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Trauma Annotated Bibliography

The following peer reviewed articles are available on the internet or on this website, when possible. Links are provided. The annotated bibliography was peer reviewed by the ISSTD and represents a thoughtful summary of what are believed to be salient information in the articles noted. If you have questions or comments about this material, then please contact the website editor. Some of the articles go to links at one of the outstanding sites on the internet that has a collection of articles related to trauma and dissociation, David Baldwins site: Trauma Information Pages. His site is linked from additional areas on this site. We are grateful to David for his outstanding work, which has been ongoing for many years.

What is a trauma?
What are the types of traumatic events?
What is acute stress disorder, ASD?
What is post-traumatic stress disorder, PTSD?
What is complex PTSD?
What is the spectrum of trauma related disorders?
Co-morbid Conditions
Trauma, Dissociation, and the Child
Neurobiology, Somatization and Affect Dysregulation
Traumatic Reactions in Acute and Chronic or Multiple Traumatizations

Briere, J. & Elliott, D.
Boudreaux, E.
Breslau , N.
Brewin, C.R.
Brewin, Andrews, et.al.
Carlson, Dalenberg
Classen, Koopman, Spiegel
Elliott, D.M.
Golier, J
Green, B.L.
Heffernan, K. & Cloitre, M.
Kessler, R.C.
Krupnick, J.L.
Koenen, K.C.
McFarlane, A.C
Messman-Moore, T.L.
Pimlott-Kubiak, S. & Cortina, L.M.
van der Kolk, B.A, et.al (1)
van der Kolk, B.A., et.al (2)

What is a trauma?

Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults.
J Consult Clin Psychol. 2000 Oct;68(5):748-66
Brewin CR, Andrews B, Valentine JD.

Subdepartment of Clinical Health Psychology, University College London, England. c.brewin@ucl.ac.uk

Annotated Abstract: Brewin et al use meta-analysis to explore which of 14 risk factors for PTSD are most linked with the likelihood of getting the disorder.  The pre trauma risk factors the examined were: civilian/military status, gender, age at trauma, race,  education, previous trauma, and general childhood adversity, psychiatric history, reported childhood abuse, and family psychiatric history these latter three had more uniform predictive effects.  The peri and post trauma risk factors studies were the severity of the trauma, lack of social support following the traumatic event and additional life stress and these tended to have stronger predictive effects than the pretrauma factors.  The finding that events following the trauma are most predictive of PTSD may not be as clear as it first appears, proximal variables such as psychiatric history or a history of childhood abuse may effect the distal risk factors of support and continuing adversity.  For instance some folk may have more difficulty because of their past in finding or asking for help.  This is a very important study about which clinicians should know.

Kessler, R.C., Sonnega, A., Bromet, E, Hughes, M. & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbiditiy Survey. Archives of General Psychiatry, 52, 1048-1063.

This study is a large probability study (N = 5877) of men and women between 15-54 years; part of National Comorbidity Study. PTSD rates: Lifetime prevalence for PTSD: 10% women, 5% men. Women had more than twice the rate of PTSD than did men (10.4% vs. 5%). Trauma rates: Lifetime prevalence of trauma exposure for men was 60.7% and women were 51.2%, which is significantly different. The majority of people with some type of lifetime trauma had actually experienced two or more trauma. Most common traumas for whole sample: witnessing someone be injured or killed, being in a natural disaster, and being in a life-threatening accident.

Gender differences : Men were significantly more likely to experience each of those last 3 traumas, as well as physical attacks, combat experience, and being threatened with a weapon, held captive or kidnapped. Women were more likely to report higher rates of rape, sexual molestation, childhood parental neglect, and childhood physical abuse. Rape was most common trauma to be associated with PTSD for both men and women, after which the most traumatic events for men: combat, childhood neglect and childhood physical abuse; versus sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse among women

A Conceptual Framework for the Impact of Traumatic Experiences
Trauma, Violence, & Abuse, Vol. 1, No. 1, 4-28 (2000)
Eve B Carlson, National Center for PTSD, Palo Alto VA Health Care System
Constance J. Dalenberg, California School of Professional Psychology-San Diego

This conceptual framework for the effects of traumatic experiences addresses what makes an experience traumatic, what psychological responses are expected following such events, and why symptoms persist after the traumatic experience is over. Three elements are considered necessary for an event to be traumatizing: The event must be experienced as extremely negative, uncontrollable, and sudden. The initial core responses to trauma include reexperiencing and avoidance symptoms that occur across four modes of experience. Explanations of how each response is theoretically linked to traumatic events are offered to clarify how the responses reflect the natural human response to uncontrollable, negative, and sudden events. The framework delineates the behavioral learning and cognitive processes that elucidate the persistence of the initial response to trauma. Five factors are proposed that influence the response to trauma, including biological factors, developmental level at the time of trauma, severity of the stressor, social context, and prior and subsequent life events. Finally, secondary and associated responses to trauma are discussed that are common across many types of traumatic experience. These include depression, aggression, substance abuse, physical illnesses, low self-esteem, identity confusion, difficulties in interpersonal relationships, and guilt and shame.

What are the types of traumatic events?

Terr, L. C. (1991). Childhood traumas: an outline and overview. American Journal of Psychiatry, 148(1), 10-20.

