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Teicher MH, Andersen SL, Polcari A, Anderson CM, Navalta CP. (2002)
Department of Psychiatry, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA. email:
Developmental neurobiology of childhood stress and trauma.   
Psychiatr Clin North Am. 2002 Jun;25(2):397-426, vii-viii.

ABSTRACT Severe early stress and maltreatment produces a cascade of events that have the potential to alter brain development. The first stage of the cascade involves the stress-induced programming of the glucocorticoid, noradrenergic, and vasopressin-oxytocin stress response systems to augment stress responses. These neurohumors then produce effects on neurogenesis, synaptic overproduction and pruning, and myelination during specific sensitive periods. Major consequences include reduced size of the mid-portions of the corpus callosum; attenuated development of the left neocortex, hippocampus, and amygdala along with abnormal frontotemporal electrical activity; and reduced functional activity of the cerebellar vermis. These alterations, in turn, provide the neurobiological framework through which early abuse increases the risk of developing post-traumatic stress disorder (PTSD), depression, symptoms of attention-deficit/hyperactivity, borderline personality disorder, dissociative identity disorder, and substance abuse.

Terr Lenore C. (2003)
"Wild Child": How Three Principles of Healing Organized 12 Years of Psychotherapy   
Journal of the American Academy of Child & Adolescent Psychiatry 2003; 42(12):1401-1409

ABSTRACT Methods of conducting psychotherapy in the most severe forms of childhood posttraumatic stress disorder (PTSD), especially in those traumas discovered very early in life, are rarely reported. This paper presents such a report and in the process emphasizes three elements of treatment: abreaction (full emotional expression of the traumatic experience), context (understanding and gaining perspective on the experience), and correction (finding ways personally or through society to prevent or repair such experiences). With traumatized children, all three elements may be inserted into their therapeutic play, art, and/or talk. An overarching mood of light humor helps the transference stay positive and the child interested. The case of "Cammie," an infant who was bitten, shaken, and sexually abused, and whose 25-day-old sister was discovered at home, murdered, is the subject of this report. This little girl, upon removal at 13 months of age from her home of origin, growled, bit, sniffed sexual organs, rarely spoke, and behaved like the "feral children" described in the classic psychiatric literature. Two respected professionals diagnosed her as mentally retarded. A year in an outstanding foster home did little to improve her. At 29 months of age she was brought to the author, who saw enough imagination and pithy language to believe the child to be intelligent but severely traumatized. The author had begun to conceptualize three principles of PTSD treatment after a study of normal schoolchildren's reactions to the 1986 Challenger disaster. These three principles were used with varying emphases at different phases throughout the "wild child's" 12-year course of once-monthly therapy. Improvement beyond anyone's expectations ensued.

Thomas, Ann. (2001)
Factitious and malingered dissociative identity disorder: clinical features observed in 18 cases  
Journal of Trauma and Dissociation (ISSN: 1529-9732), v. 2, no. 4, pp. 59-77 (2001).

ABSTRACT This paper compares the clinical features of 18 persons given a diagnosis of factitious or malingered Dissociative Identity Disorder with those of 18 matched persons who were given a diagnosis of genuine Dissociative Identity Disorder, taken from a sample of 129 second opinion consultations. Clinical features suggesting a factitious diagnosis or malingering included having a score above 60 on the Dissociative Experiences Scale (DES), reporting dissociative symptoms inconsistent with the reporting on the DES, being able to tell a chronological life story and to sequence temporal events, using the first person over a range of affect, being able to express strong negative affect, bringing "proof" of a dissociative diagnosis to the consultation, having told persons other than close confidants about the alleged abuse or alleged dissociative diagnosis, reporting alleged abuse that was inconsistent with the medical or psychiatric history or volunteering allegations of cult or ritualized abuse, telling of alleged abuse without accompanying shame, guilt, or suffering, having been involved in community self-help groups, not having symptoms of co-morbid PTSD, and having obvious secondary gain in having a dissociative diagnosis. Given the potential legal ramifications of making a false positive diagnosis of Dissociative Identity Disorder and recognizing that the treatment for persons with valid dissociative psychopathology differs from the treatment of factitious illness, it is prudent to be able to separate the two groups.

Timmerman IG , Emmelkamp PM. (2001)
Forensic Psychiatric Clinic Veldzicht, P.O. Box 20, 7707 ZG Balkbrug, The Netherlands.
The relationship between traumatic experiences, dissociation, and borderline personality pathology among male forensic patients and prisoners.  
J Personal Disord 2001 Apr;15(2):136-

