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TRAUMA AND DISSOCIATION
Charles R. Marmar M.D.
Department of Psychiatry,
University of California, San Francisco and
Department of Veterans Affairs Medical
Center, San Francisco
The past decade has witnessed an intense reawakening of interest in the study
of trauma and dissociation. In particular, the contributions of Janet, which
had been largely eclipsed by developments within modern ego psychology and cognitive
behav-ioral therapy, have enjoyed a resurgence of interest. Putnam (1989) and
van der Kolk and van der Hart (1989) have provided a contemporary reinterpreta-tion
of the contributions of Janet to the understanding of traumatic stress and dissociation.
Recent research on the interrelations among trauma, memory, and dissociation
is presented in a forthcoming book by Bremner and Marmar.
Paralleling the resurgence of interest in theoretical studies of trauma and
dissociation, there has been a proliferation of research studies addressing
the rela-tionship of trauma and general dissociative tenden-cies. Chu and Dill
(1990) reported that psychiatric patients with a history of childhood abuse
reported higher levels of dissociative symptoms than those without histories
of child abuse. Carlson and Rosser-Hogan (1991), in a study of Cambodian refugees,
reported a strong relat ionship between the amount of trauma the refugees had
experienced and the severity of both traumatic stress response and dissociative
reactions. Spiegel and colleagues (1988) compared the hynotizability of Vietnam
combat veterans with PTSD to patients with generalized anxiety disorders, affective
disorders, and schizophrenia, as well as to the normal comparison group. The
group with PTSD was found to have hypnotizability scores that were higher than
both the psychopathological and normal controls.
Recent empirical studies have supported a strong relationship among trauma,
dissociation, and per-sonality disturbances. Herman and colleagues (1989) found
a high prevalence of traumatic histories in patients with borderline personality
disorder. A pro-found relationship has been reported for childhood trauma and
multiple personality disorder (MPD). Kluft (1993) proposes that the dissociative
processes that underlie multiple personality development con-tinue to serve
a defense function for individuals who have neither the external nor internal
resources to cope with traumatic experiences. Coons and Milstein (1986) reported
that 85% of a series of 20 MPD patients had documented allegations of childhood
abuse. Simi-lar observations have been made by Frischholz (1985) and Putnam
and colleagues (1986), who reported rates of severe childhood abuse as high
as 90% in patients with MPD. The nature of the childhood trauma in many of these
cases is notable for its severity, multiple elements of physical and sexual
abuse, threats to life, bizarre elements, and profound rupture of the sense
of safety and trust when the perpetrator is a primary caretaker or other close
relationship.
Peritraumatic Dissociation. The studies reviewed clearly demonstrate the relationship
between trau-matic life experience and general dissociative response. One fundamental
aspect of the dissociative response to trauma concerns immediate dissociation
at the time the traumatic event is unfolding. Trauma victims not uncommonly
will report alterations in the experience of time, place, and person, which
confers a sense of unreality of the event as it is occurring. Dissociation during
trauma may take the form of altered time sense, with time being experienced
as slowing down or rapidly accelerated; profound feelings of unreality that
the event is occurring, or that the individual is the victim of the event; experiences
of depersonalization; out-of-body experiences; bewilderment, confusion, and
disorientation; altered pain perception; altered body image or feelings of disconnection
from onešs body; tunnel vision; and other experiences reflecting immediate dissociative
responses to trauma. We have designated these acute dissociative responses to
trauma as peritraumatic dissociation.
Although actual clinical reports of peritraumatic dissociation date back nearly
a century, systematic investigation has occurred more recently. Wilkinson (1983)
investigated the psychological reponses of sur-vivors of the Hyatt Regency Hotel
skywalk collapse in which 114 people died and 200 were injured. Survi-vors commonly
reported depersonalization and derealization experiences at the time of the
structural collapse. Holen (1993), in a long-term prospective study of survivors
of a North Sea oil rig disaster, found that the level of reported dissociation
during the trauma was a predictor of subsequent PTSD. Koopman and colleagues
(1994) investigated predic-tors of posttraumatic stress symptoms among survi-vors
of the 1991 Oakland Hills firestorm. In a study of 187 participants, dissociative
symptoms at the time the firestorm was occurring more strongly predicted subsequent
posttraumatic symptoms than did anxi-ety and the subjective experience of loss
of personal autonomy.
Peritraumatic Dissociative Experiences Questionnaire. Based on the important
clinical and early research observations on peritraumatic dissociation as a
risk
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factor for chronic PTSD, we embarked on a series of studies
to develop a reliable and valid measure of peritraumatic
dissociation. We designated this measure the Peritraumatic
Dissociative Experiences Questionnaire (Marmar et al., 1996).
In a first study with the PDEQ, the relationship of
peritraumatic dissociation and posttraumatic stress was in-
vestigated in male Vietnam theater veterans (Marmar et al.,
1994). In a first replication of this finding, the relationship of
peritraumatic dissociation with symptomatic distress was
determined in emergency services personnel exposed to
traumatic critical incidents (Weiss et al., 1995; Marmar et al.,
1996). In a second replication, the relationship of peritraumatic
dissociation and posttraumatic stress was investigated in
female Vietnam theater veterans (Tichenor et al., 1994).