Childhood psychic trauma appears to be a crucial etiological factor in the development of a number of serious disorders both in childhood and in adulthood. Like childhood rheumatic fever, psychic trauma sets a number of different problems into motion, any of which may lead to a definable mental condition. The author suggests four characteristics related to childhood trauma that appear to last for long periods of life, no matter what diagnosis the patient eventually receives. These are visualized or otherwise repeatedly perceived memories of the traumatic event, repetitive behaviors, trauma-specific fears, and changed attitudes about people, life, and the future. She divides childhood trauma into two basic types and defines the findings that can be used to characterize each of these types. Type I trauma includes full, detailed memories, "omens," and misperceptions. Type II trauma includes denial and numbing, self-hypnosis and dissociation, and rage. Crossover conditions often occur after sudden, shocking deaths or accidents that leave children handicapped. In these instances, characteristics of both type I and type II childhood traumas exist side by side. There may be considerable sadness. Each finding of childhood trauma discussed by the author is illustrated with one or two case examples.

What is Acute Stress Disorder?

Brewin, C. R., Andrews, B., Rose, S., & Kirk, M. (1999). Acute stress disorder and posttraumatic stress disorder in victims of violent crime. American Journal of Psychiatry, 156(3), 360-366.

OBJECTIVE: In a group of crime victims recruited from the community, the authors investigated the ability of both a diagnosis of acute stress disorder and its component symptoms to predict posttraumatic stress disorder (PTSD) at 6 months. METHOD: A mixed-sex group of 157 victims of violent assaults were interviewed within 1 month of the crime. At 6-month follow-up 88% were reinterviewed by telephone and completed further assessments generating estimates of the prevalence of PTSD. RESULTS: The rate of acute stress disorder was 19%, and the rate of subsequent PTSD was 20%. Symptom clusters based on the DSM-IV criteria for acute stress disorder were moderately strongly interrelated. All symptom clusters predicted subsequent PTSD, but not as well as an overall diagnosis of acute stress disorder, which correctly classified 83% of the group. Similar predictive power could be achieved by classifying the group according to the presence or absence of at least three reexperiencing or arousal symptoms. Logistic regression indicated that both a diagnosis of acute stress disorder and high levels of reexperiencing or arousal symptoms made independent contributions to predicting PTSD. CONCLUSIONS: This exploratory study provides evidence for the internal coherence of the new acute stress disorder diagnosis and for the symptom thresholds proposed in DSM-IV. As predicted, acute stress disorder was a strong predictor of later PTSD, but similar predictive power may be possible by using simpler criteria.

Classen C, Koopman C, Hales R, Spiegel D. (1998). Acute stress disorder as a predictor of posttraumatic stress symptoms. American Journal of Psychiatry, 155, 620-624.

OBJECTIVE: Using the DSM-IV diagnostic criteria for acute stress disorder, the authors examined whether the acute psychological effects of being a bystander to violence involving mass shootings in an office building predicted later posttraumatic stress symptoms. METHOD: The participants in this study were 36 employees working in an office building where a gunman shot 14 persons (eight fatally). The acute stress symptoms were assessed within 8 days of the event, and posttraumatic stress symptoms of 32 employees were assessed 7 to 10 months later. RESULTS: According to the Stanford Acute Stress Reaction Questionnaire, 12 (33%) of the employees met criteria for the diagnosis of acute stress disorder. Acute stress symptoms were found to be an excellent predictor of the subjects posttraumatic stress symptoms 7-10 months after the traumatic event. CONCLUSIONS: These results suggest not only that being a bystander to violence is highly stressful in the short run, but that acute stress reactions to such an event further predict later posttraumatic stress symptoms.

What is Post-traumatic Stress Disorder?

Breslau , N., Chilcoat, H.D., Kessler, R.C., & Davis , G.C. (1999). Previous exposure to trauma and PTSD effects of subsequent trauma: Results from the Detroit Area Survey of Trauma. American Journal of Psychiatry, 156, 902-907.

This is a representative sample of 2,181 adults in Detroit interviewed by phone. PTSD was assessed in regard to a randomly selected trauma from their list of life time traumas. Controlled for sex and type of index trauma. Having experienced multiple previous traumatic events had a stronger effect than a single previous event.

The effects of assaultive violence persisted almost unchanged despite the passage of time. Those who’d experienced multiple events of assaultive violence in childhood were more likely to have PTSD from trauma in adulthood. In fact, “a history of two or more traumatic events involving assaultive violence in childhood was associated with a nearly fivefold greater risk that a traumatic event in adulthood would lead to PTSD (p. 905)”. But even a single previous event of assaultive violence, whether in childhood or adulthood, was associated with a higher risk of PTSD in adulthood.

There was no evidence that a trauma in childhood was associated with a higher risk of PTSD than a trauma that occurred later. Age at exposure was not related to the risk of PTSD. Rather, assaultive violence seems to have a unique status in terms of the risk of PTSD that it engenders.

“The results presented here indicate that women’s higher risk of PTSD is not attributable to sex differences in history of previous exposure to trauma.”(p. 906). They think that the enduring vulnerability to anxiety disorders that starts with childhood trauma may involve “cognitive predispositions, such as helplessness and that ‘experiences in childhood may set up some long-term sensitization to danger’ (p. 905-6).” They conclude that these findings are consistent with a “sensitization hypothesis” which was first discussed by researchers who found that Vietnam vets who’d experienced childhood trauma were more vulnerable to developing PTSD from adult trauma than those with no previous trauma.

McFarlane, A.C. (2000). Posttraumatic stress disorder: A model of the longitudinal course and the role of risk factors. Journal of Clinical Psychiatry, 61 Suppl 5, 15-20.

