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The Dissociative Subtype of PTSD

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VOLUME 29/NO. 3 • ISSN: 1050-1835 • 2018 Research Quarterly advancing science and promoting understanding of traumatic stress Published by: Francesca L. Schiavone National Center for PTSD Department of Psychiatry, University of Toronto VA Medical Center (116D) 215 North Main Street Paul Frewen, PhD White River Junction Department of Psychiatry, University of Western Ontario Vermont 05009-0001 USA The Dissociative Department of Psychology, University of Western Ontario (802) 296-5132 Margaret McKinnon, PhD FAX (802) 296-5135 Subtype of PTSD: An Mood Disorders Program, St. Joseph’s Healthcare, Email: [email protected] Department of Psychiatry and Behavioural Neuroscience, McMaster University and Homewood Research Institute All issues of the PTSD Research Update of the Literature Quarterly are available online at: Ruth A. Lanius, MD, PhD www.ptsd.va.gov Department of Psychiatry, University of Western Ontario Department of Neuroscience, University of Western Ontario Editorial Members: Editorial Director Matthew J. Friedman, MD, PhD Introduction the existing literature on the unique features of this Bibliographic Editor subpopulation. It will also describe implications for Misty Carrillo, MLIS The most recent revision of the Diagnostic and treatment and future directions for research. Managing Editor Statistical Manual of Mental Disorders (DSM-5) Heather Smith, BA Ed includes, for the first time, a dissociative subtype Correlates of the Dissociative Subtype of posttraumatic stress disorder (PTSD+DS). Prior The two largest sets of data regarding the dissociative National Center Divisions: to the DSM-5, the diagnostic criteria for PTSD Executive emphasized trauma-related undermodulation of subtype are a systematic review of latent class White River Jct VT emotion, focusing on reliving and hyperarousal and profile analytic studies by Hansen, Ross, and Behavioral Science symptoms such as hypervigilance and exaggerated Armour (2017) and a large study using data from the Boston MA startle. PTSD+DS, in addition to meeting full criteria World Mental Health Surveys (Stein et al., 2013). Dissemination and Training for PTSD, captures people who additionally respond Estimates of the prevalence of PTSD+DS among Menlo Park CA to trauma-related stimuli with dissociative symptoms patients with PTSD have varied from 6% to 44.6%, Clinical Neurosciences (depersonalization or derealization) and associated with Hansen et al. finding a mean prevalence of West Haven CT emotional detachment. This is in addition to the 20.35%. Data from the World Mental Health Surveys, Evaluation two dissociative symptoms contained in the core a large and demographically broad sample, puts the West Haven CT diagnostic criteria for PTSD: dissociative flashbacks prevalence of PTSD+DS at 14.4% of those with Pacific Islands and dissociative amnesia (for the traumatic event). PTSD. Notably, these data also suggest that the Honolulu HI PTSD has also been moved out of the anxiety dissociative subtype is represented across a broad Women’s Health Sciences disorders section and into a new category: trauma range of countries and types of index trauma. In this Boston MA and stressor-related disorders. It is increasingly sample, PTSD+DS was associated with increased understood that PTSD is not simply a disorder of re-experiencing symptoms, male sex, history of fear, but involves multiple other symptom domains childhood trauma, history of trauma prior to the and neurological pathways. The new inclusion of index trauma, high degree of psychiatric comorbidity, PTSD+DS, as well as the creation of a separate severe functional impairment, and suicidality (Stein trauma and stressor-related disorders category, et al., 2013). Hansen et al.’s systematic review found reflects this critical shift in understanding. that while the existing literature is heterogeneous with respect to risk factors and correlates of In recent years, compelling evidence has emerged PTSD+DS (perhaps in part due to different that PTSD+DS represents a distinct clinical populations and different operational definitions of population with distinct neurobiological and PTSD+DS), there was a tendency towards an epidemiological features. This review will summarize association with childhood trauma exposure and Continued on page 2 Authors’ Addresses: Francesca L. Schiavone is affiliated with the Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. Paul Frewen, PhD is affiliated with the Department of Psychiatry and the Department of Psychology, University of Western Ontario, London, Ontario, Canada. Margaret McKinnon PhD is affiliated with the Mood Disorders Program, St. Joseph’s Healthcare, Hamilton, Ontario, Canada, the Department of Psychiatry and Behavioural