Across the four studies, the PDEQ has been demonstrated
to be internally consistent, strongly associated with mea-
sures of traumatic stress response, strongly associated with
a measure of general dissociative tendencies, strongly asso-
ciated with level of stress exposure, and unassociated with
measures of general psychopathology. These studies sup-
port the reliability and convergent, discriminant, and predic-
tive validity of the PDEQ. Strengthening these findings are
two independent studies utilizing the PDEQ by investigators
in other PTSD research programs. Bremner and colleagues
(1992), utilizing selective items from the PDEQ as part of a
measure of peritraumatic dissociation, reported a strong
relationship of peritraumatic dissociation with posttrau-
matic stress response in an independent sample of Vietnam
War veterans. In the first prospective study with the PDEQ,
Shalev and colleagues (1996) examined the relationship of
PDEQ ratings gathered in the first week following trauma
exposure to posttraumatic stress symptomatology at 5
months. In this study of acute-physical-trauma victims ad-
mitted to an Israeli teaching hospital emergency room, PDEQ
ratings at 1 week predicted stress symptomatology at 5
months, over and above exposure levels, social supports,
and Impact of Event scores in the first week. This study is
noteworthy in that it is the first finding with the PDEQ in
which ratings were gathered prospectively.
Mechanisms for Peritraumatic Dissociation. The strong repli-
cated findings relating peritraumatic dissociation to subse-
quent PTSD raise theoretically important questions concern-
ing the mechanisms that underlie peritraumatic dissociation.
Speculation concerning psychological factors underlying
trauma-related dissociation date back to the early contribu-
tions of Breuer and Freud (1895/1955). In their formulation,
traumatic events are actively split off from conscious experi-
ence but return in the disguised form of symptoms. The
dissociated complexes have an underground psychological
life, causing hysterics to "suffer mainly from reminiscences."
Janet (1889) proposed that trauma-related dissociation oc-
curred in individuals with a fundamental constitutional
defect in psychological functioning, which he designated la
misere psychologique. Janet proposed that normal individuals
have sufficient psychological energy to bind together their
mental experiences, including memories, cognitions, sensa-
tions, feelings, and volition, into an integrated synthetic
whole under the control of a single personal self with access
to conscious experience (Nemiah, in press). From Janet's
perspective, peritraumatic dissociation results in the coexist-
ence within a single individual of two or more discrete,
dissociative streams of consciousness, each existing inde-
pendently from the others, each with rich mental contents,
including feelings, memories, and bodily sensations, and
each with access to conscious experience at different times.
Contemporary psychological studies of peritraumatic dis-
sociation have focused on individual differences in the thresh-
old for dissociation. It is also possible that the threshold for
peritraumatic dissociation or generalized dissociative vul-
nerability is a heritable trait, aggravated by early trauma
exposure and correlated with hypnotizability, as suggested
by Spiegel and colleagues (1988).
A second line of investigation concerning the underlying
mechanisms for peritraumatic dissociation focuses on the
neurobiology and neuropharmacology of anxiety. A yohim-
bine challenge study by Southwick and colleagues (1993)
suggests that, in individuals with PTSD, flashbacks occur in
the context of high-threat arousal states. It is also significant
that panic-disordered patients frequently report dissociative
reactions at the height of their anxiety attacks. The effects of
yohimbine in triggering flashbacks in PTSD patients and
panic attacks in patients with panic disorder is mediated by
a central catecholamine mechanism, as yohimbine serves as
an alpha-adrenergic receptor antagonist, resulting in in-
creased firing of locus ceruleus neurons. These observations
suggest that the relationship between peritraumatic disso-
ciation and PTSD may, for some individuals, be mediated by
high levels of anxiety during the trauma.
Marmar et al. (1996) reported on individual differences in
the level of peritraumatic dissociation during critical-inci-
dent exposure in emergency services personnel. They found
the following factors to be associated with greater levels of
peritraumatic dissociation: younger age; higher levels of
exposure during critical incident; greater subjective per-
ceived threat at the time of critical incident; poorer general
psychological adjustment; poorer identity formation; lower
levels of ambition and prudence, as defined by the Hogan
Personality Inventory; greater external locus of control; and
greater use of escape/avoidance and emotional self-control
coping. Taken together these findings suggest that emer-
gency services personnel with less work experience, more
vulnerable personality structures, higher subjective levels of
perceived threat and anxiety at the time of incidence occur-
rence, greater reliance on the external world for an internal
sense of safety and security, and greater use of maladaptive
coping strategies are more vulnerable to peritraumatic dis-
sociation.
Treatment for Trauma Related Dissociation. To date, no con-
trolled clinical trials have been reported of psychosocial or
pharmacological intervention specifically targeting trauma-
related dissociation. Kluft (1993), in an overview of clinical
reports on treatment approaches for trauma-related disso-
ciation, recommends individual, supportive-expressive
psychodynamic psychotherapy, augmented as needed with
hypnosis or drug-facilitated interviews. In 1993, van der Hart
and Spiegel advocated the use of hypnosis as a way of
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creating a safe, calm mental state in which the patient has
control over traumatic memories, as an approach to the
treatment of trauma-induced dissociative states presenting
as hysterical psychosis.
Contemporary psychodynamic approaches to the treat-
ment of trauma-related dissociation emphasize the estab-
lishment of the therapeutic alliance, reconstruction of trau-
matic memories, working through of problematic weak and
strong self-concepts activated by the trauma, and transfer-
ence interpretation aimed at helping the patient process
perceived threats in the relationship with the therapist with-
out resorting to dissociation (Horowitz, 1986; Marmar, 1991).
As the previously dissociative elements are brought in to a
more coherent self, the further use of traditional
psychodynamic psychotherapy can help the patient solidify
gains, mourn losses, and resolve conflicts through interpre-
tation.
From a neuropharmacological point of view, Pitman (per-
sonal communication, 1994) has advocated the use of medi-
cations to lower threat arousal levels at the time of traumatic
occurrence. Alpha-2 adrenergic agonists, beta-blockers, or
other nonsedating, antiarousal agents, could be provided to
emergency services personnel to aid in the modulation of
arousal responses to life-threatening or gruesome exposure.
Advances in critical-incident stress-debriefing procedures
may lead to psychological interventions that lower immedi-
ate threat appraisal and consequently reduce the likelihood
of sustained peritraumatic dissociation.