Posttraumatic stress disorder (PTSD) differs from other anxiety disorders in that experience of a traumatic event is necessary for the onset of the disorder. The condition runs a longitudinal course, involving a series of transitional states, with progressive modification occurring with time. Notably, only a small percentage of people that experience trauma will develop PTSD. Risk factors, such as prior trauma, prior psychiatric history, family psychiatric history, peritraumatic dissociation, acute stress symptoms, the nature of the biological response, and autonomic hyperarousal, need to be considered when setting up models to predict the course of the condition. These risk factors influence vulnerability to the onset of PTSD and its spontaneous remission. In the majority of cases, PTSD is accompanied by another condition, such as major depression, an anxiety disorder, or substance abuse. This comorbidity can also complicate the course of the disorder and raises questions about the role of PTSD in other psychiatric conditions. This article reviews what is known about the emergence of PTSD following exposure to a traumatic event using data from clinical studies.

What is complex PTSD?

van der Kolk, Bessel A.; Roth, Susan; Pelcovitz, David;Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation to Trauma. Journal of Traumatic Stress, Vol 18(5), Oct 2005. pp. 389-399.

Children and adults exposed to chronic interpersonal trauma consistently demonstrate psychological disturbances that are not captured in the posttraumatic stress disorder (PTSD) diagnosis. The DSM-IV (American Psychiatric Association, 1994) Field Trial studied 400 treatment-seeking traumatized individuals and 128 community residents and found that victims of prolonged interpersonal trauma, particularly trauma early in the life cycle, had a high incidence of problems with (a) regulation of affect and impulses, (b) memory and attention, (c) self-perception, (d) interpersonal relations, (e) somatization, and (f) systems of meaning. This raises important issues about the categorical versus the dimensional nature of posttraumatic stress, as well as the issue of comorbidity in PTSD. These data invite further exploration of what constitutes effective treatment of the full spectrum of posttraumatic psychopathology. (PsycINFO Database Record (c) 2007 APA, all rights reserved)(from the journal abstract)

Ford, Julian D.; Stockton, Patricia; Kaltman, Stacey (2006) Disorders of Extreme Stress (DESNOS) Symptoms Are Associated With Type and Severity of Interpersonal Trauma Exposure in a Sample of Healthy Young Women. ; Journal of Interpersonal Violence, Vol 21(11), pp. 1399-1416.

Conducted structured interviews of 345 college women. Most (84%) had experienced at least one traumatic event but DESNOS syndrome was rare (1% prevalence). However, DESNOS symptoms were reported by a majority of participants.  After controlling for PTSD, other anxiety disorders, and affective disorders, DESNOS symptom severity was associated in a dose-response manner with a history of one-time interpersonal trauma and with more severe interpersonal trauma.  Noninterpersonal trauma was correlated with PTSD and dissociation but not with DESNOS severity.

Zlotnick, Caron; Zakriski, Audrey L.; Shea, M. Tracie; The long-term sequelae of sexual abuse: Support for a complex posttraumatic stress disorder. Journal of Traumatic Stress, Vol 9(2), Apr 1996. pp. 195-205.

This study examined the relationship between childhood sexual abuse and symptoms of a newly proposed complex posttraumatic stress disorder (PTSD) or disorder of extreme stress not otherwise specified (DESNOS). Compared to 34 women without histories of sexual abuse, 74 survivors of sexual abuse showed increased severity on DESNOS symptoms of somatization, dissociation, hostility, anxiety, alexithymia, social dysfunction, maladaptive schemas, self-destruction, and adult victimization. In addition, a logistic regression found that a complex of symptoms representing DESNOS was significantly related to a history of sexual abuse. Consistent with other studies, the results of this study provide support for the idea that symptoms of DESNOS characterize survivors of sexual abuse. (PsycINFO Database Record (c) 2006 APA, all rights reserved)(from the journal abstract

What is the spectrum of trauma related disorders?

Moreau, C., & Zisook, S. (2002). Rationale for a posttraumatic stress spectrum disorder. Psychiatric Clinics of North America, 25, 775-790.

An understanding of PTSD and stress-related conditions is in its infancy. This is not surprising given the fact PTSD was not recognized as a distinct diagnostic entity until 1980. Since that time, the diagnostic classification has undergone continuous change as our understanding of PTSD is refined. The authors believe that PTSD can be best understood through a dimensional conceptualization viewed along at least three spectra: (1) symptom severity, (2) the nature of the stressor, and (3) responses to trauma. Along the severity spectrum, studies that review diagnostic thresholds reveal significant prevalence of PTSD symptoms and impairment that results from subthreshold conditions. Comorbidity patterns suggest that when PTSD is associated with other psychiatric illness, diagnosis is more difficult and the overall severity of PTSD is considerably greater. With regard to a stressor criteria spectrum, the diagnostic nomenclature initially only recognized severe forms of trauma personally experienced. More recently, however, the persons subjective response and events occurring to loved ones were included. This has greatly broadened the stressor criteria by leading to an appreciation of the range of precipitating stressors and the potential impact of "low-magnitude" events. Given that responses to trauma vary considerably, another possible spectrum includes trauma-related conditions. Traumatic grief, somatization, acute stress disorder and dissociation, personality disorders, depressive disorders, and other anxiety disorders all have significant associations with PTSD. Further research is needed to clarify and expand the current understanding of PTSD and other trauma-related conditions. Consideration of the severity of symptoms and the range of stressors coupled with the various disorders precipitated by trauma should greatly influence scientific research. The future undoubtedly will bring a refinement of the current understanding of PTSD and improved treatments.

Yen, S., Shea, M.T., Battle, C.L., Johnson, D.M., Zlotnick, C., Dolan-Sewell, R., Skodol, A.E., Grilo, C.M., Gunderson, J.G., Sanislow, C.A., Zanarini, M.C., Bender, D.S., Rettew, J.B., & McGlashan, T.H. (2002). Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders: Findings from the collaborative longitudinal personality disorders study. Journal of Nervous and Mental Disease, 190(8), 510-518.

