ABSTRACT Examined traumatic experiences, posttraumatic stress disorder (PTSD), major depression disorder (MDD) and dissociative symptoms in 40 refugees from former Yugoslavia (ages 15-54 yrs). Interviews investigated the presence of traumatic experiences during and after the the war in Bosnia. The presence of PTSD or MDD was determined using the Structured Clinical Interview for DSM-IV. Ss also completed other scales, including the Dissociative Experiences Scale and the Hopkins Symptom Checklist, which investigates somatization, obsession-compulsion, interpersonal sensitivity, depression, and anxiety. The results suggest that refugees from former Yugoslavia are at high risk for trauma-related psychiatric disorders. The rate of PTSD in the sample was 50%, and the rate of MDD was 35%. Ss with PTSD reported a significantly higher number of traumatic experiences compared to the rest of the sample. A nonsignificant association was found between dissociation and the number of different traumatic experiences and between association and PTSD. These findings support the hypothesis that, despite a common link with traumatic experiences, dissociation and PTSD are two distinct types of symptoms.

ABSTRACT Een aantal controversen over de dissociatieve identiteitstoornis (DIS) worden besproken. Bestudering van deze controversen maakt duidelijk dat zij samenhangen met het gebruik van begrippen als 'identiteit' en 'bewustzijn' in de definitie van de DIS. Deze begrippen zijn afkomstig uit de filosofie en geoperationaliseerd met onvoldoende empirische onderbouwing om te worden gebruikt in psychiatrische ziektebeelden zoals de DIS. Dit zet de validiteit van dit psychiatrische ziektebeeld onder druk. Bij nadere analyse komen frappante overeenkomsten naar voren tussen controversen over bewustzijn en zelfconcept die heersen in de postmoderne filosofie, en de controversen over de DIS. Het lijkt erop dat de psychiatrie niet alleen de begrippen, maar ook de bijbehorende controversen heeft gemporteerd uit de filosofie. De gevolgen hiervan voor de psychiatrie worden besproken, en de noodzaak voor de psychiatrie om zelfstandig tot een conceptuele benadering van de DIS te komen. Dit moet worden gebaseerd op empirisch onderzoek en een klinische operationalisering van het begrip identiteitsstoornis, gericht op een nadere differentiatie van geheugenfuncties.

Feeny NC , Zoellner LA, Foa EB (2000)
University of Pennsylvania School of Medicine, Philadelphia, USA.  
Anger, dissociation, and posttraumatic stress disorder among female assault victims.     
J Trauma Stress 2000 Jan;13(1):89-100

ABSTRACT The goal of the present study was to explore the relationship between anger and dissociation and their relationship to symptoms of post-trauma pathology. One hundred four female assault victims were assessed prospectively 2, 4, and 12 weeks post-assault. Measures of posttraumatic stress disorder (PTSD) severity, social functioning, anger, and dissociation were obtained at all assessments. Results revealed that differentiation between symptoms that predict later PTSD and impaired social functioning first becomes evident at 4 weeks post-assault. At 4 weeks post-assault, anger expression was predictive of later PTSD severity, whereas dissociation was predictive of poorer later functioning.

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.(1998)
Department of Preventive Medicine, Southern California Permanente Medical Group (Kaiser Permanente), San Diego 92111, USA.  
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.     
Am J Prev Med. 1998 May;14(4):245-58.

ABSTRACT BACKGROUND: The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. METHODS: A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. RESULTS: More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. CONCLUSIONS: We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Field, Nigel P; Classen, Catherine C; Butler, Lisa D; Koopman, Cheryl; Zarcone, Julia; Spiegel, David. (2001)
Revictimization and information processing in women survivors of childhood sexual abuse.
Journal of Anxiety Disorders (ISSN: 0887-6185), v. 15, no. 5, pp. 459-469 (2001)

ABSTRACT This study examined the effect of sexual revictimization on information processing of trauma-related stimuli in a sample of child sexual abuse (CSA) survivors diagnosed with PTSD. 51 treatment-seeking women participated in this study. Participants completed the Sexual Experiences Survey regarding sexual revictimization in the last 6 months and performed a modified emotional Stroop task in which they named the colors of neutral words (e.g., apple), general threat words (e.g., malignant and death), and sexual/victimization words (e.g., penis and abuser). As predicted, the revictimized participants (n = 16) took significantly longer to color-name sexual/victimization words than did the nonrevictimized participants. These results suggest that revictimization serves to prime preexisting "trauma" memory networks, thereby amplifying the impact of childhood sexual trauma on selective attention toward trauma-related stimuli.

