Culture, trauma and dissociation: A broadening perspective for our field.

In the field of trauma and dissociation, culture has a significant influence on the clinical presentation of patients. A growing body of literature addresses the relationship between culture and dissociation. Studies of this relationship though, evoke the important, but at the same time extremely sensitive issue of cross-cultural comparisons. In this editorial, I provide a limited overview of various ways in which cultural influences have been addressed in the field of trauma and dissociation. Most studies have examined the occurrence of dissociative disorders in clinical populations in different cultures and countries. Some have focused on normative dissociation as a response to traumatic events in non-clinical samples from different cultures. This editorial also explores the concepts of double consciousness and black consciousness, which have emerged from the fields of social psychology and black psychology; and how these concepts influence our thinking about non-clinical dissociation. Culture-related challenges in the field of trauma and dissociation create opportunities for training in cultural competence for therapists. Qualitative research methods might be best suited to future research on the relationship between culture, trauma and dissociation. The chances of reaching a thorough and deep understanding of the influence of culture on trauma and dissociation might be best if the entire spectrum of dissociation is studied - from normal to pathological dissociation, and in its different manifestations from universal to those unique to certain cultural groups.

Traditionality, Spirituality and Somatoform Dissociation Symptoms in Chinese Buddhists.

To evaluate the relationship between spiritual experience and hysterical experiences in Buddhist participants in ethnic groups in China, this cross-sectional study recruited 39 participants aged 16-57 years old, and self-administered surveys were administered in two villages, one city and one town by four research assistants in the Inner Mongolia and Qinhai areas. Binary logistic regression analyses were used to evaluate the factors associated with somatoform dissociation symptoms. Surveys were completed by 639 participants (mean age 31 years; 54.6% females) in 2017. Binary regression models showed that diverging from tradition and having a college education or above were associated with suffering from somatoform dissociation symptoms. By contrast, participants with higher experiences and older people were less likely to experience somatoform dissociation symptoms. Our current research highlights the contribution of spiritual experiences and traditional values to reducing somatization dissociation symptoms, and the findings could help to promote a new relationship between psychiatry and spiritual experiences that will benefit both mental health professionals and those who seek their assistance.

Reliability of the Dissociative Trance Disorder Interview Schedule: A preliminary report.

One hundred inpatients in a hospital-based Trauma Program in the USA were interviewed with the Dissociative Trance Disorder Interview Schedule (DTDIS). There were no significant differences for the DTDIS total score or any of the subscale scores on test-retest: all t-values comparing the two administrations of the DTDIS were below 0.7, and all p-values were above 0.5. Cronbach's alpha for the US sample was 0.966 and for the Israeli sample it was 0.971. The findings indicate that the DTDIS has good reliability and may be suitable for use in cross-cultural research; however, the results require replication by independent researchers in a variety of cultures and languages, and in both clinical and nonclinical samples.

Dissociation From a Cross-Cultural Perspective: Implications of Studies in Brazil.

A major issue in the study of dissociation concerns the cross-cultural validity of definitions and measurements used to identify and classify dissociative disorders. There is also extensive debate on the etiological factors underlying dissociative experiences. Cross-cultural research is essential to elucidate these issues, particularly regarding evidence obtained from countries in which the study of dissociation is still in its infancy. The aim of this article was to discuss Brazilian research on the topic of dissociation, highlighting its contributions for the understanding of dissociative experiences in nonclinical populations and for the validity and relevance of dissociative disorders in the contexts of psychiatry, psychology, and psychotherapy. We also consider the ways in which dissociative experiences are assimilated by Brazilian culture and religious expressions, and the implications of Brazilian studies for the sociocultural investigation of dissociation. We conclude by addressing the limitations of these studies and potential areas for future research.

Dissociative trance and spirit possession: Challenges for cultures in transition.

The cross-cultural validity of dissociative possession and trance disorders is a matter of some debate, limiting research and meaningful interpretation of prevalence data. Intimate to these concerns is the status of spirit possession categories studied in the social sciences, particularly anthropology. These two categories are phenomenologically related and display similar epidemiological associations. In India, dissociative and conversion disorders are fairly common in clinical settings. There is no doubt that there are true cultural variations in possession and trance disorders. A new framework may enable clinicians to better understand possession states and spirit possession.

Predicting three types of dissociation in female survivors of intimate partner violence.