The association between trauma and personality disorders (PDs), while receiving much attention and debate, has not been comprehensively examined for multiple types of trauma and PDs. The authors examined data from a multisite study of four PD groups: schizotypal, borderline (BPD), avoidant, and obsessive-compulsive, and a major depression comparison group. Rates of traumatic exposure to specific types of trauma, age of first trauma onset, and rates of posttraumatic stress disorder are compared. Results indicate that BPD participants reported the highest rate of traumatic exposure (particularly to sexual traumas, including childhood sexual abuse), the highest rate of posttraumatic stress disorder, and youngest age of first traumatic event. Those with the more severe PDs (schizotypal, BPD) reported more types of traumatic exposure and higher rates of being physically attacked (childhood and adult) when compared to other groups. These results suggest a specific relationship between BPD and sexual trauma (childhood and adult) that does not exist among other PDs. In addition, they support an association between severity of PD and severity of traumatic exposure, as indicated by earlier trauma onset, trauma of an assaultive and personal nature, and more types of traumatic events

McDowell, D.M., Levin, F.R., & Nunes, E.V. (1999). Dissociative identity disorder and substance abuse: The forgotten relationship. Journal of Psychoactive Drugs, 31, 71-83.

The treatment and research of dissociative disorders, particularly dissociative identity disorder (DID), are hampered by professional skepticism and diagnostic uncertainties. Almost always associated with severe and sustained childhood trauma, its chief manifestations are at least two distinct and separate identities which have an independent manner of existing in the world. It is also associated with a high degree of psychiatric comorbidity. Among the most frequent diagnoses found in patients with DID are substance use and dependence. For a variety of reasons there has been little dialogue among the disciplines that study patients with trauma and those that study and treat substance abuse. Clinicians dealing with a primarily substance-abusing population are likely to encounter but not recognize these patients. The authors present several representative cases illustrative of features of patients with DID. The epidemiology, phenomenology and presentation of DID, as well as its relation to posttraumatic stress disorder are discussed. Little systematic investigation exists on the treatment of DID in general, and substance abuse in DID in particular. The authors draw upon the existing literature, and their experience to discuss treatment strategies aimed at treating patients with both diagnoses. Ignoring either diagnosis is likely to be detrimental to patients; both disorders and their coexistence need to be addressed.

McClellan, J., Adams, J., Douglas, D., McCurry, C., & Storck, M. (1995). Clinical characteristics related to severity of sexual abuse: A study of seriously mentally ill youth. Child Abuse & Neglect, 19, 1245-1254.

OBJECTIVE: In this study we examined demographic, social, and clinical variables related to sexual abuse histories in a sample of severely mentally ill youth. METHOD: Data were collected via a retrospective chart review of all patients treated over a 5-year period (1987-1992) at a tertiary care public sector psychiatric hospital. The sample was divided into four groups: no history of sexual abuse (n = 226); isolated events (n = 62); intermittent abuse (n = 61); and chronic (n = 150). RESULTS: Youth with sexual abuse histories were more often female, had higher rates of social chaos and associated physical abuse and neglect, and had higher rates of post-traumatic stress disorder (PTSD) and substance abuse disorders. Chronically abused subjects came from the most chaotic and abusive backgrounds; were younger when first abused; had the highest number of abusers; were more likely to have been molested; and were more often abused by their father/stepfather and/or their mother/stepmother. Using logistic regression analyses, sexual abuse histories were predicted by sexually inappropriate behaviors, symptoms of PTSD and borderline personality disorders, dissociative symptoms, substance abuse and animal cruelty. CONCLUSION: Sexual abuse histories were quite common in this sample. Sexually abused subjects had increased rates of inappropriate sexual behaviors, substance abuse, and post-traumatic reactions; and were frequently exposed to other confounding environmental risk factors, including physical abuse, family problems and social chaos.

Janssen, I., Krabbendam, L., Hanssen, M., Bak, M., Vollebergh, W., de Graaf, R. et al. (2005). Are apparent associations between parental representations and psychosis risk mediated by early trauma? Acta Psychiatrica Scandinavica, 112, 372-375.

OBJECTIVE: It was investigated whether the reported association between representations of parental rearing style and psychosis does not represent a main effect, but instead is a proxy indicator of the true underlying risk factor of early trauma. METHOD: In a general population sample of 4045 individuals aged 18-64 years, first ever onset of positive psychotic symptoms at 3-year follow-up was assessed using the Composite International Diagnostic Interview and clinical interviews if indicated. Representations of parental rearing style were measured with the Parental Bonding Instrument (PBI). RESULTS: Lower baseline level of PBI parental care predicted onset of psychotic symptoms 2 years later. However, when trauma was included in the equation, a strong main effect of trauma emerged at the expense of the effect size of PBI low care. CONCLUSION: The results suggest that associations between representations of parental rearing style and psychosis may be an indicator of the effect of earlier exposure to childhood trauma.

Gunderson, J.G., & Sabo, A. (1993). The phenomenological and conceptual interface between borderline personality disorder and post-traumatic stress disorder. American Journal of Psychiatry, 150(1), 19-27.

OBJECTIVE: The authors explore the conceptual and phenomenological interface between posttraumatic stress disorder (PTSD) and borderline personality disorder as well as the therapeutic and research implications of this interface. METHOD: They systematically review the relevant empirical, conceptual, and clinical literature. RESULTS: These seemingly separate disorders are related. Borderline personality disorder is often shaped in part by trauma, and individuals with borderline disorder are therefore vulnerable to developing PTSD. CONCLUSIONS: The authors draw a distinction between the enduring effects that traumas can have on formation (or change) of axis II personality traits (including those found in borderline personality disorder) and acute symptomatic reactions to trauma, called PTSD, that are accompanied by specific psychophysiological correlates. They describe the implications of these conclusions for DSM-IV, therapy, and future research.
Janssen, I., Krabbendam, L., Hanssen, M., Bak, M., Vollebergh, W., de Graaf, R. et al. (2005). Are apparent associations between parental representations and psychosis risk mediated by early trauma? Acta Psychiatrica Scandinavica, 112, 372-375.

