Acute dissociative reaction to spontaneous delivery in a case of total denial of pregnancy: Diagnostic and forensic aspects.

This article presents the history of a 21-year-old female college student with total denial of pregnancy who experienced an acute dissociative reaction during the spontaneous delivery at home without medical assistance where the newborn died immediately. Psychiatric examination, self-report questionnaires, legal documents, and witness reports have been reviewed in evaluation of the case. Evidence pointed to total denial of pregnancy, that is, until delivery. The diagnoses of an acute dissociative reaction to stress (remitted) and a subsequent PTSD were established in a follow-up examination conducted 7 months after the delivery. Notwithstanding the inherently dissociative nature of total denial of pregnancy, no other evidence has been found about pre-existing psychopathology. For causing the newborn's death, the patient faced charges for "aggravated murder," which were later on reduced into "involuntary manslaughter." Given the physical incapacity to perform voluntary acts due to the loss of control over her actions during the delivery, and the presence of an acute dissociative reaction to unexpected delivery, the legal case represents an intricate overlap between "insanity" and "incapacitation" defenses. The rather broad severity spectrum of acute dissociative conditions requires evaluation of the limits and conditions of appropriate legal defenses by mental health experts and lawyers. Denial of pregnancy as a source of potential stress has attracted little interest in psychiatric literature although solid research exists which documented that it is not infrequent. Arguments are presented to introduce this condition as a diagnostic category of female reproductive psychiatry with a more neutral label: "unperceived pregnancy."

DSM-5's posttraumatic stress disorder with dissociative symptoms: challenges and future directions.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, formally recognizes a dissociative subtype of posttraumatic stress disorder (PTSD; PTSD with dissociative symptoms). This nomenclative move will boost empirical and theoretical efforts to further understand the links between dissociation, trauma, and PTSD. This article examines the empirical literature showing that patients with PTSD can be divided into 2 different groups based on their neurobiology, psychological symptom profile, history of exposure to early relational trauma, and depersonalization/derealization symptoms. It then explores the conceptual and empirical challenges of conceiving 1 of these types as reflecting a "dissociative" type of PTSD. First, this classification is based on the presence of a limited subset of dissociative symptoms (i.e., depersonalization, derealization). This sets aside an array of positive and negative psychoform and somatoform dissociative symptoms that may be related to PTSD. Second, empirical evidence suggests heightened dissociation in PTSD compared to many other disorders, indicating that dissociation is relevant to PTSD more broadly rather than simply to the so-called dissociative subtype. This article sets out important issues to be examined in the future study of dissociation in PTSD, which needs to be informed by solid conceptual understandings of dissociation.

Association of Childhood Complex Trauma and Dissociation With Complex Posttraumatic Stress Disorder Symptoms in Adulthood.

This study replicates and extends prior research on the relationship of childhood complex trauma (CCT) and complex posttraumatic stress disorder (cPTSD) in adulthood, examining the role of psychoform and somatoform dissociation as a potential mediator. CCT, dissociation, and cPTSD were assessed in a large sample of adult psychiatric inpatients. Almost two thirds of participants reported having experienced CCT. Path analyses with bootstrap confidence intervals demonstrated a relationship between CCT, psychoform (but not somatoform) dissociation, and cPTSD. In addition, psychoform dissociation partially mediated the relationship between CCT and adult cPTSD symptoms. Dissociation (pathological or nonpathological psychoform and somatoform symptoms) warrants further clinical and scientific study as a potential link between CCT and the presence of adult cPTSD symptoms and/or the dissociative subtype of PTSD.

Cognitive and affective dimensions of difficulties in emotional functioning in somatoform disorders and borderline personality disorder.

BACKGROUND: To study difficulties in emotional functioning in two mental disorders that have been associated with difficulties in identifying and modulating emotions: borderline personality disorder (BPD) and somatoform disorder (SoD). SAMPLING AND METHODS: In 472 psychiatric inpatients, difficulties in emotional functioning were measured using the Bermond-Vorst Alexithymia Questionnaire. RESULTS: Profiles of difficulties in emotional functioning were identified, suggesting that patients diagnosed with BPD with or without SoD were more likely to report difficulty identifying emotions and less likely to report reduced ability to fantasize or 'pensée opératoire' (externally oriented thinking) than patients diagnosed with SoD only and patients with mixed anxiety and affective disorders. SoD patients were more likely to report reduced ability to phantasize or pensée opératoire than difficulty identifying emotions. Patients with mixed anxiety and affective disorders were more likely to report reduced ability to experience emotions than patients diagnosed with BPD and/or SoD. CONCLUSIONS: By using a finer-grained perspective on difficulties in emotional functioning some evidence was found for the existence of cognitive-emotional profiles that may provide more clinically relevant information than alexithymia as just a unitary construct. Further research on cognitive-emotional profiles of difficulties in emotional functioning is needed to advance the understanding, diagnosis and treatment of mental disorders.

