Mindfulness and pathological dissociation fully mediate the association of childhood abuse and PTSD symptomatology
Introduction
Childhood abuse is linked to a variety of psychiatric disorders like borderline personality disorder, antisocial personality disorder, depression, anxiety disorders, somatoform disorder, eating disorders and especially PTSD (Infurna et al., 2016; Molnar, Buka, & Kessler, 2001; Moulton, Newman, Power, Swanson, & Day, 2015; Schimmenti, Di Carlo, Passanisi, & Caretti, 2015; Stein et al., 1996, Varese et al., 2012). PTSD is characterized by anxiety sensitivity (Lang, Kennedy, & Stein, 2002), deficits in cognitive control (Bomyea, Amir, & Lang, 2012) and an attentional bias towards trauma-related stimuli (Buckley, Blanchard, & Neill, 2000). Individuals with PTSD show difficulties in the inhibition of the limbic system and in the integration of cognition and emotion (van der Kolk, 2006). The extreme fear responses of individuals with PTSD to trauma reminders in different contexts than the traumatic situation have been linked to hippocampal dysfunction (Acheson, Gresack, & Risbrough, 2012) and disruptions of the brain's alarm network due to altered functional connectivity of amygdala complexes (Rabellino et al., 2016).
Psychological theories of PTSD are based on the premise that individuals’ dysfunctional coping strategies prevent the integration of traumatic memories into the biographical memory and are therefore responsible for the maintenance of post-traumatic symptoms (Ehlers and Clark, 2000, Foa and Kozak, 1986). Dysfunctional coping strategies include thought suppression, safety behaviors, experiential avoidance, rumination and self-harming behavior (Low, Jones, MacLeod, Power, & Duggan, 2000; Marx and Sloan, 2005, Shipherd and Beck, 2005). Yet, the inability of individuals with PTSD to effectively process and integrate traumatic memories and associated emotions, action tendencies, thoughts and body sensations needs further clarification. Lately, many authors have stressed the key role of dissociation in PTSD (e.g., Dalenberg & Carlson, 2012). According to Nijenhuis (2017a), PTSD should be understood as a dissociative disorder as it includes a division of the personality into one psychobiological subsystem that tries to avoid traumatic memories and to function in daily life and at least one-second psychobiological subsystem that is fixated in the traumatic past and defensive actions. The question whether these subsystems have necessarily to be conscious is still up to discussion (Nijenhuis, 2017b, Schimmenti and Caretti, 2014).
Trauma-related dissociation can be described as processes of compartmentalization of psychological functioning regarding the experience of time, thought, body and emotion, and processes of detachment like numbing, derealisation and depersonalization (Holmes et al., 2005, Lanius, 2015). It corresponds to an overactivation of the medial prefrontal cortex, which has an inhibitory effect on the limbic system (Lanius et al., 2010). Hence, dissociation serves to avoid aversive trauma-related memories (van der Kolk et al., 1996). Peritraumatic and persistent pathological dissociation have been identified as important predictors of PTSD symptomatology (Briere, Scott, & Weathers, 2005; Marx and Sloan, 2005, Twaite and Rodriguez-Srednicki, 2004). Pathological dissociation has therefore been termed an “insufficiently recognized major feature” of PTSD (van der Hart, Nijenhuis, & Steele, 2005). It is particularly prominent in survivors of childhood abuse (Frewen, Brown, Steuwe, & Lanius, 2015).
Furthermore, pathological dissociation has been found to mediate the relationship of childhood abuse and dysfunctional coping mechanisms like risk-taking behaviors, suicidal ideation, thought control methods, eating disorders or self-harming behavior (Barlow and Goldsmith, 2014, Kisiel and Lyons, 2001, Low et al., 2000, Moulton et al., 2015). It also has repeatedly been shown to negatively impact treatment outcomes of trauma-focused psychotherapy (Bae, Kim, & Park, 2015; Cloitre, Chase Stovall-McClough, Miranda, & Chemtob, 2004; Kleindienst et al., 2016), stimulating research in how to adapt trauma-focused treatments to the needs of patients with severe dissociative symptomatology (Cloitre, Petkova, Wang, & Lu, 2012; van der Hart, Groenendijk, Gonzalez, Mosquera, & Solomon, 2014). Taking into account these findings, we hypothesize that pathological dissociation should be an important aspect of any explanation of how childhood abuse leads to adult PTSD symptomatology.