Brady, K.T. (1997). Posttraumatic stress disorder and comorbidity: Recognizing the many faces of PTSD. Journal of Clinical Psychiatry, 58(Suppl 9), 12-15.

Posttraumatic stress disorder (PTSD) commonly occurs with other psychiatric disorders. Data from a recent epidemiologic survey indicate that approximately 80% of individuals with PTSD meet criteria for at least one other psychiatric diagnosis. PTSD is particularly likely to be comorbid with affective disorders, other anxiety disorders, somatization, substance abuse, and dissociative disorders. Comorbidity may affect the presentation and clinical course of PTSD. Because of the relative frequency of traumatic events and the heterogeneity of presentation of PTSD, screening for traumatic events and PTSD should be standard in both psychiatric and primary care practice. Additionally, individuals with PTSD should be screened for psychiatric comorbidity. Accurate assessment of comorbidity may be important in determining optimal psychotherapeutic and pharmacotherapeutic treatment options for individuals with PTSD.

Zanarini, M.C., Yong, L., Frankenburg, F.R., Hennen, J., Reich, D.B., Marino, M.F., & Vujanovic, A.A. (2002). Severity of reported childhood sexual abuse and its relationship  to severity of borderline psychopathology and psychosocial impairment among borderline inpatients. Journal of Nervous and Mental Disease, 190(6), 381-387.

This study has two purposes. The first purpose is to describe the severity of sexual abuse reported by a well-defined sample of borderline inpatients. The second purpose is to determine the relationship between the severity of reported childhood sexual abuse, other forms of childhood abuse, and childhood neglect and the severity of borderline symptoms and psychosocial impairment. Two semistructured interviews of demonstrated reliability were used to assess the severity of adverse childhood experiences reported by 290 borderline inpatients. It was found that more than 50% of sexually abused borderline patients reported being abused both in childhood and in adolescence, on at least a weekly basis, for a minimum of 1 year, by a parent or other person well known to the patient, and by two or more perpetrators. More than 50% also reported that their abuse involved at least one form of penetration and the use of force or violence. Using multiple regression modeling and controlling for age, gender, and race, it was found that the severity of reported childhood sexual abuse was significantly related to the severity of symptoms in all four core sectors of borderline psychopathology (affect, cognition, impulsivity, and disturbed interpersonal relationships), the overall severity of borderline personality disorder, and the overall severity of psychosocial impairment. It was also found that the severity of childhood neglect was significantly related to five of the 10 factors studied, including the overall severity of borderline personality disorder, and that the severity of other forms of childhood abuse was significantly related to two of these factors, including the severity of psychosocial impairment. Taken together, the results of this study suggest that the majority of sexually abused borderline inpatients may have been severely abused. They also suggest that the severity of childhood sexual abuse, other forms of childhood abuse, and childhood neglect may all play a role in the symptomatic severity and psychosocial impairment characteristic of borderline personality disorder.

Trauma, Dissociation, and the Child

The human face of the diagnostic controversy. By Joy Silberg
An optimistic look at dissociation. By Joy Silberg
When treatment fails with traumatized children…why? By Fran Waters
Recognizing dissociation in preschool children by Fran Waters
Atypical DID adolescent case. by Fran Waters

Commentary: This short series of articles by Joy Silberg and Fran Waters are useful to read as a short series and help orientate and illustrate many of the issues relevant to children and adolescents who have suffered experiences which result in an un-integrated sense of themselves.  Both Joy and Fran have been presidents of ISSTD, and both are child psychologists.
Joy’s reflection as President of ISSTD in “The human face of the diagnostic controversy” describes clearly the problems a child faces following a combination of abuse and neglect within his or her home. She notes how difficult but how necessary it is for health care workers to read and recognize the symptoms, inhibitions, behaviours and responses of the child as communications about their past.

Joys President’s column: “An optimistic look at dissociation” again takes a clinical case of child but this time the child is observed intermittently overtime by Dr Silberg to show us the presentation of a traumatized child progressing through developmental stages to adulthood.
“When treatment fails with traumatized children…why?” written by Fran Waters is a poignant but helpful look at why many child therapists lack even a minimal understanding of the impact of trauma on a child’s identity and development.  She names several of the major issues: therapists can lack sight of the big picture, do an inadequate trauma assessment, misunderstand the encoding of trauma, ignore the significance of early attachment relationships especially to their abusive biological parents, have an exclusive focus on alleviation of symptoms and fail to identify the triggers of disturbed behaviors and affect, ignore multiple diagnoses and derailed treatment, employ poly-pharmacy with minimal efficacy, and exclusively use of talk/cognative behvioral therapies, with an overall lack of understanding of dissociative processes or states. By naming these common errors she briefly draws our attention to the suffering these failures can cause.
“Recognizing dissociation in preschool children” by Fran Waters describes the vulnerability of very young children to caregivers who are frightening or inadequately responsive.  She briefly reviews the relevant literature and describes manifestations of dissociation in this population.  She uses a beautifully describes young patient’s difficulties to illustrate her points and emphasises the need for proper recognition and treatment of dissociative symptoms in preschool children.  Fran’s article “Atypical DID adolescent case” uses a detailed description of an adolescent girl to shed light on the sudden onset of a set of dissociative symptoms following treatment for her eating disorder.  The phenomenology and assessment process is notes as well as the necessity for family intervention.  This case highlights critical factors in treating adolescents such as early recognition and intensive treatment.  The essential ingredient  of a positive transference to the therapist and exploration of impaired parent-child attachment relationships as a “precursor” or proclivity to dissociate should be analyzed.  The paper by Joy Silbery called “Parenting the dissociative child” is a short and helpfully optimistic essay identifying the salient features of working with families who have a dissociative child.  In it she realistically notes key ideas and possible warning signs of a worsening situation with brief phrases that illustrate a practical point.  Her understanding of both the child and the parents help the reader imagine how to work within the family and not feel alienated and judgmental.