A phenomenological analysis of disaster-related experiences in fire and emergency medical services personnel.

This article explores the experiences of fire and Emergency Medical Services (EMS) personnel during and immediately after a technological event using a phenomenological approach. Personnel engaged in the rescue operations during and immediately after the Ghislenghien gas explosion reflected upon their experiences in their responses to a specially designed, self-reporting questionnaire that included open-ended questions. Firefighters reported more perceived threat and direct exposure to death than did EMS personnel. Qualitative analysis indicates that the central characteristics of this potentially traumatizing event were the suddenness and massiveness of the impact, and the fact that it involved young victims and/or multiple deaths. With regard to emotions, powerlessness, horror, fear, a sense of apocalypse, and grief were experienced by both firefighters and EMS personnel. Firefighters noted that the death of colleagues, the involvement of friends and family, the massive impact, and exposure to the burned victims were most shocking. Emergency Medical Services personnel and in-hospital staff reported the impact, the confrontation with death, the involvement of friends and family, and the pain, suffering, and screaming of burned victims as the most shocking aspects of this event. Qualitative differences in the lived experiences of firefighters, EMS personnel, and in-hospital staff might be explained by differences in life threat, contact with death, and various degrees of training.

Dissociation in trauma: a new definition and comparison with previous formulations.

Amid controversy regarding the psychobiological construct of dissociation, efforts to formulate a precise definition of dissociation are rare. Some understandings of dissociation are so broad that a host of common psychobiological phenomena would qualify as dissociative. Overly narrow conceptualizations of dissociation exclude phenomena that originally, and for good reasons, have been regarded as dissociative. A common lack of conceptual distinctions between dissociation as process, organization, deficit, psychological defense, and symptom adds to the current confusion. In previous publications, we criticized many of these perspectives and proposed a detailed psychobiological theory of dissociation in trauma. However, what has remained missing is a precise definition of dissociation in trauma. This article first presents such a definition and elucidates its various components. Next the new definition is compared with several other major definitions of the concept. The strengths of the new formulation are highlighted and discussed.

Predicting stabilizing treatment outcomes for complex posttraumatic stress disorder and dissociative identity disorder: an expertise-based prognostic model.

The purpose of this study was to develop an expertise-based prognostic model for the treatment of complex posttraumatic stress disorder (PTSD) and dissociative identity disorder (DID). We developed a survey in 2 rounds: In the first round we surveyed 42 experienced therapists (22 DID and 20 complex PTSD therapists), and in the second round we surveyed a subset of 22 of the 42 therapists (13 DID and 9 complex PTSD therapists). First, we drew on therapists' knowledge of prognostic factors for stabilization-oriented treatment of complex PTSD and DID. Second, therapists prioritized a list of prognostic factors by estimating the size of each variable's prognostic effect; we clustered these factors according to content and named the clusters. Next, concept mapping methodology and statistical analyses (including principal components analyses) were used to transform individual judgments into weighted group judgments for clusters of items. A prognostic model, based on consensually determined estimates of effect sizes, of 8 clusters containing 51 factors for both complex PTSD and DID was formed. It includes the clusters lack of motivation, lack of healthy relationships, lack of healthy therapeutic relationships, lack of other internal and external resources, serious Axis I comorbidity, serious Axis II comorbidity, poor attachment, and self-destruction. In addition, a set of 5 DID-specific items was constructed. The model is supportive of the current phase-oriented treatment model, emphasizing the strengthening of the therapeutic relationship and the patient's resources in the initial stabilization phase. Further research is needed to test the model's statistical and clinical validity.

Affect dysregulation and dissociation in borderline personality disorder and somatoform disorder: differentiating inhibitory and excitatory experiencing states.