REFERENCES
JANET, P. (1889). L'automatisme psychologique: Essai de psychologie
experimentale sur les formes inferieures de l'activite humaine. Paris:
Alcan.
BREUER, J., & FREUD, S. (1955). Studies on hysteria. In J.
Strachey (Ed. and Trans.), The standard edition of the complete
psychological works of Sigmund Freud (Vol. 2). London: Hogarth
Press. (Original work published 1895).
SELECTED ABSTRACTS
BREMNER, J.D., & BRETT, E.A. (1997). Trauma-related disso-
ciative states and long-term psychopathology in posttraumatic
stress disorder. Journal of Traumatic Stress, 10, 37-49. Dissociative
responses to trauma have been hypothesized to be associated with
long-term increases in psychopathology. The purpose of this study
was to examine dissociative responses to premilitary, combat-
related and postmilitary traumatic events and long-term psycho-
pathology in Vietnam combat veterans with (n = 34) and without (n
= 28) PTSD. PTSD patients reported higher levels of dissociative
states at the time of combat-related traumatic events than non-
PTSD patients. Higher levels of dissociative states persisted in
PTSD patients in the form of higher levels of dissociative states in
response to postmilitary traumatic events. In addition, dissociative
responses to combat trauma were associated with higher long-term
general dissociative symptomatology as measured by scores on the
Dissociative Experience Scale, as well as increases in the number of
flashbacks since the time of the war. These findings are consistent
with previous formulations that dissociation in the face of trauma
is a marker of long-term psychopathology.
BREMNER, J.D. & MARMAR, C. (Eds.) (in press). Trauma,
memory, and dissociation. Washington, DC: American Psychiatric
Press. [Abstract not available at press deadline]
BREMNER, J.D., SOUTHWICK, S.M., BRETT, E., FONTANA,
A., ROSENHECK, R.A., & CHARNEY, D.S. (1992). Dissociation
and posttraumatic stress disorder in Vietnam combat veterans.
American Journal of Psychiatry, 149, 328-332. OBJECTIVE: This study
compared current dissociative symptoms and dissociation at the
time of specific traumatic events in Vietnam combat veterans with
PTSD and Vietnam combat veterans without PTSD. METHOD:
Vietnam combat veterans who sought treatment for PTSD (N = 53)
were compared to Vietnam combat veterans without PTSD (N = 32)
who sought treatment for medical problems. Dissociative symp-
toms were evaluated with the Dissociative Experiences Scale.
Dissociation at the time of a combat-related traumatic event was
evaluated retrospectively with the modified Dissociative Experi-
ences Questionnaire. The Combat Exposure Scale was used to
measure level of combat exposure. RESULTS: There was a signifi-
cantly higher level of dissociative symptoms, as measured by the
Dissociative Experiences Scale, in patients with PTSD (mean = 27.0,
SD = 18.0) than in patients without PTSD (mean = 13.7, SD = 16.0).
This difference persisted when the difference in level of combat
exposure was controlled with analysis of covariance. PTSD patients
also reported more dissociative symptoms at the time of combat
trauma, as measured retrospectively by the Dissociative Experi-
ences Questionnaire (mean = 11.5, SD = 1.6) than non-PTSD pa-
tients (mean = 1.8, SD = 2.1). CONCLUSIONS: Dissociative symp-
toms are an important element of the long-term psychopathologi-
cal response to trauma.
CARLSON, E. B., & ROSSER-HOGAN, R. (1991). Trauma expe-
riences, posttraumatic stress, dissociation, and depression in
Cambodian refugees. American Journal of Psychiatry, 148, 1548-
1551. OBJECTIVE: The authors' goal was to determine the levels of
trauma and psychiatric symptoms in a randomly selected group of
Cambodian refugees and to determine the relationship between
the amount of trauma experienced and subsequent psychiatric
symptoms. METHOD: Data on traumatic experiences and symp-
toms of posttraumatic stress, dissociation, depression, and anxiety
were collected on 50 randomly selected Cambodian refugees who
had resettled in the United States. RESULTS: Subjects experienced
multiple and severe traumas and showed high levels of all symp-
toms measured. 43 (86 percent) of the subjects met DSM-III-R
criteria for PTSD, 48 (96 percent) had high dissociation scores, and
40 (80 percent) could be classified as suffering from clinical depres-
sion. Correlations between trauma scores and symptom scores and
among symptom scores were moderate to large. CONCLUSIONS:
These results indicate that a high proportion of Cambodian refu-
gees who are not psychiatric patients suffer from severe psychiatric
symptoms and that there is a relationship between the amount of
trauma they experienced and the severity of these symptoms.
CHU, J.A. & DILL, D.L. (1990). Dissociative symptoms in rela-
tion to childhood physical and sexual abuse. American Journal of
Psychiatry, 147, 887-892. Studies have reported high rates of child-
hood abuse in people with psychiatric illness. This study examined
whether dissociative symptoms are specific to patients with histo-
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ries of abuse. 98 female psychiatric inpatients completed self-report
instruments that focused on childhood history of trauma, dissocia-
tive symptoms, and psychiatric symptoms in general. 63 percent of
the subjects reported physical and/or sexual abuse. 83 percent had
dissociative symptom scores above the median score of normal
adults, and 24 percent had scores at or above the median score of
patients with PTSD. Subjects with a history of childhood abuse
reported higher levels of dissociative symptoms than those who
did not.
HERMAN, J. L., PERRY, J. C., & VAN DER KOLK, B. A. (1989).
Childhood trauma in borderline personality disorder. American
Journal of Psychiatry, 146, 490-495. Abstracted in PTSD Research
Quarterly, 3(3), 1992.