Neurobiology, Somatization and Affect Dysregulation

Schore, A.N. (2001). The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22(1-2), 201-269.

A primary interest of the field of infant mental health is in the early conditions that place infants at risk for less than optimal development. The fundamental problem of what constitutes normal and abnormal development is now a focus of developmental psychology, infant psychiatry, and developmental neuroscience. In the 2nd part of this sequential work, the author presents interdisciplinary data to more deeply forge the theoretical links between severe attachment failures, impairments of the early development of the right brains stress coping systems, and maladaptive infant mental health. He comments on topics such as the negative impact of traumatic attachments on brain development and infant mental health, the neurobiology of infant trauma, the neuropsychology of a disorganized/disoriented attachment pattern associated with abuse and neglect, the etiology of dissociation and body-mind psychopathology, the effects of early relational trauma on enduring right hemispheric function, and some implications for models of early intervention. These findings suggest direct connections between traumatic attachment, inefficient right brain regulatory functions, and both maladaptive infant and adult mental health.

van der Kolk, B.A., Pelcovitz, D., Roth, S., Mandel, F.S., MacFarlane, A., & Herman, J.L. (1996). Dissociation, somatization, and affect dysregulation: the complexity of adaptation to trauma. American Journal of Psychiatry, 153 , (7), pp. 83-93.

This study investigated the relationships between exposure to extreme stress, the emergence of PTSD and symptoms of dissociation, somatization and affect dysregulation. The PTSD field trial for the DSM-IV studied 395 traumatized treatment-seeking subjects and 125 non-treatment-seeking subjects who had also been exposed to traumatic experiences. Subjects were assessed by the High Magnitude Stressor Events Structured Interview, the NIMH Diagnostic Interview Schedule PTSD module, the PTSD module of the Structured Clinical Interview of the DSM-III (SCID). Affect dysregulation, dissociation and somatization were measured with the Structured Interview for Disorders of Extreme Stress (SIDES, an instrument designed specifically for the study). In order to examine the correlations between PTSD, somatization, dissociation, and affect dysregulation (or associated features), subjects were divided into two groups: those with and those without lifetime PTSD. Groups were compared for endorsement of associated features. To examine the relationship between current and lifetime PTSD, no PTSD, and the presence/absence of associated features, the authors divided the subjects into 3 groups – those with current PTSD, those with lifetime PTSD but not currently meeting the criteria for it, and those who have never had PTSD. A third division of subjects was made in order to study the effects of age at onset and the nature of the trauma – early-onset interpersonal trauma, late-onset interpersonal trauma, and disaster trauma.

PTSD, dissociation, somatization and affect dysregulation were found to be highly interrelated, tending not to occur in isolation but rather co-occurring in the same person. It appears that co-occurrence is related to their age when the trauma took place and the nature of the event. “The occurrence of pure PTSD is the exception, rather than the rule.” (p. 89). Subjects who were diagnosed with current PTSD endorsed symptoms of dissociation, somatization and affect dysregulation at much higher rate than those who once but no longer met criteria for PTSD. However, these individuals still had much higher levels of endorsement of these associated features than subjects who never met the criteria for PTSD. Interestingly, those who no longer suffered from PSTD still reported suffering from high levels of dissociation, somatization and affect dysregulation. This suggests it is important to inquire about past trauma and make the association between trauma history and current symptomatology. The study also supports results from precious studies that indicate that the age of onset and nature of the traumatic experience affect the “complexity of the clinical outcome.” Those who had experienced abuse at or before 14, ended up with significantly more dissociative problems, trouble managing anger as well as self-destructive and suicidal behaviors as compared with those who were older when the trauma occurred or were victims of a disaster.

Co-morbid Conditions

Golier, J., Yehuda, R., & Bierer, L.M. (2003). The Relationship of Borderline Personality Disorder to Posttraumatic Stress Disorder and Traumatic Events. American Journal of Psychiatry, 160(11), 2018-2024.

The authors examined the relationship of borderline personality disorder to posttraumatic stress disorder (PTSD) with respect to the role of trauma and the timing of trauma exposure.

The Trauma History Questionnaire and the PTSD module of the Structured Clinical Interview for DSM-III-R were administered to 180 male and female outpatients with a diagnosis of one or more DSM-III-R personality disorders. Path analysis was used to evaluate the relationship between borderline personality disorder and PTSD.

High rates of early and lifetime trauma were found for the subject group as a whole. Compared to subjects without borderline personality disorder, subjects with borderline personality disorder had significantly higher rates of childhood/adolescent physical abuse (52.8% versus 34.3%) and were twice as likely to develop PTSD. In the path analysis of the relationship between borderline personality disorder and PTSD, none of the different types of paths (direct path, indirect paths through adulthood traumas, paths sharing the antecedent of childhood abuse) was significant. The associations with both trauma and PTSD were not unique to borderline personality disorder; paranoid personality disorder subjects had an even higher rate of co-morbid PTSD than subjects without paranoid personality disorder, as well as elevated rates of physical abuse and assault in childhood/adolescence and adulthood.