Affect dysregulation and dissociation may be associated with borderline personality disorder (BPD) and somatoform disorder (SoD). In this study, both under-regulation and over-regulation of affect and positive and negative somatoform and psychoform dissociative experiences were assessed. BPD and SoD diagnoses were confirmed or ruled out in 472 psychiatric inpatients using clinical interviews and clinical multidisciplinary consensus. Affect dysregulation and dissociation were measured using self-reports. Under-regulation (but not over-regulation) of affect was moderately related to positive and negative psychoform and somatoform dissociative experiences. Although both BPD and SoD can involve dissociation, there is a wide range of intensity of both somatoform and psychoform dissociative phenomena in patients with these diagnoses. Compared with other groups, SoD patients more often reported low levels of dissociative experiences and reported fewer psychoform (with or without somatoform) dissociative experiences. Compared with the other groups, patients with both BPD and SoD reported more psychoform (with or without somatoform) dissociative experiences. Evidence was found for the existence of 3 qualitatively different forms of experiencing states. Over-regulation of affect and negative psychoform dissociation, commonly occurring in SoD, can be understood as inhibitory experiencing states. Under-regulation of affect and positive psychoform dissociation, commonly occurring in BPD, can be understood as excitatory experiencing states. The combination of inhibitory and excitatory experiencing states commonly occurred in comorbid BPD + SoD. Distinguishing inhibitory versus excitatory states of experiencing may help to clarify differences in dissociation and affect dysregulation between and within BPD and SoD patients.

Relations among peritraumatic dissociation and posttraumatic stress: a critical review.

This paper critically reviews the empirical literature addressing the relationship of peritraumatic dissociation to posttraumatic stress. PSYCHLIT and MEDLINE literature searches were conducted to identify relevant studies. The list of articles generated was supplemented by a review of their bibliographies, which resulted in a total of 53 empirical studies. These studies were classified according to the type of potentially traumatizing event investigated and discussed. In the majority of studies, evidence was found for a positive association between peritraumatic dissociation and posttraumatic stress. However, research in this area is limited by several methodological differences and shortcomings with respect to study design, sample characteristics, measurement instruments, and control for moderating or mediating variables. In addition, research is also limited by conceptual problems and the lack of specific time parameters for the occurrence of peritraumatic dissociation. The literature is evaluated according to these methodological differences or shortcomings, and directions for future research are provided.

Memory transfer for emotionally valenced words between identities in dissociative identity disorder.

The present study aimed to determine interidentity retrieval of emotionally valenced words in dissociative identity disorder (DID). Twenty-two DID patients participated together with 25 normal controls and 25 controls instructed to simulate DID. Two wordlists A and B were constructed including neutral, positive and negative material. List A was shown to one identity, while list B was shown to another identity claiming total amnesia for the words learned by the first identity. The identity claiming amnesia was tested for intrusions from list A words into the recall of words from list B and recognition of the words learned by both identities. Test results indicated no evidence of total interidentity amnesia for emotionally valenced material in DID. It is argued that dissociative amnesia in DID may more adequately be described as a disturbance in meta-memory functioning instead of an actual retrieval inability.

Posttraumatic stress following childbirth: a review.

To assess the empirical basis of prevalence and risk factors of childbirth-related posttraumatic stress symptoms and PTSD in mothers, the relevant literature was critically reviewed. A MEDLINE and PSYCHLIT search using the key words "posttraumatic stress", "PTSD", "childbirth" and "traumatic delivery" was performed. The generated list of articles was supplemented by a review of their bibliographies. A total of 31 articles was selected. The primary inclusion criterion was report of posttraumatic stress symptoms or PTSD specifically related to childbirth. Case studies and quantitative studies on regular childbirth and childbirth by emergency cesarean section were identified. Consistency among studies was found with regard to development of posttraumatic stress symptoms as a consequence of traumatic delivery. Methodological issues concerning prevalence and risk factors were discussed. Case studies and quantitative studies confirm that childbirth may be experienced as so emotionally intense that it can lead to the development of posttraumatic stress symptoms or even a PTSD-profile. Among the identified risk factors were a history of psychological problems, trait anxiety, obstetric procedures, negative aspects in staff-mother contact, feelings of loss of control over the situation, and lack of partner support. The conclusion of the current review is twofold. First, traumatic reactions to childbirth are an important public health issue. Secondly, studying childbirth offers opportunity to prospectively study the development of posttraumatic stress reactions.