ABSTRACT In the present study the relationship between traumatic experiences, dissociation, and borderline personality disorder pathology is examined in a group of 39 male forensic patients and 192 male prisoners. Sexual and emotional abuse are significantly more common among forensic patients than among prisoners. Patients also report a broader range of different kinds of traumas. Prisoners report significantly more dissociative symptoms. Analyses of the relationship of type of trauma on the one hand and dissociation and borderline personality pathology on the other show that sexual abuse is significantly associated with borderline personality pathology but not with dissociation among the patients. In the prison sample these associations are found only for familial but not extrafamilial sexual abuse. When the subjects are grouped on account of presence or absence of a borderline personality disorder, highly significant differences on dissociation are found between both groups. The results from this study lend support to the hypothesis that sexual abuse is not related to dissociative symptoms but merely to borderline personality pathology. Because most subjects in this study are not patients, these findings are not likely to be confounded by false memories of traumatic events that are recovered by psychotherapy. Furthermore, dissociative symptoms are found to be related to borderline personality pathology and not to the experience of traumatic events.
Peter M. Thomas (2005)
Dissociation and Internal models of Protection: Psychotherapy with child abuse survivors
Psychotherapy: Theory, Research, Practice, Training Spring 2005 Vol. 42, No. 1, 20-36

ABSTRACTThis article presents strategies for treating child abuse survivors based on a theory of interpersonal protection that integrates research in attachment, developmental psychopathology, trauma, dissociation, and experiential psychotherapy. The theory proposes that abused children do not form internal working models of an effective protector, with the result that they have difficulty defending themselves against interpersonal aggression and internal self-criticism; thus, a core psychotherapy task is to help survivors develop adequate representations of protection. The article provides case examples and describes interventions targeting the client-therapist relationship, other client relationships, client self-criticism, and traumatic memories. The author discusses dissociation as an intervention marker; client verbal and nonverbal feedback to therapist interventions; subselves and internal roles; the "inner critic"; guided imagery, role-plays, and dramatic enactment methods; and directions for future research.

Svenn Torgersen; Sissel Lygren; Per Anders Řien; Ingunn Skre; Sidsel Onstad; Jack Edvardsen; Kristian Tambs; Einar Kringlen (2000)
A twin study of personality disorders  
Comprehensive Psychiatry November/December 2000 • Volume 41 • Number 6

ABSTRACT No twin study has previously investigated the whole range of personality disorders (PDs) recorded by interviews. Based on twin and patient registries, 92 monozygotic (MZ) and 129 dizygotic (DZ) twin pairs were interviewed with the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Observed prevalence rates from a normal population study of more than 2,000 individuals were used in combination with data from the present study to generate statistics assumed to be valid for a normal twin population, and these statistics were used for structural equation modeling. The best-fitting models had a heritability of .60 for PDs generally, .37 for the eccentric (A) cluster, .60 for the emotional (B) cluster, and .62 for the fearful (C) cluster. Among the specific PDs, the heritability appeared to be .79 for narcissistic, .78 for obsessive-compulsive, .69 for borderline, .67 for histrionic, .61 for schizotypal, .57 for dependent, .54 for self-defeating, .29 for schizoid, .28 for paranoid, and .28 for avoidant PDs. The best-fitting models never included shared-in-families environmental effects. However, a model with only shared familial and unique environmental effects could not be ruled out for dependent PD. Shared familial environmental effects may also influence the development of any PD and borderline PD. Passive-aggressive PD did not seem to be affected by genes or family environment at all. The low occurrence of antisocial PD in the twin sample precluded any model for this disorder. PDs seem to be more strongly influenced by genetic effects than almost any axis I disorder, and more than most broad personality dimensions. However, we observed a large variation in heritability among the different PDs, probably partly because of a moderate sample size and low prevalence of the specific disorders.

Troisi, A. et al (2000)
Affect regulation in alexithymia: an ethological study of displacement behavior during psychiatric interviews   
Journal of Nervous and Mental Disease Vol. 188 (2000), no. 1 (jan), pag. 13-18.

ABSTRACT Displacement activities (i.e., self-directed behaviors such as self-touching, scratching, and self-grooming) are a reliable ethological indicator of increased emotional and physiological arousal throughout the phylogenetic scale. We hypothesized that, in alexithymic individuals, the failure to regulate cognitively distressing emotions might result in increased displacement behavior. The nonverbal behavior of 30 patients with depressive or anxiety disorders was video-recorded during psychiatric interviews and analyzed using an ethological scoring system. Before being interviewed, each patient completed the Twenty-Item Toronto Alexithymia Scale (TAS-20), the Beck Depression Inventory (BDI), and the state form of the State-Trait Anxiety Index (STAI-S). Ethological data confirmed the hypothesis of the study. The patients with more pronounced alexithymic features showed a significantly higher frequency of displacement activities during interviews. At the same time, these patients reported levels of self-rated anxiety and depression equivalent to those reported by nonalexithymic patients. Such a dissociation between cognitive appraisal of emotion and nonverbal behavior reflecting increased emotional arousal supports the view that alexithymia implies a failure to elevate emotions from a preconceptual level of organization to the conceptual level of mental representations

Tsai, Guochuan E. , Condie, Donald; Wu, Ming-Ting; Chang, I-Wen (1999)
Laboratory of Molecular and Psychiatric Neuroscience, Mailman Research Center, McLean Hospital, Belmont, MA 02478, USA.
Functional magnetic resonance imaging of personality switches in a woman with dissociative identity disorder.   
Harvard Review of Psychiatry. Vol 7(2), Jul-Aug 1999, 119-122.