Previous research suggests that studying the effect of dissociation is particularly important in survivors of intimate partner violence because of the risk of revictimization. The current study investigated demographic variables, child and current abuse characteristics, coping style, and cognitive distortions as predictors of peritraumatic, trait, and posttraumatic stress disorder (PTSD)-related dissociation in a sample of female intimate partner violence survivors. The sample consisted of 372 women, the majority African American, with an average age of 34.41 years (SD = 8.09). Peritraumatic dissociation was significantly predicted by child physical abuse, current abuse injury, cognitive distortions about safety, and problem disengagement coping. Trait dissociation was significantly predicted by minority race, personal income, and cognitive distortions about safety and self-worth. PTSD-related dissociation was significantly predicted by cognitive distortions about self-worth, problem and emotion disengagement coping, and peritraumatic dissociation. In the models predicting both trait and PTSD-related dissociation, abuse characteristics significantly predicted dissociation until the entry of cognitive variables into the model. The analysis indicated a significant indirect effect of cognitive distortions on the relationship between current sexual aggression and trait dissociation. Results also suggested that there were indirect effects of both cognitive distortions and peritraumatic dissociation on the relationships between current psychological abuse/injury and PTSD-related dissociation. Findings point to the importance of cognitions in the development and maintenance of dissociation and suggest that treatments designed to help clients accept and process traumatic events may help reduce dissociation and in turn prevent future revictimization.

Assessment of dissociation in Bosnian treatment-seeking refugees in Denmark.

BACKGROUND: Dissociative experiences are common in traumatized individuals, and can sometimes be mistaken for psychosis. It is difficult to identify pathological dissociation in the treatment of traumatized refugees, because there is a lack of systematic clinical descriptions of dissociative phenomena in refugees. Furthermore, we are currently unaware of how dissociation measures perform in this clinical group. AIMS: To describe the phenomenology of dissociative symptoms in Bosnian treatment-seeking refugees in Denmark. METHOD: As a part of a larger study, dissociation was assessed systematically in 86 Bosnian treatment-seeking refugees using a semi-structured clinical interview (Structured Interview for Disorders of Extreme Stress-dissociation subscale; SIDES-D) and a self-report scale (Dissociative Experiences Scale; DES). RESULTS: The SIDES-D indicated twice as high prevalence of pathological dissociation as the DES. According to the DES, 30% of the refugees had pathological dissociation 15 years after their resettlement. On the SIDES-D, depersonalization and derealization experiences were the most common. Also, questions about depersonalization and derealization at times elicited reporting of visual and perceptual hallucinations, which were unrelated to traumatic re-experiencing. Questions about personality alteration elicited spontaneous reports of a phenomenon of "split" pre- and post-war identity in the refugee group. Whether this in fact is a dissociative phenomenon, characteristic of severe traumatization in adulthood, needs further examination. CONCLUSIONS: Knowledge of dissociative symptoms in traumatized refugees is important in clinical settings to prevent misclassification and to better target psychotherapeutic interventions. Much development in the measurement of dissociation in refugees is needed.

Ethnic variation in whether dissociation mediates the relation between traumatic life events and attenuated positive psychotic symptoms.

The present study sought to determine whether dissociative experiences mediated the relationship between traumatic life events and attenuated positive psychotic symptoms in a non-treatment-seeking sample of racial and ethnic minority young adults. Participants (n = 549) completed a self-report inventory for psychosis risk (i.e., the Prodromal Questionnaire; R. L. Loewy, C. E. Bearden, J. K. Johnson, A. Raine, & T. D. Cannon, 2005), from which a total number of attenuated positive psychotic symptoms was assessed. Participants also completed a checklist of potentially traumatic life events and a traumatic dissociation scale. Hierarchical linear regression models and bootstrapping results indicated that dissociation mediated the relationship between traumatic life events and attenuated positive psychotic symptoms. Stratified analyses of Black, Asian, and Hispanic subgroups revealed that full mediation was only evident in the Black subgroup of young adults. Partial mediation was found among the Hispanic group, and no mediation occurred in the Asian subgroup. For the latter, traumatic life events were not significantly associated with dissociative experiences. A dissociative response style may be particularly relevant to trauma-exposed Black young adults exhibiting subclinical psychotic experiences and less so for Asian young adults. Trauma-induced dissociative experiences should be assessed further in clinical high-risk studies, especially among Black traumatized youth.

Dissociative experiences in epilepsy--a neuropathological and sociodemographic study in a Chinese population.