HOLEN, A. (1993). The North Sea oil rig disaster. In J. P. Wilson
& B. Raphael (Eds.), International handbook of traumatic stress syn-
dromes (pp. 471-478). New York: Plenum Press. Survivors of the
Alexander L. Kielland, an oil rig that capsized in the North Sea with
great loss of life, were followed over an eight-year period. A wide
range of long-term consequences was studied. At the time of the
disaster dissociation was found to be significantly associated with
the general short-term outcome. This was less so in the long term,
where it was found to be associated with the avoidance score on the
Impact of Event Scale.
KOOPMAN, C., CLASSEN, C. C., & SPIEGEL, D. (1994). Predic-
tors of posttraumatic stress symptoms among survivors of the
Oakland/Berkeley, Calif., firestorm. American Journal of Psychiatry
151, 888-894. OBJECTIVE: The purpose of this study was to exam-
ine factors predicting the development of posttraumatic stress
symptoms after a traumatic event, the 1991 Oakland/Berkeley
firestorm. The major predictive factors of interest were dissociative,
anxiety, and loss of personal autonomy symptoms reported in the
immediate aftermath of the fire; contact with the fire; and life
stressors before and after the fire. METHOD: Subjects were re-
cruited from several sources so that they would vary in their extent
of contact with the fire. Of 187 participants who completed self-
report measures about their experiences in the aftermath of the
firestorm, 154 completed a follow-up assessment. Of these 154
subjects, 97 percent completed the follow-up questionnaires 7-9
months after the fire. The questionnaires included measures of
posttraumatic stress and life events since the fire. RESULTS: Disso-
ciative and loss of personal autonomy symptoms experienced in
the fire's immediate aftermath, as well as stressful life experiences
occurring later, significantly predicted posttraumatic stress symp-
toms measured 7-9 months after the firestorm by a civilian version
of the Mississippi Scale for Combat-Related PTSD and the Impact
of Event Scale. Dissociative symptoms more strongly predicted
posttraumatic symptoms than did anxiety and loss of personal
autonomy symptoms. Intrusive thinking differs from other kinds
of posttraumatic symptoms in being related directly to the trauma
and previous stressful life events. CONCLUSIONS: These findings
suggest that dissociative symptoms experienced in the immediate
aftermath of a traumatic experience and subsequent stressful expe-
riences are indicative of risk for the later development of posttrau-
matic stress symptoms. Such measures may be useful as screening
procedures for identifying those most likely to need clinical care to
help them work through their reactions to the traumatic event and
to subsequent stressful experiences.
MARMAR, C. R. (1991). Brief dynamic psychotherapy of post-
traumatic stress disorder. Psychiatric Annals, 21, 404-414. The suc-
cess of short-term psychotherapeutic interventions depends on the
ability of the patient and therapist to enter quickly into a collabora-
tive working process. Brief dynamic psychotherapy has its greatest
applicability for individuals who present with PTSD several months
to several years following traumatic stress events. Acute cata-
strophic stress reactions occur within hours or a few days of
traumatic stress exposure. The impact of a traumatic event on the
person's self-concept serves as an organizer for the unfolding of the
treatment process. The brief treatment approach is best suited for
relatively well-functioning individuals who suffer a single trau-
matic event in adult life.
MARMAR, C.R., WEISS, D.S., METZLER, T.J., & DELUCCHI, K.
(1996). Characteristics of emergency services personnel related to
peritraumatic dissociation during critical incident exposure.
American Journal of Psychiatry, 153 (Festschrift Supplement), 94-102.
Abstracted in PTSD Research Quarterly, 8(2), 1997.
MARMAR, C.R., WEISS, D.S., SCHLENGER, W.E., FAIRBANK,
J.A., JORDAN, B.K., KULKA, R.A. & HOUGH, R.L. (1994).
Peritraumatic dissociation and posttraumatic stress in male Viet-
nam theater veterans. American Journal of Psychiatry 151, 902-907.
OBJECTIVE: The aim of this study was to determine the reliability
and validity of a proposed measure of peritraumatic dissociation
and, as part of that effort, to determine the relationship between
dissociative experiences during disturbing combat trauma and the
subsequent development of PTSD. METHOD: A total of 251 male
Vietnam theater veterans from the Clinical Examination Compo-
nent of the National Vietnam Veterans Readjustment Study were
examined to determine the relationship of war zone stress expo-
sure, retrospective reports of dissociation during the most disturb-
ing combat trauma events, and general dissociative tendencies
with PTSD case determination. RESULTS: The total score on the
Peritraumatic Dissociation Experiences Questionnaire-Rater Ver-
sion was strongly associated with level of posttraumatic stress
symptoms, level of stress exposure, and general dissociative ten-
dencies and weakly associated with general psychopathology scales
from the MMPI-2. Logistic regression analyses supported the incre-
mental value of dissociation during trauma, over and above the
contributions of level of war zone stress exposure and general
dissociative tendencies, in accounting for PTSD case determina-
tion. CONCLUSIONS: These results provide support for the reli-
ability and validity of the Peritraumatic Dissociation Experiences
Questionnaire-Rater Version and for a trauma-dissociation linkage
hypothesis: the greater the dissociation during traumatic stress
exposure, the greater the likelihood of meeting criteria for current
PTSD.
PUTNAM, F.W. (1989). Pierre Janet and modern views of
dissociation. Journal of Traumatic Stress, 2, 413-429. Pierre Janet's
numerous important contributions to the understanding of disso-
ciative disorders grew out of his background in philosophy, psy-
chology, and medicine. A religious and even mystical man, he
tempered his lifetime studies of psychopathology with precise
observation and rigorous documentation. Janet was the first to
articulate the clinical principles of the dissociative disorders and to
systematically explore and treat the traumatic memories underly-
ing dissociated behavior. He pioneered the use of abreaction and
age-regression hypnotherapy techniques for exploring hidden
trauma. Our clinical understanding of the dissociative disorders
and their treatment stems in large measure from Pierre Janet's
careful and thoughtful investigations a century ago.
