PTSD, emotion dysregulation, and dissociative symptoms in a highly traumatized sample
Introduction
Dissociation, which involves disruptions in the usually integrated functions of memory, identity, and perception of self and environment, is thought to play an important role in posttraumatic stress disorder for many individuals (PTSD; Stovall-McClough and Cloitre, 2006, Briere et al., 2005, Van der Kolk et al., 1996). Dissociative symptoms that may co-occur with PTSD can interfere with emotional activation and may negatively impact trauma-focused treatment success (Cloitre et al., 2004, Price et al., 2014, Spitzer et al., 2007). Dissociative symptoms have also been shown to contribute to functional impairment in PTSD and may also be associated with overall severity of PTSD symptoms (Branscomb, 1991, Cloitre et al., 2002, Norman et al., 2007).
The type of dissociation most often studied in relation to PTSD is peritraumatic dissociation, which is the tendency for one to dissociate during or soon after a traumatic event. Numerous studies have shown that peritraumatic dissociation is a significant risk factor for the development of PTSD (Bremner et al., 1992, Kumpula et al., 2011, Marmar et al., 1994, Shalev et al., 1996; Tichenor et al., 1996; Weiss et al., 1995). However, two recent studies (both described in Briere et al., 2005) in trauma-exposed and normative samples demonstrated that persistent dissociation in response to trauma cues was significantly associated with PTSD, and peritraumatic dissociation was no longer related to PTSD when persistent dissociation was included in analyses. Furthermore, the researchers found that generalized dissociation (i.e., dissociative symptoms related to a change in consciousness that is not necessarily tied to a trauma cue) remained associated with PTSD independent of peritraumatic or persistent trauma-related dissociation. This dissociative capacity may reflect an effort to tolerate strong and distressing emotional responses.
Emotion dysregulation, more generally, has previously been linked to increased vulnerability for the development and maintenance of PTSD and other trauma-related psychopathology (Bradley et al., 2011, Kring, 2008, McLaughlin et al., 2011). Research on children exposed to childhood maltreatment has shown that traumatized children are more likely to show emotion regulation difficulties, which can then lead to the trauma-related psychopathology (Burns et al., 2010, Herman, 1992, McLaughlin et al., 2011, Van der Kolk et al., 1991). Research also shows that poor emotion regulation is predictive of greater PTSD symptom severity (Tull et al., 2007) and predicts level of overall adaptive functioning in individuals with PTSD (Cloitre et al., 2005), suggesting that emotion dysregulation may be a mechanism that accentuates or perpetuates PTSD symptoms.
Growing evidence supports a dissociative subtype of PTSD (Lanius et al., 2010, Lanius et al., 2012, Wolf et al., 2012) and this has been included in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders, (DSM-5; APA, 2013). In particular, symptoms of depersonalization and/or derealization in the context of PTSD symptoms constitute the dissociative subtype of PTSD. This subtype is supported by fMRI research by Lanius et al. (2010) showing separate neural manifestations of dissociative and hyperarousal subtypes of PTSD. The researchers found that dissociative PTSD patients appear to experience emotional under-engagement in response to traumatic memories evidenced by abnormally high activation in brain regions involved in emotion regulation and prefrontal inhibition of the limbic regions of the brain. Other fMRI research with PTSD participants supports this, showing that participants with dissociative PTSD demonstrated enhanced prefrontal activation during conscious fear processing tasks compared with non-dissociative PTSD patients (Felmingham et al., 2008). Other research on civilian participants with PTSD also found that individuals with high levels of dissociation showed significantly increased early cortical responses to emotional stimuli, suggesting that dissociative symptoms may be associated with greater automatic reactivity to threat stimuli (Klimova et al., 2013). These studies provide support for the idea that dissociation is a form of emotion regulation used to cope with high levels of arousal.
However, we still know little about the complex relationship between dissociative symptoms, PTSD, and overall emotion regulation tendencies. Furthermore, most research has focused on only trauma-related dissociation (i.e., dissociation in the presence of trauma cues or memories). Since it is clear that dissociation may occur more generally in day to day life (whether or not trauma cues are present), there is still a great deal to understand about what impacts general dissociative tendencies. The above evidence points to the possibility of emotion dysregulation mediating the association between PTSD symptoms and dissociative tendencies. The goal of this study was to examine the potential relationship among these variables in a highly-traumatized, economically disadvantaged population. Specifically, the current study explored how PTSD symptoms and emotion dysregulation are related to dissociative symptoms, focusing on the unique effects of PTSD symptoms and emotion dysregulation dimensions to better understand how dissociation may be addressed in a treatment context.
Section snippets
Procedure
Participants were drawn from an NIMH-funded study of risk factors for the development of PTSD in a low socioeconomic, primarily African American urban population. Participants were recruited from waiting rooms in the gynecology and primary care medical (non-psychiatric) clinics at Grady Memorial Hospital, a publicly funded hospital in Atlanta, Georgia. We did not narrow our recruitment to specific selection criteria, but approached any individual in the waiting room. During the recruitment
Results
To determine the extent of association between our predictor variables and dissociative symptoms, we first calculated Pearson correlation coefficients. Both childhood abuse and adult trauma exposure were significantly positively correlated with overall dissociative symptoms at r = 0.24 (p < .01) and r = 0.17 (p < .05), respectively. As shown in Table 1, current PTSD symptom severity was also significantly positively correlated with overall dissociative symptom score as well as all six
Discussion
To our knowledge, this is the first study to examine associations between PTSD, emotion dysregulation, and general dissociative symptoms. Compared with other studies that focus on dissociation in the presence of trauma reminders (e.g., Lanius et al., 2010, Lanius et al., 2012, Wolf et al., 2012), this study focused on generalized dissociative tendencies that occur in daily life (and may or may not be a result of a trauma reminder). Understanding the connection between these variables is
Role of the funding source
This work was primarily supported by the National Institute of Mental Health (MH071537; MH100122; MH102890) and the National Institute of Child Health and Human Development (HD071982). Support also included Emory and Grady Memorial Hospital General Clinical Research Center, NIH National Centers for Research Resources (M01 RR00039), and the Burroughs Welcome Fund.
Contributors
Abigail Powers is the corresponding author on this manuscript and took the primary role in literature review, manuscript preparation, and statistical analysis, as well as helped with data collection and study conceptualization. Dorthie Cross, Negar Fani, and Bekh Bradley assisted with data collection, overall conceptualization of the study, and revising manuscript drafts.
Conflict of interest
There are no known conflicts of interest associated with this publication for any of the authors and there has been no significant financial support for this work that could have influenced its outcome.
Acknowledgments
We would like to thank Allen W. Graham, BA and all the Grady Trauma Project staff and volunteers for their assistance in data collection and making this research possible.
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