BACKGROUND: It is well known that dissociative experiences coexist with various epilepsy syndromes. However, the prevalence of dissociative experiences in different subtypes of epilepsy remains unknown. This is especially important because of the current prevalent view that the etiology of dissociation in seizures is neurobiological rather than psychosocial. The amygdala especially has been implicated in such dissociative features of epilepsy. This would indirectly imply that the patients with CPS have higher prevalence of dissociative symptoms compared with those with GTCS. METHODOLOGY: We studied and compared the dissociative experiences as well as the depression and anxiety levels between 24 patients suffering from temporal lobe epilepsy and 26 patients suffering from generalized tonic-clonic seizures. We used the Dissociative Experiences Scale to evaluate the dissociative experiences. A third group of healthy individuals was included as the control group. The statistical significance was fixed at 0.05. RESULTS: There were significant differences between the scores of DES-II of the healthy individuals and those of patients with epilepsy. However, there were no significant differences between the DES scores of different patients with epilepsy categorized according to neuropathology. There were also no significant differences between HAM-A and HAM-D scores between groups with epilepsy, but the scores were higher than those of the healthy individuals. There were significant differences between the DES scores in different sociodemographic groups such that higher scores were observed in groups with lower education (p<0.05). In addition, the scores on DES were higher in individuals with low socioeconomic status than in those with high socioeconomic status. CONCLUSION: The patients with temporal lobe epilepsy and those with generalized tonic-clonic seizures have similar dissociative experiences which are both more than those found in individuals without epilepsy. However, these dissociative experiences may not be related to the neuropathological parameters as much as they are to the sociodemographic parameters like education, age, socioeconomic status, and sex. This shows that the psychopathology of dissociation in epilepsy is similar to that of the general population.

Ethnic syndromes as disguise for protest against colonialism: three ethnographic examples.

Historical connections are suggested between the domination of 1 culture by another and dissociative spiritual and religious responses to that oppression. Connections are drawn between colonial oppression, trauma, and 3 examples of dissociation and spirit possession: the Zar cult of Southern Sudan, "Puerto Rican syndrome" or ataque, and the Balinese trance dance. Discussed by means of these examples are the role and functions of spirit possession as a means of escape from unbearable reality, where it becomes a form of the expression of needs and desires forbidden by authorities, a way of entering an identity not subject to traditional authorities, and reenactment of traumatic experience.

Dissociation and symptoms of culture-bound syndromes in North America: a preliminary study.

The aim of this study was to determine whether classical culture-bound syndromes occur among psychiatric inpatients with dissociative disorders in North America. The Dissociative Trance Disorder Interview Schedule, the Dissociative Experiences Scale, and the Dissociative Disorders Interview Schedule were administered to 100 predominantly Caucasian, American, English-speaking trauma program inpatients at a hospital in the United States. The participants reported high rates of childhood physical and/or sexual abuse (87%), dissociative disorders (73%), and membership in the dissociative taxon (78%). They also reported a wide range of possession experiences and exorcism rituals, as well as the classical culture-bound syndromes of latah, bebainan, amok, and pibloktoq. Our data are consistent with the view that possession and classical culture-bound syndromes are predominantly dissociative in nature and not really culture-bound from the perspective of Caucasian, English-speaking America.

The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5.

BACKGROUND: There is considerable debate about the cross-cultural applicability of the posttraumatic stress disorder (PTSD) category as currently specified. Concerns include the possible status of PTSD as a Western culture-bound disorder and the validity of individual items and criteria thresholds. This review examines various types of cross-cultural validity of the PTSD criteria as defined in DSM-IV-TR, and presents options and preliminary recommendations to be considered for DSM-5. METHODS: Searches were conducted of the mental health literature, particularly since 1994, regarding cultural-, race-, or ethnicity-related factors that might limit the universal applicability of the diagnostic criteria of PTSD in DSM-IV-TR and the possible criteria for DSM-5. RESULTS: Substantial evidence of the cross-cultural validity of PTSD was found. However, evidence of cross-cultural variability in certain areas suggests the need for further research: the relative salience of avoidance/numbing symptoms, the role of the interpretation of trauma-caused symptoms in shaping symptomatology, and the prevalence of somatic symptoms. This review also indicates the need to modify certain criteria, such as the items on distressing dreams and on foreshortened future, to increase their cross-cultural applicability. Text additions are suggested to increase the applicability of the manual across cultural contexts: specifying that cultural syndromes-such as those indicated in the DSM-IV-TR Glossary-may be a prominent part of the trauma response in certain cultures, and that those syndromes may influence PTSD symptom salience and comorbidity. CONCLUSIONS: The DSM-IV-TR PTSD category demonstrates various types of validity. Criteria modification and textual clarifications are suggested to further improve its cross-cultural applicability.