SHALEV, A.Y., PERI, T., CANETTI, L. & SCHREIBER, S. Predic-
tors of PTSD in injured trauma survivors: A prospective study.
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(1996). American Journal of Psychiatry 153, 219-225. OBJECTIVE: The
aim of this study was to prospectively examine the relationship
between immediate and short-term responses to a trauma and the
subsequent development of PTSD. METHOD: All patients con-
secutively admitted to a general hospital were screened for the
presence of physical injury due to a traumatic event. 51 eligible
subjects were assessed 1 week and 6 months after the trauma.
The initial assessment included measures of event severity,
peritraumatic dissociation, and symptoms of intrusion, avoid-
ance, depression, and anxiety. The follow-up assessments added
the PTSD module of the Structured Clinical Interview for DSM-
III-R - Non-Patient Version and the civilian trauma version of
the Mississippi Scale for Combat-Related PTSD. RESULTS: 13
subjects (25.5 percent) met PTSD diagnostic criteria at follow-
up. Subjects who developed PTSD had higher levels of
peritraumatic dissociation and more severe depression, anxiety,
and intrusive symptoms at the 1-week assessment. Peritraumatic
dissociation predicted a diagnosis of PTSD after 6 months over
and above the contribution of other variables and explained 29.4
percent of the variance of PTSD symptom intensity. Initial
scores on the Impact of Event Scale predicted PTSD status with
92.3 percent sensitivity and 34.2 percent specificity. Symptoms
of avoidance that were initially very mild intensified in the
subjects who developed PTSD. CONCLUSION: Peritraumatic
dissociation is strongly associated with the later development of
PTSD. Early dissociation and PTSD symptoms can help the
clinician identify subjects at higher risk for developing PTSD.
SPIEGEL, D., HUNT, T., & DONDERSHINE, H.E. (1988).
Dissociation and hypnotizability in posttraumatic stress dis-
order. American Journal of Psychiatry, 145, 301-305. The authors
compared the hypnotizability of 65 Vietnam veteran patients
with PTSD to that of a normal control group and four patient
samples using the Hypnotic Induction Profile. The patients with
PTSD had significantly higher hypnotizability scores than pa-
tients with diagnoses of schizophrenia (N = 23); major depres-
sion, bipolar disorder - depressed, and dysthymic disorder (N =
56); and generalized anxiety disorder (N = 18) and the control
sample (N = 83). This finding supports the hypothesis that
dissociative phenomena are mobilized as defenses both during
and after traumatic experiences. The literature suggests that
spontaneous dissociation, imagery, and hypnotizability are im-
portant components of PTSD symptoms.
TICHENOR, V., MARMAR, C.R., WEISS, D.S., METZLER,
T.J., & RONFELDT, H.M. (1996). The relationship of
peritraumatic dissociation and posttraumatic stress: findings
in female Vietnam theater veterans. Journal of Consulting and
Clinical Psychology, 64, 1054-1059. This study examined the rela-
tionship of dissociation at the time of trauma, as assessed by the
Peritraumatic Dissociation Experiences Questionnaire, Rater
Version (PDEQ-RV), and posttraumatic stress symptoms in a
group of 77 female Vietnam theater veterans. PDEQ-RV ratings
were found to be associated strongly with posttraumatic stress
symptomatology, as measured by the Impact of Event Scale, and
also positively associated with level of stress exposure and
general dissociative tendencies, measured by the Dissociative
Experiences Scale. The PDEQ-RV was unassociated with gen-
eral psychiatric symptomatology, as assessed by the clinical
scales of the Minnesota Multiphasic Personality Inventory-2.
The PDEQ-RV was predictive of posttraumatic stress symptoms
beyond the contributions of level of stress exposure and general
dissociative tendencies. The findings provide further support
for the reliability and validity of the PDEQ-RV as a measure of
peritraumatic dissociation.
VAN DER HART, O. & SPIEGEL, D. (1993). Hypnotic assess-
ment and treatment of trauma-induced psychoses: The early
psychotherapy of H. Breukink and modern views. Interna-
tional Journal of Clinical and Experimental Hypnosis, 41, 191-209.
The role of hypnotizability assessment in the differential diag-
nosis of psychotic patients is still unresolved. In this article, the
pioneering work of Dutch psychiatrist H. Breukink (1860-1928)
during the 1920s is used as early evidence that hypnotic capacity
is clinically helpful in differentiating highly hypnotizable psy-
chotic patients with dissociative symptomatology from
schizophrenics. Furthermore, there is a long tradition of em-
ploying hypnotic capacity in the treatment of these dissociative
psychoses. The ways in which Breukink used hypnosis for
diagnostic, prognostic, and treatment purposes are summa-
rized and discussed in light of both old and current views. He
felt that hysterical psychosis was trauma-induced, certainly
curable, and that psychotherapy using hypnosis was the treat-
ment of choice. Hypnosis was used for symptom-oriented
therapy, as a comfortable and supportive mental state, and for
the uncovering and integrating of traumatic memories. For the
latter purpose, Breukink emphasized a calm mental state, both
in hypnosis and in the waking state, therapy discouraging
emotional expression, which he considered dangerous in psy-
chotic patients. In the discussion, special attention is paid to the
role and dangers of the expression of trauma-related emotions.
VAN DER KOLK, B.A., BROWN, P., & VAN DER HART, O.
(1989). Pierre Janet on post-traumatic stress. Journal of Trau-
matic Stress, 2, 365-378. More than one hundred years ago, in
1889, Pierre Janet published L'Automatisme Psychologique, his
first work to deal with how the mind processes traumatic
experiences. Janet claimed that vehement emotions interfere
with proper appraisal and appropriate action. Failure to con-
front the experience fully leads to dissociation of the traumatic
memories and their return as fragmentary reliving experiences:
feeling states, somatic sensations, visual images, and behavioral
reenactments. A century later, Janet still provides an unsur-
passed framework for integrating current knowledge about the
psychodynamic, cognitive, and biological effects of human trau-
matization.
