissociative symptoms in patients with PTSD, and improvement of these dissociative symptoms was associated with a decrease in both PTSD and depression severity.

Associations among betrayal trauma, dissociative posttraumatic stress symptoms, and substance use among women involved in the criminal legal system in three US cities

BACKGROUND

Betrayal trauma, as defined by (Freyd, 1996), refers to a subcategory of trauma characterized by a significant violation of trust surrounding interpersonal maltreatment (physical, sexual, or emotional). Previous research has shown that people with betrayal trauma histories experience greater dissociative symptoms of posttraumatic stress disorder and co-morbid substance use disorder symptoms. Women in the criminal legal system commonly have significant histories of betrayal trauma and related posttraumatic stress symptoms and substance use. However, no studies have specifically explored the impact of dissociative posttraumatic stress symptoms on substance use outcomes in this population. Additionally, no studies have explored whether betrayal trauma relates to nonfatal overdoses.

METHODS

This cross-sectional survey study of N = 508 women with criminal legal system involvement examined the indirect effects of betrayal trauma history on substance use outcomes through dissociative posttraumatic stress symptoms.

RESULTS

Multivariate analyses supported an indirect effect of betrayal trauma on substance use severity, daily substance use, and history of overdose, but not alcohol use severity, through dissociative symptoms.

CONCLUSIONS

Women in the criminal legal system with betrayal trauma and dissociative symptoms may be at risk for substance use and related outcomes (i.e., overdose). Future work is needed to examine whether targeting such symptoms may improve substance use treatment and prevention of serious outcomes in this population.

Somatoform Dissociative Symptoms Have No Impact on the Outcome of Trauma-Focused Treatment for Severe PTSD

For patients with complex or other severe forms of PTSD, particularly in cases with dissociative symptoms, different treatment approaches have been suggested. However, the influence of somatoform dissociation on the effectiveness of trauma-focused treatment has hardly ever been studied. This study aims to test the hypotheses that (1) PTSD patients reporting a low level and those reporting a high level of somatoform dissociative symptoms would both benefit from an intensive trauma-focused treatment, and that (2) somatoform dissociative symptoms would alleviate. Participants were 220 patients with severe PTSD, enrolled in an intensive treatment program combining EMDR therapy and prolonged exposure therapy, without a preceding stabilization phase. Trauma history was diversified, and comorbidity was high. PTSD symptoms (CAPS-5 and PCL-5) and somatoform dissociative symptoms (SDQ-5 and SDQ-20) were assessed at pre-treatment, post-treatment and at six months after completion of treatment. The course of both PTSD and somatoform dissociative symptoms was compared for individuals reporting low and for those reporting high levels of somatoform dissociative symptoms. Large effect sizes were observed regarding PTSD symptoms reduction for patients with both low and high levels of somatoform dissociation. Somatoform dissociation did not impact improvement in terms of PTSD symptom reduction. The severity of somatoform dissociative symptoms decreased significantly in both groups. This decrease was greater for those with a positive screen for a dissociative disorder. These results add further support to the notion that the presence of strong somatoform dissociative symptoms in patients with PTSD does not necessarily call for a different treatment approach. Clinical implications are discussed.

Impact of dissociation on the effectiveness of psychotherapy for post-traumatic stress disorder: meta-analysis

BACKGROUND

Many patients with post-traumatic stress disorder (PTSD) experience dissociative symptoms. The question of whether these dissociative symptoms negatively influence the effectiveness of psychotherapy for PTSD is unresolved.

AIMS

To determine the influence of dissociative symptoms on psychotherapy outcome in PTSD.

METHOD

We conducted a systematic search in Cochrane, Embase, PILOTS, PsycINFO, PubMed and Web of Science for relevant clinical trials. A random-effects meta-analysis examined the impact of dissociation on psychotherapy outcome in PTSD (pre-registered at Prospero CRD42018086575).

RESULTS

Twenty-one trials (of which nine were randomised controlled trials) with 1714 patients were included. Pre-treatment dissociation was not related to treatment effectiveness in patients with PTSD (Pearson's correlation coefficient 0.04, 95% CI -0.04 to 0.13). Between-study heterogeneity was high but was not explained by moderators such as trauma focus of the psychotherapy or risk of bias score. There was no indication for publication bias.

CONCLUSIONS

We found no evidence that dissociation moderates the effectiveness of psychotherapy for PTSD. The quality of some of the included studies was relatively low, emphasising the need for high-quality clinical trials in patients with PTSD. The results suggest that pre-treatment dissociation does not determine psychotherapy outcome in PTSD.

Factor structure models of the SCL-90-R: Replicability across community samples of adolescents

Derogatis' Symptom Checklist-90-Revised (SCL-90-R) is one of the most widely used measures of psychological distress in both the clinical and the research settings, although its factor structure is still debated. In this study, the factor structure of the SCL-90-R has been investigated in two independent samples of Italian adolescents. Two samples of 817 (urban sample) and 507 (rural sample) adolescents attending high schools were involved. Confirmatory factorial analysis (CFA) was used alongside hierarchical nested, progressively constrained models to assess configural, metric and scalar invariance of the best models fitted by CFA. The standard nine-factor structure of the SCL-90-R resulted reproducible and invariant between the two samples, in both its correlated and hierarchical second-order implementations. Estimated reliability of the nine scales of the SCL-90-R was optimal. This study also confirmed the reproducibility of the bifactor models of the SCL-90-R with nine orthogonally independent factors and with nine correlated primary factors, which have been tested in some recent studies. Overall, the SCL-90-R measures both common and unique features of psychological distress in community samples. The measurement invariance across different levels of psychological distress in the factor structure of the SCL-90-R is an issue deserving further testing and investigation.

Prevalence and clinical correlates of dissociative subtype of posttraumatic stress disorder at an outpatient trauma clinic in South Korea

Background: Previous studies on of the dissociative subtype of posttraumatic stress disorder (d-PTSD) have relied on specialized statistical methods (i.e. profile or class analyses) for diagnosis than clinical rating available to clinicians. Objective: This study investigated the prevalence and covariates of d-PTSD diagnosed by a semi-structured interview in a cohort of outpatients with DSM-IV PTSD in a specialized trauma clinic in South Korea. Method: Data from 249 patients with civilian PTSD were examined, including demographics, clinical variables, Clinical Global Impression (CGI) Scale, and Clinician-Administered PTSD Scale (CAPS-IV). We defined d-PTSD as the presence of either depersonalization or derealization according to additional dissociative items of the CAPS. About one third (n = 82, 32.9%) of patients were designated as having d-PTSD. Results: Compared to the other patients with PTSD, those with d-PTSD were younger, had more severe PTSD symptoms, frequent interpersonal trauma, and a higher number of comorbid disorders. When these variables and their interactions were entered into a logistic regression model, younger age, severe PTSD symptoms and two or more comorbid conditions remained for the final model. We did not find a significant difference in improvement over the course of treatment between two groups. Conclusions: This study highlights the high prevalence of d-PTSD in a clinical population. Associated features of d-PTSD were similar to those reported in the Euro-American literature. Further studies are needed to better understand mechanisms and treatment options for d-PTSD.

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.