Identity state-dependent attentional bias for facial threat in dissociative identity disorder.

Biased attention for threatening stimuli has been associated with many forms of psychopathology. Attention to threatening faces presented below perceptual thresholds was assessed in patients diagnosed with dissociative identity disorder using a pictorial emotional Stroop task. Patients were tested in two different identity states, in one of which they claimed strong awareness of trauma. Attentional bias for social threat proved state-dependent in the patients and deviated from the patterns observed in controls.

Transfer of newly acquired stimulus valence between identities in dissociative identity disorder (DID).

Patients with Dissociative Identity Disorder (DID) frequently report episodes of interidentity amnesia, that is amnesia for events experienced by other identities. The goal of the present experiment was to test the implicit transfer of trauma-related information between identities in DID. We hypothesized that whereas declarative information may transfer from one identity to another, the emotional connotation of the memory may be dissociated, especially in the case of negative, trauma-related emotional valence. An evaluative conditioning procedure was combined with an affective priming procedure, both performed by different identities. In the evaluative conditioning procedure, previously neutral stimuli come to refer to a negative or positive connotation. The affective priming procedure was used to test the transfer of this acquired valence to an identity reporting interidentity amnesia. Results indicated activation of stimulus valence in the affective priming task, that is transfer of emotional material between identities.

PTSD after childbirth: A predictive ethological model for symptom development.

BACKGROUND: Childbirth can be a traumatic experience occasionally leading to posttraumatic stress disorder (PTSD). This study aimed to assess childbirth-related PTSD risk-factors using an etiological model inspired by the transactional model of stress and coping. METHODS: 348 out of 505 (70%) Dutch women completed questionnaires during pregnancy, one week postpartum, and three months postpartum. A further 284 (56%) also completed questionnaires ten months postpartum. The model was tested using path analysis. RESULTS: Antenatal depressive symptoms (ß=.15, p<.05), state anxiety (ß=.17, p<.01), and perinatal psychoform (ß=.17, p<.01) and somatoform (ß=.17, p<.01) dissociation were identified as PTSD symptom risk factors three months postpartum. Antenatal depressive symptoms (ß=.31, p<.001) and perinatal somatoform dissociation (ß=.14, p<.05) predicted symptoms ten months postpartum. LIMITATIONS: Almost a third of our sample was lost at three months postpartum, and 44% at ten months. The sample size was relatively small. The present study did not control for prior PTSD. The PTSD A criterion was not considered an exclusion criteria for model testing, and the fit index of the ten months model was just below suggested cut-off values. CONCLUSIONS: Screening for high risk pregnant women should focus on antenatal depression, anxiety and dissociative tendencies. Hospital staff and midwives are advised to be vigilant for perinatal dissociation after intense negative emotions. To help regulate perinatal negative emotional responses, hospital staff and midwifes are recommended to provide information about birth procedures and be attentive to women's birth-related needs.

Does exposure type impact differentially over time on the development of mental health disturbances after a technological disaster?

BACKGROUND: A longitudinal study was conducted in order to assess the impact of the Ghislenghien disaster (July 30th, 2004) on physical, mental and social health in the affected population. The present study explored the risk for the development of four types of mental health disturbances (MHD) due to exposure to different aspects of this technological disaster in comparison with data obtained from previous health surveys among the population of the same province. METHODS: Surveys were conducted 5 months (T1) and 14 months (T2) after the disaster. Potential adult victims (≥15 years) were included (n = 1027 and 579 at T1 and T2 respectively). The "Symptom Checklist-90-Revised" (SCL-90-R) has been used in order to compute actual prevalence rates of somatization-, depression-, anxiety- and sleeping disturbances for three defined exposure categories: direct witnesses who have seen human damage (SHD), direct witnesses who have not seen human damage (NSHD) and indirect witnesses (IW). Those prevalence rates were compared with overall rates using the inhabitants of the province of Hainaut (n = 2308) as reference population. A mental health co-morbidity index was computed. Relative risks were estimated using logistic regression models. RESULTS: Prevalence rates of the four MHD were much higher for the SHD than for the other exposure groups, at T1 and T2. Moreover, NSHD and IW had no increased risk to develop one of the 4 types of MHD compared to the reference population. The SHD had at T1 and T2 good 5-times a higher risk for somatization, about 4-times for depression and sleeping disorders, and 5- to 6-times for anxiety disorders respectively. Further, they suffered 13 times, respectively 17 times more from all mental disorders together. CONCLUSIONS: The present study calls attention to the fact that mental health problems disturbances are significantly more prevalent and long-lasting among survivors who have directly been exposed to human damage.