WEISS, D.S., MARMAR, C.R., METZLER, T.J., & RONFELDT,
H.M. (1995). Predicting symptomatic distress in emergency
services personnel. Journal of Consulting and Clinical Psychology,
63, 361-368. This study identified predictors of symptomatic
distress in emergency services (EMS) personnel exposed to
traumatic critical incidents. A replication was performed in 2
groups: 154 EMS workers involved in the 1989 Interstate 880
freeway collapse during the San Francisco Bay area earthquake,
and 213 counterparts from the Bay area and from San Diego.
Evaluated predictors included exposure, social support, and
psychological traits. Replicated analyses showed that levels of
symptomatic distress were positively related to the degree of
exposure to the critical incident. Level of adjustment was also
related to symptomatic distress. After exposure, adjustment,
social support, years of experience on the job, and locus of
control were controlled, 2 dissociative variables remained
strongly predictive of symptomatic response. The study strength-
ens the literature linking dissociative tendencies and experi-
ences to distress from exposure to traumatic stressors.
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ADDITIONAL CITATIONS
Annotated by the Editors
COONS, P.M., & MILSTEIN, V. (1986). Psychosexual disturbances
in multiple personality: Characteristics, etiology, and treatment.
Journal of Clinical Psychiatry, 47, 106-110.
Studied male and female psychiatric inpatients who had mul-
tiple personality disorder and found that 75% had been sexually
abused and 55% had been physically abused in childhood.
Compared with inpatients who did not have a dissociative
disorder, the multiple personality patients were more likely to
have psychosexual disturbances. The authors propose that
multiple personality is an adaptive response to trauma in that an
alternate personality can permit some degree of sexual function-
ing.
DANĢU, C.V., RIGGS, D.S., HEARST-IKEDA, D.E., SHOYER, B.
G., & FOA, E.B. (1996). Dissociative experiences and posttrau-
matic stress disorder among female victims of criminal assault
and rape. Journal of Traumatic Stress, 9, 253-267.
Prospectively examined the relationship between dissociative symp-
toms and PTSD in 158 female assault victims and 46 comparison
women. A higher level of dissociative symptoms at 2 weeks was
correlated with increased severity of PTSD at 3 months among non-
sexual assault victims, but not among sexual assault victims. Disso-
ciation was linked to a history of child sexual abuse.
FRISCHHOLZ, E.J. (1985). The relationship among dissocia-
tion, hypnosis, and child abuse in the development of multiple
personality disorder. In R.P. Kluft (Ed.), Childhood antecedents
of multiple personality (pp. 99-126). Washington, DC: Ameri
can Psychiatric Press.
The concept of dissociation was originally developed to explain the
symptoms of multiple personality disorder. MPD patients are more
hypnotizable than other clinical groups, supporting the notion that
hypnosis can be appropriately characterized as a form of dissociation.
Child abuse and severity of childhood punishment have been shown
to be related to adult hypnotic responsivity.
HOROWITZ, M.J. (1986). Stress response syndromes (2nd ed.).
Northvale, NJ: Jason Aronson.
Investigates the characteristics of PTSD and other stress response
syndromes. Describes principles of brief psychodynamic psycho-
therapy for stress-induced symptoms and signs, and explores behav-
ioral therapies. Uses case histories to show how personality factors
and preexisting conflicts form a patient's reaction to a traumatic
event.
KLUFT, R.P. (1993). Multiple personality disorder. In D. Spiegel,
(Ed.), Dissociative disorders: A clinical review (pp. 17-44). Lutherville,
MD: Sidran Press.
Provides an overview of multiple personality disorder from
historical and cross-cultural perspectives. Next, the author
comprehensively describes phenomenology, etiology, differen-
tial diagnosis, comorbidity, and treatment. Includes the author's
four-factor model of etiology, which emphasizes both personal
and environmental influences on the development of MPD.
NEMIAH, J.C. (in press). Early concepts of trauma, dissociation,
and the unconscious: Their history and current implications. In
J.D. Bremner and C. Marmar (Ed.), Trauma, memory, and dissociation.
Washington, DC: American Psychiatric Press.
Compares Breuer and Freud's approach to treating dissociated
traumatic memories with Janet's approach. The author points
out that whereas Janet targeted the cognitive aspects of trau-
matic memories, Breuer and Freud additionally targeted the
distressing emotional aspects of such memories, in the process
they termed "abreaction." The author also discusses this histori-
cal work in light of contemporary perspectives on dissociation.
PUTNAM, F.W., GUROFF, J.J., SILBERMAN, E.K., BARBAN,
L., & POST, R.M. (1986).The clinical phenomenology of mul-
tiple personality disorder: Review of 100 recent cases. Jour-
nal of Clinical Psychiatry, 47, 285-293. Cited in PTSD Research
Quarterly, 3(3), 1992.
SOUTHWICK, S.M., KRYSTAL, J.H., MORGAN, C.A.,
JOHNSON, D.R., NAGY, L.M., NICOLAOU, ANDREAS,
L., HENINGER, G.R., & CHARNEY, D.S. (1993). Abnormal
noradrenergic function in posttraumatic stress disorder.
Archives of General Psychiatry, 50, 266-274.
Administered yohimbine and placebo in a cross over design to
18 male controls and 20 male military veterans with PTSD. Forty
percent of the PTSD group, but no controls, had flashbacks
during yohimbine administration. Results emphasize the role
of the noradrenergic system in PTSD.
VAN DER KOLK, B.A. & VAN DER HART, O. (1989). Pierre
Janet and the breakdown of adaptation in psychological
trauma. American Journal of Psychiatry, 146, 1530-1540. Ab-
stracted in PTSD Research Quarterly, 1(1), 1990.