A critical review of dissociative trance and possession disorders: etiological, diagnostic, therapeutic, and nosological issues.

OBJECTIVE: Although the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, acknowledges the existence of dissociative trance and possession disorders, simply named dissociative trance disorder (DTD), it asks for further studies to assess its clinical utility in the DSM-5. To answer this question, we conducted the first review of the medical literature. METHOD: The MEDLINE, CINAHL, and PsycINFO databases were searched from 1988 to 2010, seeking case reports of DTD according to the DSM or the International Classification of Diseases definitions. For each article, we collected epidemiologic and clinical data, explanatory models used by authors, treatments, and information on the outcome. RESULTS: We found 28 articles reporting 402 cases of patients with DTD worldwide. The data show an equal proportion of female and male patients, and a predominance of possession (69%), compared with trance (31%). Amnesia is reported by 20% of patients. Conversely, hallucinatory symptoms during possession episodes were found in 56% of patients and thus should feature as an important criterion. Somatic complaints are found in 34% of patients. Multiple explanatory models are simultaneously held and appear to be complementary. CONCLUSION: Data strongly suggest the inclusion of DTD in the DSM-5, provided certain adjustments are implemented. DTD is a widespread disorder that can be understood as a global idiom of distress, probably underdiagnosed in Western countries owing to cultural biases, whose incidence could increase given the rising flow of migration. Accurate diagnosis and appropriate management should result from a comprehensive evaluation both of sociocultural and of idiosyncratic issues, among which acculturation difficulties should systematically be considered, especially in cross-cultural settings.

Dissociative symptoms and reported trauma among patients with spirit possession and matched healthy controls in Uganda.

Spirit possession is a common, worldwide phenomenon with dissociative features. Studies in Europe and the United States have revealed associations among psychoform and somatoform dissociation and (reported) potential traumatic events. The aim of this study was to explore the relationships among spirit possession, dissociative symptoms and reported potentially traumatizing events in Uganda. One hundred nineteen persons with spirit possession, diagnosed by traditional healers, were compared to a matched control group of 71 nonpossessed persons. Assessments included demographic items and measures of dissociation and potentially traumatizing events. Compared to the nonpossessed group, the possessed group reported more severe psychoform dissociation and somatoform dissociation and more potentially traumatizing events. The associations between these events and both types of dissociation were significant. Yet, consistent with the cultural perception of dissociative symptoms, the participants subjectively did not associate dissociative symptoms with potentially traumatizing events. In conclusion, spirit possession deserves more interest as a possible idiom of distress and a culture-specific expression of dissociation related to potential traumatizing events.

Association of trauma-related disorders and dissociation with four idioms of distress among Latino psychiatric outpatients.

Past research on idioms of distress among U.S. Latinos has revealed that ataque de nervios and altered perceptions, such as hearing and seeing things when alone, are independent markers of higher morbidity and mental health utilization despite having no one-to-one relationships with any single psychiatric diagnosis. It has been proposed that the idioms exert this effect because they are signs of distressing dissociative capacity associated with traumatic exposure. This study examines the relationships in an ethnically diverse Latino psychiatric outpatient sample (N = 230) among interpersonal trauma, posttraumatic stress disorder (PTSD), major depressive disorder, dissociative capacity and four cultural idioms of distress associated with the popular overall category of nervios. We particularly explore how these relationships change with varied measures of traumatic exposure, including trauma severity and timing or persistence of trauma. A series of adjusted bivariate regressions assessed the matrix of associations between the idioms and the clinical variables. In this highly traumatized population, we identified a strong 'nexus' of associations between dissociation and three of the idioms: currently being ill with nerves, ataque de nervios and altered perceptions. These idioms were largely independent from PTSD and depression and were associated with trauma persistence and severity. A fourth idiom, being nervous since childhood, was not associated with any other variable and may represent a personality trait rather than a diagnosable condition. Our results validate the clinical utility of the construct of nervios as a set of specific idioms associated with dissociation that are useful markers of mental health need among Latinos independently of their association with clinical diagnoses.

Psychometric properties of the Adolescent Dissociative Experiences Scale (A-DES) in Japanese adolescents from a community sample.