Fine, Catherine G.; Berkowitz, Ami S. (2001)
The wreathing protocol: The imbrication of hypnosis and EMDR in the treatment of dissociative identity disorder and other dissociative responses.
American Journal of Clinical Hypnosis. 2001 Jan-Apr Vol 43(3-4) 275-290

ABSTRACT Proposes a protocol, called Wreathing Protocol, for the imbricated use of Eye Movement Desensitization and Reprocessing (EMDR) and hypnosis in the treatment of dissociative identity disorder (DID), Dissociative Disorder Not Otherwise Specified and chronic posttraumatic stress disorder (PTSD). The author maintains that this protocol is useful to advanced clinicians skilled in both modalities independently. The sequential steps of the Wreathing Protocol will be described and illustrated by a clinical vignette on DID. The clinical implications of the use of the Wreathing Protocol will be discussed in DID as well as the chronic post traumatic spectrum.

Fine CG (1999)
Temple University, Dept. of Psychiatry, Philadelphia, PA, USA.
The tactical-integration model for the treatment of dissociative identity disorder and allied dissociative disorders.
Am J Psychother 1999 Summer;53(3):361-76

ABSTRACT The ebb and flow of the diagnosis of Dissociative Identity Disorder (DID) and other dissociative conditions has led to the evolution of theories and treatment modalities to resolve the fluctuating and ephemerous symptoms of these conditions. This paper summarizes the structured cognitive-behavioral-based treatment of dissociative disorders that will foster not only symptom relief but also an integration of the personalities and/or ego states into one mainstream of consciousness. This model of DID therapy is called the tactical integration model; it promotes proficiency over posttraumatic and dissociative symptoms, is collaborative and exploratory, and conveys a consistent message of empowerment to the patient.

Firestone,Philip Ph.D., John M. Bradford, M.B., David M. Greenberg, M.B. and Kevin L. Nunes, B.A.
Temple University, Dept. of Psychiatry, Philadelphia, PA, USA.
Differentiation of Homicidal Child Molesters, Nonhomicidal Child Molesters, and Nonoffenders by Phallometry
Am J Psychiatry 157:1847-1850, November 2000

ABSTRACT OBJECTIVE: The purpose of this study was to examine the ability of phallometry to discriminate among homicidal child molesters, nonhomicidal child molesters, and a comparison group of nonoffenders. METHOD: Twenty-seven child molesters who had committed or had attempted a sexually motivated homicide, 189 nonhomicidal child molesters, and 47 nonoffenders were compared on demographic variables and psychometrically determined responses to aural descriptions of sexual vignettes. Two phallometric indexes were used: the pedophile index and the pedophile assault index. The pedophile index was computed by dividing the subject’s highest response to an aural description of sex with a "consenting" child by his highest response to description of sex with a consenting adult. The pedophile assault index was computed by dividing the subject’s highest response to an aural description of assault involving a child victim by his highest response to description of sex with a "consenting" child. RESULTS: Homicidal child molesters, nonhomicidal child molesters, and nonoffenders were not significantly different in age or IQ. Homicidal and nonhomicidal child molesters had significantly higher pedophile index scores than nonoffenders. Significantly more homicidal child molesters (14 [52%] of 27) and nonhomicidal child molesters (82 [46%] of 180) than nonoffenders (13 [28%] of 47) had pedophile index scores equal to or greater than 1.0, but homicidal and nonhomicidal child molesters did not differ from each other. Significantly more homicidal child molesters (17 [63%] of 27) than either nonhomicidal child molesters (71 [40%] of 178) or nonoffenders (17 [36%] of 47) had pedophile assault index scores equal to or greater than 1.0, and nonhomicidal child molesters and nonoffenders were not significantly different from each other. Within-group analyses revealed that of the three groups, only the nonhomicidal child molesters exhibited a significant difference between their pedophile index scores and their pedophile assault index scores; their pedophile index scores were higher. CONCLUSIONS: Consistent with past research, the authors found that the pedophile index is useful in differentiating homicidal and nonhomicidal child molesters from nonoffenders and that the pedophile assault index is able to differentiate homicidal child molesters from nonhomicidal child molesters and nonoffenders.

Fonagy P  (1999)   
Sub-Department of Clinical Health Psychology, University College London, England UK
The transgenerational transmission of holocaust trauma. Lessons learned from the analysis of an adolescent with obsessive-compulsive disorder.
Attach Hum Dev 1999 Apr;1(1):92-114

ABSTRACT This paper outlines an attachment-theory based model of transgenerational trauma inspired by the successful psychoanalytic treatment of a severely disturbed adolescent with obsessive-compulsive disorder who was the first child of the first daughter of a holocaust survivor. It is proposed that the transmission of specific traumatic ideas across generations may be mediated by a vulnerability to dissociative states established in the infant by frightened or frightening caregiving, which, in its turn, is trauma-related. Disorganized attachment behaviour in infancy may indicate an absence of self-organization, or a dissociative core self. This leaves the child susceptible to the internalization of sets of trauma-related ideation from the attachment figure, which remain unintegrated in the self-structure and cannot be reflected on or thought about. The disturbing effect of these ideas may be relatively easily addressed by a psychotherapeutic treatment approach that emphasizes the importance of mentalization and the role of playful engagement with feelings and beliefs rather than a classical insight-oriented, interpretive approach.