The associations of personality disorder with early trauma and PTSD were evident, but modest, in borderline personality disorder and were not unique to this type of personality disorder. The results do not appear substantial or distinct enough to support singling out borderline personality disorder from the other personality disorders as a trauma-spectrum disorder or variant of PTSD.

Heffernan, K. & Cloitre, M. (2000). A comparison of posttraumatic stress disorder with and without borderline personality disorder among women with a history of childhood sexual abuse: Etiological and clinical characteristics. Journal of Nervous and Mental Disease, 188(9), 589-595.

The study examined etiological variables and current functioning among 2 groups of outpatient women with a history of childhood sexual abuse: those with PTSD only (n=45) and those with PTSD and BPD (n=26).

Subjects were recruited through local newspaper ads and word-of-mouth. Subjects were given standardized interview set that included the Child Maltreatment Interview, Sexual Assault History Initial Interview Schedule, SCID I & II, the PTSD Symptom Scale-Self Report, BDI, STAI, Dissociative Experiences Scale, Brief Symptom Inventory, the Family Environment Scale, the Inventory of Interpersonal Problems, and the Health Services Utilization Form.

Findings: The groups did not differ in severity, frequency, or number of perpetrators of their childhood sexual abuse, or whether the perpetrator was a family member or not. The additional diagnosis of BPD was associated with earlier age of abuse onset and significantly higher rates of physical and verbal abuse by mother. Severity and frequency of PTSD symptoms were not affected by BPD diagnosis, suggesting that the personality disorder and PTSD are independent symptom constructs. The PTSD+BPD group scored higher on several other clinical measures including anger, dissociation, anxiety, and interpersonal problems. They did not differ in their frequency of use of mental health services but tended to be less compliant in their treatment.

Limitations: compliance results were available for only a small subset of the sample (PTSD-only n=20; PTSD+BPD n=10). It did reveal a trend of the PTSD-only group to be more compliant than the PTSD+BPD group (90% versus 60% respectively reporting excellent compliance with the remaining 10% and 40% of each reporting partial to adequate compliance. p < .08) The relatively weak findings here may be due to the use of a self-report measure to assess compliance or to the small size of the subset. The authors suggest that clinical reports or other objective sources of compliance reporting beside the patient may produce different results.

Traumatic Reactions in Acute and Chronic or Multiple Traumatizations

Green, B.L., Goodman, L.A. , Krupnick, J.L., Corcoran, C.B, Petty, R.M., Stockton, P. & Stern , N.M. (2000). Outcomes of single versus multiple trauma exposure in a screening sample. Journal of Traumatic Stress, 13(2), 271-286.

Studied 1909 sophomore women with only 24% response rate from surveys mailed to home. Gathered data from students at 6 D.C. colleges/universities. Used Stressful Life Events Questionnaire, which doesnt specifically ask about child sexual abuse, though does use word "molestation".

Found: 68% of the women reported at least one or more traumatic event; 38% reported two or more events. "Molestation" was 19%, sexual penetration was 14%, attempted rape was 12%. Child physical abuse or assault was 17%. (p. 277). Very few experienced only one particular event alone (less than 1 - 4% per event).

Non-interpersonal only was not associated with elevated current trauma-related symptoms. Multiple interpersonal traumas were associated with the highest risk for current trauma-related symptoms. They found evidence that multiple events have worse outcomes than single or no events. Also, interpersonal trauma, especially involving different forms of trauma (e.g., not just ongoing sexual abuse, but different perpetrators), were more distressed than those experiencing only non-interpersonal trauma.

Messman-Moore, T.L., Long, P.J. & Siegfried , N.J. (2000). The revictimization of child sexual abuse survivors: An examination of the adjustment of college women with child sexual abuse, adult sexual assault, and adult physical abuse. Child Maltreatment, 5(1), 18-27.

Studied 633 undergraduate women. Found 20.1% reported childhood sexual abuse; 27% reported unwanted sexual intercourse during adulthood; 33.2% reported physical abuse by dating partner or husband. More than half (57%) reported at least 1 trauma.

Found that cumulative trauma was more damaging than single exposure to trauma but did not find differential effects for child to adult revictimization versus multiple adult victimization. Women with revictimization and women with multiple adult assaults displayed similar levels of impaired psychological functioning.

Women with multiple adult victimizations had more depression, PTSD symptoms, interpersonal sensitivity and hostility than revictimized women. Revictimized women had more somatization and anxiety than women with multiple adult victimizations. Both of these groups of women reported more difficulties with functioning than those who had only one form of adult abuse or those without a history of trauma. The women with multiple traumas experienced more distress than women with child sexual abuse only, though these differences werent found in all areas. Women with single adult abuse did not have more distress than those with no abuse.

Briere, J. & Elliott, D. (2003). Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse & Neglect, 27, 1205-1222.

Used a stratified random sample of 1,442 men and women from US. Sent Traumatic Events Questionnaire and Trauma Symptom Inventory in mail.

Child Sexual Abuse (CSA) Sequelae : associated with elevations on all 10 scales of the TSI, even after controlling for socio-demographic variables (sex, age, race and family income) as well as subsequent interpersonal victimization as an adult, as well as child physical abuse (CPA).

In addition to above, found women had higher rates of adult interpersonal victimization. Women also rated CSA and CPA more upsetting at the time of the event than did men.

CPA sequelae :associated with all TSI scales except those related to sexual symptoms (Sexual concerns & Dysfunctional Sexual Behavior) and Tension Reduction Behavior. The associations were not as strong as with CSA.