WILKINSON, C. B. (1983). Aftermath of a disaster: The col-
lapse of the Hyatt Regency Hotel skywalks. American Journal
of Psychiatry, 140, 1134-1139. Abstracted in PTSD Research
Quarterly, 3(1), 1992.
WHAT'S NEW AT
http://www.dartmouth.edu/dms/ptsd/
We have recently acquired software that will enable us to
improve both the management of our World Wide Web site
and the quality of the material we display there.
As our Web site grows in complexity, it is increasingly
difficult to ensure that links among pages are updated to reflect
the deletion of old content and the addition of new material.
One of our new software packages will do this for us.
Another will enable us to convert many of our print publica-
tions into Portable Document Format (PDF). Anyone with the
appropriate reader software-which is available free of charge,
in versions for practically all computers-can then view or
print a PDF file. Whether viewed on screen or printed onto
paper (with a PostScript printer), a PDF file will look exactly
like the printed document. Page layout, text fonts, illustra-
tions-all will replicate the original. (Color fidelity will depend
upon the monitor and printer used, but this will seldom be a
significant issue in National Center publications.) We intend to
begin by placing PDF versions of all back issues of the PTSD
Research Quarterly on our Web site. Then we shall begin to post
PDF files for most other National Center documents.
Prev Page 7 Next
NORTHEAST PROGRAM EVALUATION CENTER:
THE EVALUATION DIVISION OF THE NATIONAL CENTER FOR PTSD
Robert Rosenheck, MD and Alan Fontana, PhD
The delivery of health care services in this country is
undergoing unprecedented change. Changes in health care
delivery appear to be inspired by a need to reduce health care
costs. From another perspective, however, the changes also
reflect an effort to use empirical data on the effectiveness and
cost of health services to provide a rational basis for deciding
which services and how much of each service are needed to
meet the needs of each patient.
The VA is the largest provider of services for PTSD in the
United States, treating approximately 87,000 veterans with
PTSD annually, at an estimated annual cost of $250 million.
Although VA services are funded by an annual Congres-
sional appropriation, VA is, nevertheless, experiencing many
of the same pressures that are affecting health care delivery
elsewhere. Major changes in large organizations like VA
present both opportunities and hazards for relatively small,
vulnerable populations like veterans with PTSD.
The Northeast Program Evaluation Center, the Evaluation
Division of the National Center for PTSD, has been charged
with monitoring the structure, process, and outcome of
PTSD treatment through this period of change. Over the past
year NEPEC has provided the Congress, VA leaders, and
field programs with extensive information on access, popu-
lation coverage, service delivery, clinical outcomes, con-
sumer satisfaction, and costs of PTSD services. These data
have provided the basis for significant changes in the deliv-
ery of VA PTSD inpatient services, and have been used to
establish benchmarks for delivery of PTSD services that will
be used to evaluate system performance in the future. Di-
rected by Robert Rosenheck MD, Clinical Professor of Psy-
chiatry at Yale Medical School, NEPEC is located on the West
Haven Campus of the VA Connecticut Health Care System.
It was established in 1987 for the purpose of evaluating new
VA programs for veterans with PTSD, homeless veterans,
and severely mentally ill veterans. Alan Fontana PhD, Re-
search Scientist at Yale, joined NEPEC in 1988 as Director of
PTSD Evaluations.
During the first 7 years of NEPEC's existence, staff were
responsible for guiding and evaluating the implementation
of over 70 PTSD outpatient clinics and over 25 new inpatient
and residential treatment units. In addition, more than 40
research and evaluation studies were published, addressing
the causes and consequences of PTSD, and the effectiveness
and cost of VA treatment. The first national outcome studies
of inpatient and outpatient PTSD treatment demonstrated
previously unexamined variability in cost and effectiveness
of various types of VA PTSD programs, and these studies
have played an important role in the reconfiguration of VA
inpatient PTSD treatment services during the past year. A
series of studies of the etiology of PTSD demonstrated the
importance of the premilitary and homecoming experiences
in the genesis of PTSD, as well as the strong relationship
between PTSD and sexual harassment and abuse among
women who served in the Vietnam Theater. Related studies
elucidated the relationship of PTSD to homelessness, sui-
cide, and anti-social behavior, and evaluated the role of race
as a factor in treatment.
As the VA has experienced changes in operating proce-
dures during the past two years, NEPEC has been asked to
provide performance data. In October 1996, the Eligibility
Reform Law required that VA maintain its capacity to treat
disabled veterans with mental illness, including those with
PTSD. NEPEC provided benchmark data for the implemen-
tation of that law, concerning the number of veterans receiv-
ing specialized PTSD treatment and on the quality of PTSD
treatment, using measures that are the standard in private
sector assessment of the performance of managed care orga-
nizations. A recent report on clinical outcomes of over 3,000
veterans, from a national sample of over 60 intensive PTSD
programs, presented the most comprehensive outcome data
yet available from any VA mental health program.
Clinical trial methods are generally inapplicable in the
evaluation of care provided in large health care systems.
New methods are needed to address specific methodological
problems of sample selection, data collection, outcome mea-
surement, and risk adjustment. These challenges are being
addressed at NEPEC, which will play a central role in na-
tional efforts to maintain accessible, high-quality services for
veterans with PTSD in the future.
Selected Bibliography
FONTANA, A. & ROSENHECK, R.A. (1997). Effectiveness and
cost of the inpatient treatment of posttraumatic stress disorder:
Comparisons of these models of treatment. American Journal of
Psychiatry, 154, 758-765.
FONTANA, A. & ROSENHECK , R.F. (1997). Outcome monitoring
of VA specialized intensive PTSD programs: FY 1996 report. West
Haven, CT: Northeast Program Evaluation Center.