Fonagy P  (1999)   
Sub-Department of Clinical Health Psychology, University College London, England UK
Relation of theory and practice in psychodynamic therapy.
J Clin Child Psychol 1999 Dec;28(4):513-20

ABSTRACT Explores the role of theory in psychodynamic practice. This article attempts to show that clinicians commonly labor under the illusion that practice is governed by the logic of theory, by deduction rather than by induction. With psychoanalytic theory and practice as an example, theory is shown to be logically independent of practice and technique. It is suggested that maintaining the illusion of a logical relation between the two can cause a petrification of practice and ultimately the downfall of a theoretical orientation. Further, the inductive use of clinical experience can generate an excessive number of irreconcilable theoretical ideas, which in turn explains the tendency of psychodynamic clinicians to eschew operationalization and rigorous theory building. The abandonment of the pretense of a logical relation, by contrast, could lead to a renewed excitement about the development of technique.

Fonagy, P. , Bateman A.   (1999)
Effectiveness of Partial Hospitalization in the Treatment of Borderline Personality Disorder: A Randomized Controlled Trial
Am J Psychiatry 156:1563-1569, October 1999

ABSTRACT These London researchers have developed a method for treating borderline personality disorder that is based on individual and group psychotherapy within a structured, partial hospitalization program. To test the effectiveness of the program, they designed a trial of 38 patients, half randomized to the partial hospitalization program and half to conventional psychiatric care. Their report details results over the first 18 months of the study. The parameters measured -- including depressive symptoms, suicidal and self-mutilatory behavior, number of inpatient days, and overall social and interpersonal function -- were all significantly improved in the patients who were randomized to partial hospitalization. In contrast, patients in the conventional care group exhibited limited improvements or deterioration over the same period. The authors say improvements in the partial hospitalization group began showing up 6 months into the study. Bateman and Fonagy plan to follow their cohort further, and stress that other confirming studies are needed. However, they say that if their results hold, partial hospitalization could prove to be an effective and less costly alternative to inpatient care.

ABSTRACT The impact of combat and sexual harassment on the severity of posttraumatic stress disorder (PTSD) is compared for 1,307 men and 197 women peacekeepers who served in the same military units. A theoretical model was proposed to express the nature of the impact. Structural equation modeling was used to evaluate the model separately for men and women. Good-fitting, parsimonious models were developed that showed substantial similarity for men and women. For men, severity of PTSD symptoms was impacted by exposure to combat directly and indirectly through fear and sexual harassment. For women, severity of PTSD symptoms was impacted by combat indirectly through the same two influences, although the mechanisms involving fear and sexual harassment were somewhat different. For both genders, moreover, PTSD severity was impacted directly by exposure to the dying of the Somali people. These similarities suggest that in modern stressful overseas military missions, both genders may be susceptible to the same types of risk for the development of PTSD. The incidence and impact of sexual harassment is particularly noteworthy in the case of men and calls for more detailed investigation in future studies

ABSTRACT The diagnostic validity of dissociative identity disorder (DID) continues to inspire controversy, with some commentators claiming that DID is a modern variant of "hysteria"; that is, attention-seeking behavior. The author asserts that DID is indeed a valid psychiatric disorder, and believes that this skeptical reaction can largely be attributed to a specific set of transference/countertransference interactions that these patients tend to inspire. The paper delineates several clinical features of DID that can easily be mistaken for hysterical phenomena, and attempts to find the roots of this confusion in the DID patients' experience of interpersonal powerlessness, which leads them to present their symptoms in an unconvincing, "hysterical" manner. Confusion between the vertical split seen in the dissociative disorders and the horizontal split characteristic of the classic hysterical personality is discussed, as is the powerful effect of observer bias in creating hysterical-appearing phenomena. The term "pseudo-hysteria" is used to denote a situation in which a genuine psychiatric disorder, DID, is perceived as an hysterical production.

Consciousness and Cognition; Vol. 10, No. 3, September 1, 2001- pp. 259-293 (doi:10.1006/ccog.2001.0493)

ABSTRACTThis article elaborates on Putnam's "discrete behavioral states" model of dissociative identity disorder (Putnam, 1997) by proposing the involvement of the orbitalfrontal cortex in the development of DID and suggesting a potential neurodevelopmental mechanism responsible for the development of multiple representations of self. The proposed "orbitalfrontal" model integrates and elaborates on theory and research from four domains: the neurobiology of the orbitalfrontal cortex and its protective inhibitory role in the temporal organization of behavior, the development of emotion regulation, the development of the self, and experience-dependent reorganizing neocortical processes. The hypothesis being proposed is that the experience-dependent maturation of the orbitalfrontal cortex in early abusive environments, characterized by discontinuity in dyadic socioaffective interactions between the infant and the caregiver, may be responsible for a pattern of lateral inhibition between conflicting subsets of self-representations which are normally integrated into a unified self. The basic idea is that the discontinuity in the early caretaking environment is manifested in the discontinuity in the organization of the developing child's self. .