Degree of exposure and peritraumatic dissociation as determinants of PTSD symptoms in the aftermath of the Ghislenghien gas explosion.

BACKGROUND: This paper investigates risk factors for the development of posttraumatic stress symptoms in the different survivor groups involved in a technological disaster in Ghislenghien (Belgium). A gas explosion instantly killed five firefighters, one police officer and 18 other people. Moreover, 132 people were wounded among which many suffered severe burn injuries. METHODS: In the framework of a large health survey of people potentially involved in the disaster, data were collected from 3,448 households, of which 7,148 persons aged 15 years and older, at 5 months (T1) and at 14 months (T2) after the explosion. Hierarchical regression was used to determine the significant predictors and to assess their proportion in variance accounted for. RESULTS: The degree of exposure to the disaster was a predictor of the severity of posttraumatic stress symptoms. Peritraumatic dissociation appeared to be the most important predictor of the development of posttraumatic stress symptoms at T1. But at T2, posttraumatic stress symptoms at T1 had become the most important predictor. Dissatisfaction with social support was positively linked to development of posttraumatic stress symptoms at T1 and to the maintenance of these symptoms at T2. Survivors who received psychological help reported significant benefits. CONCLUSIONS: In harmony with the findings from studies on technological disasters, at T1 6,0% of the respondents showed sufficient symptoms to meet all criteria for a full PTSD. At T2, 6,6% still suffered from posttraumatic stress symptoms. The symptoms of the different victim categories clearly indicated the influence of the degree of exposure on the development of posttraumatic stress symptoms. Problems inherent to retrospective scientific research after a disaster are discussed.

Interidentity amnesia for neutral, episodic information in dissociative identity disorder.

Interidentity amnesia is considered a hallmark of dissociative identity disorder (DID) in clinical practice. In this study, objective methods of testing episodic memory transfer between identities were used. Tests of both recall (interference paradigm) and recognition were used. A sample of 31 DID patients was included. Additionally, 50 control subjects participated, half functioning as normal controls and the other half simulating interidentity amnesia. Twenty-one patients subjectively reported complete one-way amnesia for the learning episode. However, objectively, neither recall nor recognition scores of patients were different from those of normal controls. It is suggested that clinical models of amnesia in DID may be specified to exclude episodic memory impairments for emotionally neutral material.

Dependency in the Treatment of Complex Posttraumatic Stress Disorder and Dissociative Disorders.

Dependency is a major and ubiquitous issue in the treatment of chronically traumatized patients, such as those with complex posttraumatic stress disorder (PTSD), trauma-related borderline personality disorder, and dissociative disorders. Within this context, the concept of dependency is often paired with pejorative adjectives, and is dichotomized and negatively compared to a preferred state of independence. This paper explores prevailing sociocultural and theoretical beliefs regarding dependency in the psychotherapy of trauma survivors, provides a working definition of dependency, offers an analysis of its complex nature, and describes the theory of structural dissociation, which helps illuminate the often contradictory manifestations of dependency in chronically traumatized patients. A distinction is made between secure and insecure dependency. Finally, this paper outlines the collaborative therapeutic process required to manage insecure dependency productively within a phase-oriented treatment model. Countertransference responses that interfere with a patient's conflicts regarding dependency are also discussed.

Trauma and traumatized populations in Israel: the Israel Journal of Psychiatry and Related Sciences, 1963-2002.

In Europe and the U.S., awareness of interpersonal traumatization has disappeared and reappeared, seemingly connected to socio-historical conditions. The authors wanted to explore this phenomenon in Israel, a complex, multicultural, society that has yet to know peace. Content analysis of a professional journal, the Israel Journal of Psychiatry, was the method of choice. This journal has existed since the fifteenth year of Israel's existence and, because it is published in English, is in active dialogue with the rest of the world. Striking parallels were found between the timing and focus on traumas in the published articles and the socio-cultural context.