The term “mindfulness” describes the capacity to purposely and non-judgementally pay attention in the present moment (Kabat-Zinn, 1994). Mindfulness helps to focus attention and to distance oneself from aversive internal experiences, cognitions and action tendencies. PTSD is characterized by low levels of mindfulness (Bernstein, Tanay, & Vujanovic, 2011), reduced emotional acceptance (Tull, Barrett, McMillan, & Roemer, 2007) and “lack of clarity of emotions” (Ehring & Quack, 2010). Survivors of childhood abuse are known to show particularly severe difficulties in identifying and labeling emotions (Frewen, Dozois, Neufeld, & Lanius, 2008). Due to their limited access to effective emotion regulation strategies, individuals with PTSD feel easily overwhelmed by emotions and have difficulties in goal-directed behavior when upset (Lilly and Lim, 2013, Tull et al., 2007). Mindfulness and acceptance, on the contrary, have been found to be helpful in post-traumatic adjustment (Thompson, Arnkoff, & Glass, 2011).
According to Ehlers and Clark (2000), emotional responses in chronic PTSD depend on negative appraisals of traumatic events and of trauma sequelae. Mindfulness has been found to mediate this association of appraisals and post-traumatic symptoms (Glück, Tran, Raninger, & Lueger-Schuster, 2016). Thus, mindfulness may be considered a key coping mechanism helping to attenuate the negative effects of dysfunctional trauma-related cognitions. We therefore hypothesize that mindfulness deficits are an important aspect of the explanation of the link of childhood abuse and adult PTSD symptomatology.
Even though the relationship of mindfulness and pathological dissociation is not yet fully clear, mindfulness has been shown to be negatively associated to pathological dissociation (Escudero-Pérez et al., 2016, Perona-Garcelan et al., 2014). Consequently, many authors recommend the use of mindfulness-interventions in the treatment of trauma-related pathological dissociation (Frewen and Lanius, 2015, Zerubavel and Messman-Moore, 2015). Yet, even though the detached states of consciousness characteristic for pathological dissociation contrast with many aspects of mindfulness, the two concepts are by no means redundant (Walach, Buchheld, Buttenmüller, Kleinknecht, & Schmidt, 2006).
In summary, there is strong empirical evidence that victims of childhood abuse show high levels of pathological dissociation and low levels of mindfulness and that pathological dissociation plays a crucial role in PTSD. Yet, still too little is known about the role not only pathological dissociation, but also mindfulness deficits play for the relationship between childhood abuse and PTSD symptoms in adults. Hence, using mediation analysis, we investigated whether pathological dissociation and mindfulness mediate the relationship between childhood abuse and PTSD in a severely traumatized naturalistic treatment sample. Multiple mediation analysis allows to assess the degree to which the effect of an independent variable on a dependent variable is direct or via indirect pathes. We hypothesized that the inability to recognize trauma-related internal sensations, cognitions, emotions and action tendencies for what they are, i.e. traumatic memories, and to process these memories due to dissociation and mindfulness deficits should fully explain the relationship of childhood abuse and adult PTSD.
Section snippets
Participants and Procedure
We analyzed the data of 218 inpatients (female = 182; male = 36) with an average age of 47.7 years (SD = 10.3). Overall, 199 patients (91%) were German citizens. Two hundred and seven patients (95%) had some kind of secondary school qualifications and 42 (19%) had graduated from university. Sixty-five patients (30%) were married, 71 (33%) had children and 96 (44%) were living with their partner a the time of admission. Forty-three patients (20%) worked full-time at the time of admission and 170
Sample characteristics
At least low to moderate sexual or physical abuse in the CTQ was reported by 188 patients (86.2%). One hundred and twenty patients (55.0%) reported both at least low to moderate childhood sexual and at least low to moderate physical abuse. Mean ratings in the IES-R were high for intrusions (M = 28.9; SD = 5.7), avoidance (M = 25.9; SD = 7.1), and hyperarousal (M = 29.1; SD = 5.4). Mean scores were found to be 18.5 (SD = 18.4) in the DES-T and 64.7 (SD = 11.6) in the FMI. Descriptive statistics and
Discussion
The aim of this study was to investigate the mediating roles of pathological dissociation and mindfulness deficits in the relationship of childhood trauma and PTSD. Results were consistent with our hypotheses. First, we replicated prior findings that childhood abuse is significantly associated with mindfulness deficits (Elices et al., 2015, Frewen et al., 2015). Second, as predicted by the trauma model of dissociation (Dalenberg et al., 2012), we found a significant association of childhood
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosure of interest
The authors declare that they have no competing interest.
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