ABSTRACTPsychiatric patients who engage in self-destructive behavior by cutting, burning, or abrading their skin are currently one of the most difficult-to-treat groups in both inpatient and outpatient settings. The complexities of treating these patients, the risk factors associated with this symptom, and the rise in the prevalence of self-mutilation in America’s adolescents and young adults provided the impetus for the current study. This article explores aspects of aggression, dependency, object relations, defensive structure, and psychic boundary integrity that may contribute to the genesis and maintenance of self-mutilation. Rorschach protocols from 90 borderline personality-disordered inpatients (48 self-mutilators and 42 non-self-mutilators) were scored using five psychoanalytic content scales. Results indicate that self-mutilating patients exhibit greater incidence of primary process aggression, severe boundary disturbance, pathological object representations, defensive idealization, devaluation, and splitting than did a matched group of non-self-mutilating borderline patients. Clinical theory and technical recommendations are considered in light of the current empirical findings. .

ABSTRACT Discusses alleged methodological flaws and biases in a study of psychiatrists' attitudes toward the diagnostic validity of dissociative identity disorder.

ABSTRACT Objective: To examine the lifetime prevalence of trauma experiences and post-traumatic stress disorder (PTSD). Method: Questionnaire-assessed PTSD, the type of traumatic event experienced, perceived trauma impact, and trauma frequency in 1824 randomly selected men and women. Results: PTSD lifetime prevalence was estimated at 5.6% with a 1 : 2 male-to-female ratio, in spite of men reporting greater trauma exposure. The highest PTSD risk was associated with sexual and physical assault, robbery and multiple trauma experiences. Controlling for trauma type did not account for gender differences, while controlling for experienced distress did. Conclusion: The conditional probability for PTSD varied as a function of trauma type, frequency and impact of the event, with increased rates associated with prevalent trauma exposure and higher perceived distress. The latter accounted for the gender effect, suggesting that gender differences in PTSD in part

ABSTRACT Most individuals who, shortly after trauma, express symptoms of posttraumatic stress disorder (PTSD) recover within 1 year of their traumatic experiences. In contrast, those who remain ill for 1 year rarely recover completely. This study prospectively evaluated predictors of PTSD at 4 months and 1 year. The authors followed 236 trauma survivors (aged 16-65 yrs) recruited from admissions to a general hospital's emergency room for 4 months, at which point 41 (17.4%) met diagnostic criteria for PTSD. 23 of these individuals, and 39 individuals without PTSD at 4 months, were assessed again at 1 year. Depressive symptoms were the best predictors of PTSD at both time points. Intrusive symptoms and peritraumatic dissociation were better at predicting 4-month PTSD than 1-year PTSD. It is concluded that the occurrence of depression during the months that follow a traumatic event is an important mediator of chronicity in PTSD.

ABSTRACT A 49-year old combat veteran sustained a right frontal cerebral infarct at the age of 45 years. The patient's family reports that prior to the infarct he had a preoccupation with memories of combat, as well as nightmares, avoidance of reminders, and multiple arousal symptoms. Since his recovery from the infarct, the patient and his family continue to relate significant arousal symptoms but deny any continued history of preoccupation with traumatic memories, reminder avoidance, or nightmares. The resolution of a limited number of symptoms in this patient following damage to the right frontal cortex suggests that some of the symptoms of PTSD may be amenable to current biological interventions.

Am J Psychiatry. 2000 Jun;157(6):1012-3

ABSTRACT OBJECTIVE: The goal of this study was to determine the frequency of dissociative disorders in Dutch psychiatric inpatients. METHOD: During a period of 12 months, 122 consecutively admitted adult psychiatric patients were screened with the Dissociative Experiences Scale. Patients scoring 25 and higher and a random selection of patients scoring lower than 25 were blindly interviewed with the Structured Clinical Interview for DSM-IV Dissociative Disorders, Revised. Interviews were scored independently by a blind rater. RESULTS: Ten (8%) of the 122 patients were diagnosed as having a dissociative disorder; two (2%) were diagnosed as having a dissociative identity disorder. Two patients (2%) had factitious dissociative identity disorder. CONCLUSIONS: The rate of dissociative disorders in this group of Dutch patients is comparable to the rates reported in other European studies but lower than rates reported in North American studies.