Effect sizes : The size of abuse-symptom relationships was relatively small. Once all the covariates were removed (which makes the following estimates very conservative and small), the additional variance in any TSI scale accounted for by CSA or CPA ranged from 6% to 10%. However, the relationship between smoking and lung cancer is r = .12, meaning 1% of variance accounted for. So this has great clinical significance, although clearly, other variables impact these symptoms.

Elliott, D.M., Mok, D.S. & Briere, J. (2004). Adult sexual assault: Prevalence, symptomatology, and sex differences in the general population. Journal of Traumatic Stress, 17, 203-211.

This is a large national stratified random sample of general population. Sample of 941 returned mail surveys using Traumatic Events Survey and Trauma Symptom Inventory (TSI). Found that women are more likely than men to experience most types of interpersonal trauma including child sexual assault, partner violence, and stalking. Men are more likely to be victims of physical assault and as likely to experience child physical abuse. Between 13-25% of women experience sexual assault at some time in the lives while between .6% and 7.2% of men experience it.

Their figure on page 207 is excellent. It shows that both females and males with adult sexual assault (ASA) are more symptomatic on all 10 scales of the TSI compared to men and women without ASA. Men fair much worse than the women with ASA on 8 of the 10 scales. These results were found despite an average of 14 years passing since the last incident of ASA.

Revictimization: women who had experienced ASA were over twice as likely to have experienced CSA as women with no experience of ASA. Men with ASA were five times more likely to have a history of CSA than men with no ASA.

Koenen, K.C. et al. (2002). A twin registry study of familial and individual risk factors for trauma exposure and posttraumatic stress disorder. Journal of Nervous and Mental Disease, 190, 209-218.

The authors looked at male twins (N=6744) from Vietnam registry to explore why familial psychopathology increased risk for PTSD among offspring. They found that those from families with psychopathology had earlier age at first trauma, exposure to multiple traumas, and a number of preexisting psychiatric conditions in the twins increased their risk of developing PTSD.

They interpret their findings as suggesting that the associations between family psychopathology and PTSD may be mediated by increased risk of traumatic exposure and by preexisting disorders in twins. The authors believe that their data support the sensitization hypothesis: multiple traumas increasing the sensitization to later traumas.

Krupnick, J.L., Green, B.L., Stockton , P., Goodman, L., Corcoran, C. & Petty R. (2004). Mental health effects of adolescent trauma exposure in a female college sample: Exploring differential outcomes based on experiences of unique trauma types and dimensions. Psychiatry, 67, 264-279.

Authors selected 209 participants from their larger study of college women who completed questionnaires. This subset came in for interviews. They selected those who reported having been abused after age 12 (to prevent confounding by developmental level). Did SCID interviews of Axis I disorders and borderline personality disorder (BPD). They didn’t find much BPD because screen out those who had earlier trauma.

They found that single traumas were not worse in terms of association with more psychiatric disorders than no trauma exposure except in the case of sexual assault. Ongoing abuse and multiple single traumas were associated with more psychological disorders including PTSD. All trauma groups had increased general distress (SCL-90-R). Almost identical rates of PTSD in the ongoing abuse and the one time sexual assault group, so they concluded that this shows that sexual assault is particularly damaging.

The authors interpret their data as supporting Janoff-Bulman’s 1992 “assertion that deliberately perpetrated traumas are more difficult to integrate than accidental/non-deliberate events, probably because they pose both a greater threat to personal safety and bodily integrity and a greater sense of betrayal” (p. 274).

Pimlott-Kubiak, S. & Cortina, L.M. (2003). Gender, victimization and outcomes: Re-conceptualizing risk. Journal of Consulting and Clinical Psychology, 71, 528-539.

This is a study with outstanding methodology. It takes on the “women are vulnerable (Breslau, Chilcoat, Kessler & Davis, 1999)” vs. “type of event makes any gender vulnerable” gender debate. Used a sample of 16,000 people from a nationally representative telephone survey. Part of the National Violence Against Women Study. Had 8,000 men and 8,000 women so could do sophisticated analyses to see if women truly are more vulnerable to impact of trauma than men. Also used a number of outcomes, not just PTSD, which they claim helps to better understand the true impact of trauma (e.g., depression, which was hypothesized, and found to be higher in traumatized and non-traumatized women; drinking was hypothesized to be higher in traumatized men and non-traumatized men). Only looked at interpersonal aggression which included adult emotional abuse and stalking.

Found NO gender effects after controlling for earlier exposure. Those with most exposure to trauma had the most psychological and health symptoms. Sexual trauma was associated with particularly severe outcomes. The authors interpret their data to refute the theory that women are more vulnerable to pathological outcomes.

Boudreaux, E., Kilpatrick, D.G., Resnick, H.S, Best, C.L, & Saunders, B.E . (1998). Criminal victimization, posttraumatic stress disorder, and co-morbid psychopathology among a community sample of women. Journal of Traumatic Stress, 11(4), 665-678.

They used criminal victimization data. Found that at a univariate level: People who were victims of violent crime were more likely than non-victims to currently suffer from depression, agoraphobia, OCD, social phobia and simple phobia

With multiple regression, PTSD was a strong mediator between victimization and many other Axis I disorders. "While demographics, victimization status, and crime factors may still have direct associations with non-PTSD Axis I disorders, the strongest and most consistent association seemed to be indirectly through their relation with PTSD" (p. 673). Completed rape was the crime most likely to be associated with having a non-PTSD Axis I disorder, which is similar to findings for PTSD (Kilpatrick et al., 1989).

Women with PTSD were at markedly elevated risk for having another Axis I disorder. At least 64% of those with PTSD had another Axis I disorder.