ABSTRACT I Investigated the neuronal substrate involved in the personality switches of dissociative identity disorder (DID) by conducting an functional magnetic resonance imaging (MRI) of a 47-yr-old with DID while she was switching personalities. It was found that bilateral reduction of hippocampal volume in this S with comorbid posttraumatic stress disorder (PTSD) and DID, consistent with the reported reduction of hippocampal volume in patients with PTSD secondary to childhood trauma. In addition functional MRI during volitionally induced personality switch showed changes in hippocampal and medial temporal activity correlated with the switch, suggesting that personality switch may result from changes in hippocampal and temporal function.

Tutkun H, Savas HA, Zoroglu SS, Esgi K, Herken H, Tiryaki N. (2004)
Relationship between alexithymia, dissociation and anxiety in psychiatric outpatients from Turkey.  
Isr J Psychiatry Relat Sci. 2004;41(2):118-24.

ABSTRACT Several studies have examined the relationship between dissociation and alexithymia. In this study, the objective was to investigate whether there was a relationship between alexithymia, dissociation and state and trait anxiety in psychiatric outpatients. The evaluations of psychiatric outpatients (n=154) were based on the Toronto Alexithymia Scale, the Dissociative Experiences Scale and the State and Trait Anxiety Index. The data were analyzed using chi2 test and multiple covariance analyses. Subjects with alexithymia (46.8%) were significantly less educated and showed higher state and trait anxiety. The mean Toronto Alexithymia Scale total score of the female and male patients was similar. The mean Dissociative Experiences Scale score of the study group was 10.8 (sd=9.8, ranged 0 to 45). A multivariate analysis of covariance showed that state and trait anxiety was a significant covariant for the Toronto Alexithymia Scale-Difficulty Identifying Feelings subscale. Only the trait anxiety was a significant covariant for the Toronto Alexithymia Scale-Difficulty Expressing Feelings subscale. The overall main effect of dissociation was not significant on the Toronto Alexithymia Scale total and subscales. These data suggest that dissociation is fundamentally a different construct from alexithymia, while state and trait anxiety are closely related to alexithymia.

Twaite JA, Rodriguez-Srednicki O. (2004)
Neurodynamics, Inc., Tenafly, New Jersey, USA.mail:
Childhood sexual and physical abuse and adult vulnerability to PTSD: the mediating effects of attachment and dissociation.  
J Child Sex Abus. 2004;13(1):17-38.

ABSTRACT Two hundred and eighty-four adults from the metropolitan New York area reported on their history of childhood sexual abuse (CSA), childhood physical abuse (CPA), and on the nature of their exposure to the terrorist attack on the World Trade Center. The respondents also completed the Impact of Events Scale-Revised (IES-R), the Attachment Style Questionnaire (ASQ) and the Dissociative Experiences Scale (DES). Those reporting histories of CSA and/or CPA were found to endorse more serious symptoms of PTSD, as did those who witnessed the terrorist attack live. The presence of secure attachments and dissociative symptoms were related significantly to both CSA and CPA, and to scores on the IES-R. Adult attachment and dissociation were found to mediate the relationship between childhood abuse and severity of PTSD.

Tyrrell CL, Dozier M, Teague GB, Fallot RD.  (1999)
Department of Psychology, University of Delaware, Newark 19716-2577, USA.
Effective treatment relationships for persons with serious psychiatric disorders: the importance of attachment states of mind.
J Consult Clin Psychol 1999 Oct;67(5):725-33

ABSTRACT Participants were 54 clients with serious psychiatric disorders and 21 clinical case managers. Clients' serious psychiatric disorders included Axis I diagnoses, such as schizophrenia and bipolar disorder. This study examined how attachment states of mind of both clients and case managers influenced the effectiveness of therapeutic relationships and client functioning. Client and case manager attachment states of mind interacted in predicting the working alliance and client functioning. Specifically, clients who were more deactivating with respect to attachment had better alliances and functioned better with less deactivating case managers, whereas clients who were less deactivating worked better with more deactivating case managers. These findings highlight the importance of clinicians and clients being matched in ways that balance their interpersonal and emotional strategies. 

Tyron WW (1998)
Department of Psychology, Fordham University, Bronx, NY 10458-5198, USA.
A neural network explanation of posttraumatic stress disorder.
J Anxiety Disord 1998 Jul-Aug;12(4):373-85

ABSTRACT An introduction to connectionistic neural networks and their importance for behavior therapists was provided by Tryon (1995a). This article shows that the bidirectional associative memory connectionistic neural networks model meets all four of Jones and Barlow's (1990) requirements and all five of Brewin, Dalgleish, and Joseph's (1996) requirements for a theoretical explanation of posttraumatic stress disorder (PTSD). The bidirectional associative memory model provides a theoretical basis for explaining the clinical symptom constellation of PTSD, with special emphasis on why trauma is re-experienced through memory; accounts for individual variation in symptom severity, including why some people do not develop PTSD; explains why persons with PTSD are comorbid with depression, generalized anxiety, and substance abuse; explains how abnormal behavior derives from normal memory formation processes; and makes novel predictions.