FONTANA, A.F. & ROSENHECK, R.A. (1996). Improving the
efficiency of outpatient treatment for posttraumatic stress disor-
der. Administration and Policy in Mental Health, 23, 197-210.
FONTANA, A.F. & ROSENHECK, R.A. (1994). Posttraumatic
stress disorder among Vietnam theater veterans: A causal model
of etiology in a community sample. Journal of Nervous and Mental
Disease, 182, 677-684.
FONTANA, A.F., SCHWARTZ, L.S., ROSENHECK, R.A. (1997).
Posttraumatic stress disorder among female Vietnam veterans: A
causal model of etiology. American Journal of Public Health, 87, 169-
175.
ROSENHECK, R.A. & FONTANA, A.F. (1994). A model of
homelessness among male veterans of the Vietnam War genera-
tion. American Journal of Psychiatry, 151, 421-427.
ROSENHECK, R.A. & FONTANA, A.F. (1995). Do Vietnam-era
veterans who suffer from posttraumatic stress disorder avoid VA
mental health services? Military Medicine, 160, 136-142.
ROSENHECK, R.A., FONTANA, A.F., & COTTROL, C. (1995).
Effect of clinician-veteran racial pairing in the treatment of
posttraumatic stress disorder. American Journal of Psychiatry, 152,
555-563.
Prev Page 8 Next
PILOTS UPDATE
We are well into the triennial revision of the PILOTS Thesaurus,
the controlled vocabulary of terms that we use to standardize our
indexing of the traumatic stress literature. We are adding many
new descriptors, and deleting a few that have not proved useful to
our indexers. In many cases, we are modifying the scope of an
existing descriptor, or changing its relationship to other terms in the
Thesaurus. These changes will enable us to keep up with new
trends in the traumatic stress literature and to make the database
more useful to users from a growing number of disciplines.
Some changes are forced upon us by front-page events. The
Rwandan genocide had tumultuous effects on the politics of Zaire,
leading to the overthrow of the Mobotu regime and the resumption
of the country's earlier name. But we cannot simply follow the new
Kinshasa government's example. The descriptor "Congolese" has
already been reserved for publications about the other Congo, the
one whose capital is Brazzaville; and recent civil warfare there
suggests that Congo (Brazzaville) is as likely to call forth contribu-
tions to the PTSD literature as is Congo (Kinshasa). These paren-
thetical distinctions are employed by the U.S. State Department,
whose example we would ordinarily follow. However, parenthe-
ses have a definite meaning in Boolean searching, and using them
as part of a PILOTS descriptor would be incompatible with the
software used by the Dartmouth College computers that host the
PILOTS database. So we shall continue to employ "Congolese"
with respect to traumatic stress in Congo (Brazzaville), and
"Zairians" for Congo (Kinshasa). We shall expand the scope notes
for these terms to explain precisely to whom each refers. And we
shall not be too surprised if a future Kinshasa government changes
the name of the country yet again.
Other changes reflect new developments in the assessment and
treatment of PTSD. Distinctions among drugs that once seemed
sharp might be elided by new pharmacological discoveries. Inno-
vations in psychotherapy might give rise to a new literature. There
may be considerable argument among practitioners about the
efficacy of Thought Field Therapy, but from a bibliographer's
viewpoint the existence of a literature about it makes it an entity as
valid as any more-established treatment approach.
The most important changes in the PILOTS Thesaurus arise from
a better understanding of the traumatic stress literature. When we
began our indexing work, we based our descriptors for mental
disorders on the terminology established by DSM-III-R. But only in
the case of PTSD did we restrict our use of a descriptor to those
papers describing symptoms that met the formal criteria for the
DSM diagnosis. While this can be defended in the case of disorders
infrequently mentioned in the literature of traumatic stress, it has
not worked well in dealing with the voluminous literature on
dissociative symptoms associated with traumatic events. So we
intend to restrict "Dissociative Disorders" to those papers reporting
symptoms supporting the formal diagnosis, and to employ a new
descriptor ("Dissociative Symptoms") for papers dealing with less
pervasive dissociative phenomena or with dissociation viewed as a
symptom of PTSD.
In this case, as in several others, we shall have to examine all the
papers that we had indexed under the established term to find those
whose descriptors must be changed to conform to the new edition
of the Thesaurus. Unlike many databases, which implement changes
on a prospective basis only, the PILOTS database applies new or
changed descriptors on a retrospective basis. This makes it easier for
searchers to find what they need, but it imposes a substantial
burden on the National Center's bibliographical staff, and a lesser
one on database users. It is our task not only to improve the
Thesaurus but also to ensure that it is applied consistently to the
traumatic stress literature, both old and new. It is the user's task to
ensure that he or she is using the latest version of the PILOTS
Thesaurus and the PILOTS Database User's Guide whenever search-
ing the database.
We published the first edition of the User's Guide in October 1971,
and the second edition in November 1994. Both contained the
complete PILOTS Thesaurus, as well as instructions for the data-
base. It would seem appropriate to publish a third edition in
November 1997, but we have reservations about this.
The rapidly-changing environment in which we operate has
made each edition of the PILOTS Database User's Guide outdated
almost from the date of publication. We have no reason to expect the
pace of change to slacken. With this in mind, as well as the cost of
publishing and distributing a printed manual, we are wondering if
the third edition of the User's Guide should appear in electronic
form, as a series of hypertext-linked pages on our Web site. This
would allow revisions to be made on a timely basis, and would also
make the User's Guide available whenever and wherever it was
needed.
We solicit suggestions from PILOTS database users and from
readers of the PTSD Research Quarterly, on both the future of the
PILOTS Database User's Guide and the revision of the PILOTS
Thesaurus. We have posted an outline of proposed changes on our
Web site, at BR> Thesaurus_Revision.html>,
and we are eager to hear what
those who use the traumatic stress literature have to say about them.
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