The purpose of this study was to examine the psychometric properties of the Adolescent Dissociative Experiences Scale (A-DES) applied to Japanese adolescents in school. A large sample of normal adolescents (N = 2,272) aged 11 to 18 years completed the A-DES, and the factor structure, frequency, and differences by gender and age were examined. The scores of Japanese adolescents were comparable to the results of similarly aged adolescents in the United States, England, and Turkey but much higher than those recorded in The Netherlands, Finland, and Sweden. In particular, adolescents aged 11 to 12 seemed to have more dissociative experiences than older adolescents. Out of 1-, 2-, 3-, and 4-factor structures that exploratory factor analyses regarded as competing models, confirmatory factor analyses seemed to support a 3-factor structure: depersonalization, disintegration of conscious control, and amnesia. The future implications of these results for clinicians and professionals who assess dissociative tendency in adolescents are described.

Dissociative disorders among Chinese inpatients diagnosed with schizophrenia.

The purpose of this study was to assess the prevalence of dissociative disorders in a sample of Chinese psychiatric inpatients. Participants in the study were 569 consecutively admitted inpatients at Shanghai Mental Health Center, China, of whom 84.9% had a clinical diagnosis of schizophrenia based on the Chinese Classification and Diagnostic Criteria of Mental Disorders, Version 3. All participants completed a self-report measure of dissociation (the Dissociative Experiences Scale), and none had a prior diagnosis of a dissociative disorder. A total of 96 randomly selected participants were interviewed with a structured interview (the Dissociative Disorders Interview Schedule) and a clinical interview. These 96 patients did not differ significantly from the 473 patients who were not interviewed on any demographic measures or who did not complete the self-report dissociation measure. A total of 28 patients (15.3%, after weighting of the data) received a clinical diagnosis of a dissociative disorder based on Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) criteria. Dissociative identity disorder was diagnosed in 2 patients (0.53%, after weighting). Compared to the patients without a dissociative disorder, patients with dissociative disorders were significantly more likely to report childhood abuse (57.1% vs. 22.1%), but the 2 groups did not differ significantly on any demographic measures. Dissociative disorders were readily identified in an inpatient psychiatric population in China.

The role of peripartum dissociation as a predictor of posttraumatic stress symptoms following childbirth in Israeli Jewish women.

OBJECTIVE: This study aimed to assess the role of peripartum dissociation in the development of childbirth-related posttraumatic stress (PTS) symptoms. Furthermore, it examined the relation between life-traumatizing events, in particular childhood sexual abuse (CSA), dissociation tendencies, prenatal PTS, prenatal depression, peripartum dissociation, and postnatal PTS symptoms. METHOD: A self-report questionnaire was administered to 1,003 Israeli Jewish women (sample after attrition) at mid-pregnancy (18-28 weeks) and at 2 months postnatally. RESULTS: Women with a history of CSA scored higher on all variables during pregnancy and postpartum. Prenatal PTS symptoms, depression, and dissociation tendencies coincided with higher levels of peripartum dissociation. CONCLUSION: Screening pregnant women, especially CSA victims, and implementing models of prevention and intervention can assist these women in acquiring better coping strategies during childbirth. Such practices are likely to decrease peripartum dissociation, which may in turn lessen postpartum PTS symptoms.

Is maternal PTSD associated with greater exposure of very young children to violent media?

This study examined media viewing by mothers with violence-related posttraumatic stress disorder (PTSD) and related media exposure of their preschool-age children. Mothers (N = 67) recruited from community pediatric clinics participated in a protocol involving a media-preference survey. Severity of maternal PTSD and dissociation were significantly associated with child exposure to violent media. Family poverty and maternal viewing behavior were also associated. Maternal viewing behavior mediated the effects specifically of maternal PTSD severity on child exposure. Clinicians should assess maternal and child media viewing practices in families with histories of violent trauma exposure and related psychopathology.

Racial and ethnic differences in dissociation: an examination of the dissociative experiences scale in a nonclinical population.

The present study sought to examine normative dissociation within a racially and ethnically diverse nonclinical sample. In all, 317 undergraduates, including 190 Whites and 127 racial/ethnic minorities from a large research university participated in the current study. Results indicated differences in dissociation as a function of race: African and Asian Americans reported significantly higher rates of dissociation compared to Whites. There were no differences in psychological adjustment indicators as a function of race. The findings indicate that race moderates the relationship between dissociation and psychological adjustment outcomes for Blacks (all models) and Asian Americans (1 model), such that higher rates of dissociation are associated with lower rates of psychological distress as compared to Whites.