Neuroscience, McMaster University, Hamilton, Ontario, Canada and with the Homewood Research Institute, Guelph, Ontario, Canada. Ruth A. Lanius MD, PhD is affiliated with the Department of Psychiatry and the Department of Neuroscience, University of Western Ontario, London, Ontario, Canada. Email Address: [email protected]. Continued from cover other psychopathology (e.g., depression and anxiety). Taken together, In Ginzberg et al.’s (2006) signal detection analysis of a group of the current literature suggests that the PTSD+DS phenotype may be patients with PTSD from childhood sexual abuse, the dissociative one of greater complexity and chronicity of both trauma history and subtype was associated with increased hypervigilance, sense of overall burden of illness. Association with demographic factors, foreshortened future, and sleep difficulties. At higher levels of specific comorbidities and types of trauma, and overall PTSD severity maltreatment, level of maltreatment was correlated with membership has been mixed. in the dissociative group. In Hansen, Műllerová, Elklit, and Armour’s (2016) sample of motor vehicle accident (MVA) victims and sexual There have been several latent class analyses of non-clinical/general abuse survivors, the dissociative subtype was associated with population samples (typically university students) that have overall emotion focused coping in both, and with decreased social support suggested that while only depersonalization and derealization in the MVA victims. Overall, across these populations, it is notable currently meet DSM-5 criteria for PTSD+DS, other dissociative that PTSD+DS was associated with complex, polysymptomatic symptoms are frequently associated with this subtype, as is other presentations including severe PTSD symptoms (particularly comorbid psychopathology. Blevins, Weathers, and Witte (2014) re-experiencing and hyperarousal symptoms), comorbid psychiatric found that PTSD+DS was not associated with a difference in core disorders, and high levels of childhood maltreatment. PTSD symptoms but was associated with higher levels of dissociative symptoms overall as well as associated psychopathology, such as There is also a body of literature on PTSD+DS in Veterans. In their conversion, borderline, and schizophrenia spectrum symptoms. In a latent class analysis of a sample of trauma-exposed Veterans and general population sample derived from an online survey platform, their intimate partners, Wolf, Miller, et al. (2012) did not find any the group of patients with severe PTSD and dissociative symptoms gender difference but found that the class representing the were more likely to have experienced childhood physical or sexual dissociative subtype had greater severity of flashbacks, and was abuse and were more likely to report difficulties in interpersonal associated with more childhood and adulthood sexual abuse. Wolf, relationships, emotion dysregulation, and reckless behaviour, similar Lunney, et al. (2012) conducted latent profile analyses of a sample of to the complex PTSD phenotype described in the ICD 11, but not male Vietnam war Veterans and a sample of female Veterans and currently recognized in the DSM-5 (Frewen, Brown, Steuwe, & active duty personnel and found that the dissociative subtype, Lanius, 2015). The dissociative subtype was associated not just with characterized by high levels of PTSD symptoms and high levels of depersonalization and derealization, but with other dissociative depersonalization/derealization, was more frequent in the female symptoms including memory disturbance, disengagement, time loss, sample. In the female sample specifically, PTSD+DS compared to and trance (Frewen et al., 2015). Műllerová, Hansen, Contractor, the high PTSD low dissociation group was also associated with less Elhai, and Armour (2016) similarly found that PTSD+DS was physiological and psychological reactivity to trauma-related cues, associated with three other subsets of dissociative symptoms: gaps non-white racial identity, and with comorbid personality disorder, in awareness, re-experiencing (e.g., flashbacks), and sensory misperception; very similar results were found by Ross and colleagues specifically borderline and avoidant. Overall, this supports the idea in university students, where those with PTSD+DS reported greater that PTSD+DS is associated with high symptom severity, high gaps in awareness and memory, re-experiencing, sensory comorbidity (including personality disorder), and may be associated misperception, and reckless or self-destructive behaviour (Ross, more with specific types of trauma (e.g., childhood and/or Baník, Dědová, Mikulášková, & Armour, 2018). In a sample of sexual trauma). Northern Irish university students, Armour, Contractor, Palmieri, and There is some emerging literature
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