Multivariate prediction of posttraumatic symptoms in psychiatric inpatients

Prolonged grief disorder in an inpatient psychiatric sample: psychometric properties of a new clinical interview and preliminary prevalence

BACKGROUND

Prolonged Grief Disorder (PGD) was newly included in the ICD-11 and DSM-5-TR. It is not yet part of the standard assessments in many healthcare systems, including psychiatric wards. Because disordered grief is associated with suicidality, sleep problems and substance use disorders, an investigation into PGD in psychiatric inpatients is warranted.

METHOD

We interviewed N = 101 psychiatric inpatients who were admitted to the open psychiatric wards and the day hospital of a German psychiatric hospital and who had lost a person close to them. Assessments comprised clinical interviews and self-report instruments covering PGD and other mental disorders. We specifically developed the International Interview for Prolonged Grief Disorder according to ICD-11 (I-PGD-11) for the study and examined its psychometric properties.

RESULTS

The prevalence rate of PGD among bereaved patients according to ICD-11 was 16.83% and according to DSM-5-TR 10.89%. The I-PGD-11 showed good psychometric properties (Mc Donald's ω = 0.89, ICC = 0.985). Being female, having lost a child or spouse, and unnatural or surprising circumstances of the death were associated with higher PGD scores.

TRIAL REGISTRATION

Approval was obtained by the ethics committee of the of the Goethe University Frankfurt (2021-62, 2023-17) and the Chamber of Hessian Physicians (2021-2730-evBO). The study was preregistered ( https://doi.org/10.17605/OSF.IO/K98MF ).

LIMITATIONS

We only assessed inpatients of one psychiatric clinic in Germany, limiting the generalizability of our findings.

CONCLUSION

The present study underlines the importance of exploring loss and grief in psychiatric inpatients and including PGD in the assessments. Given that a significant minority of psychiatric inpatients has prolonged grief symptoms, more research into inpatient treatment programs is needed.

Childhood Abuse, Social Support, and Long-Term Pharmacological Treatment Outcomes in Patients With Depressive Disorders

OBJECTIVES

This study was performed to investigate the roles of childhood abuse and social support in predicting short- and long-term pharmacological treatment outcomes in outpatients with depressive disorders in a naturalistic 1-year prospective design.

METHODS

Patients were recruited at a university hospital in South Korea between March 2012 and April 2017. Subjects with stepwise pharmacotherapy (switching, augmentation, combination, and mixture of these approaches) included 1246 patients at 12-week points in the acute treatment response and 1,015 patients at 12-months in the long-term treatment response. Remission was defined as Hamilton Depression Rating Scale score ≤ 7. Exposure to three types of childhood abuse (physical, emotional, and sexual) before the age of 16 and perceived social support were assessed at baseline.

RESULTS

Individual associations of childhood abuse were associated with poorer treatment outcomes in the 12-month long-term phase, and no significant individual associations were found for social support level with any period outcome. In combination, any child abuse, emotional abuse, and physical abuse were significantly associated with long-term 12-month remission rate in the presence of higher level of social support after adjustment with significant interaction terms. However, no significant interactions were found with sexual abuse.

CONCLUSION

Synergistic interactive effects of child abuse and social support levels on treatment outcomes in depressive patients were found during long-term pharmacotherapy. Thus, depressed patients with a history of childhood abuse may require specialized clinical approaches, including social support, to enhance the long-term treatment outcomes.

The dimensionality of adverse childhood experiences: A scoping review of ACE dimensions measurement

OBJECTIVE

Despite extensive research, the concept of adverse childhood experiences (ACEs) is not fully developed and there is low agreement on how the concept should be defined and measured. The purpose of this study was to 1) identify different conceptual dimensions associated with ACEs, such as timing or frequency; and 2) determine how these dimensions have been operationalized and analyzed to this point, in order to advance the conceptual understanding of ACEs.

METHODS

We conducted a scoping review of empirical journal articles on ACEs published after the original ACE-Study in 1998 to summarize the use of dimensions for the 10 conventional ACE domains. We used a PRISMA methodology to identify articles that assessed at least two of the 10 conventional ACE domains and at least two ACE dimensions. A standardized data extraction spreadsheet was used to record basic article information and specifics on ACE domains and dimensions.

RESULTS

Of 15,417 initial search results, 61 articles met all selection criteria. We identified four primary dimensions used for most ACE domains: frequency, timing, perception, and the role of the perpetrator. Additionally, we found several secondary and domain-specific dimensions, which relate to the intensity of the adverse event.

DISCUSSION

We identified the most commonly used ACE dimensions, but these lack standardized phrasing of items and response options. The inclusion of ACE dimensions may increase the accuracy of the association between ACEs and health outcomes and provide for more tailored treatment plans for people who have experienced ACEs. Future research should include a more comprehensive list of ACE domains and aim to develop a clearly articulated, standardized approach to assessing and analyzing ACE dimensions.

Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective

Dissociative identity disorder (DID) is a chronic post-traumatic disorder where developmentally stressful events in childhood, including abuse, emotional neglect, disturbed attachment, and boundary violations are central and typical etiological factors. Familial, societal, and cultural factors may give rise to the trauma and/or they may influence the expression of DID. Memory and the construction of self-identity are cognitive processes that appear markedly and centrally disrupted in DID and are related to its etiology. Enduring decoupling of psychological modes may create separate senses of self, and metamemory processes may be involved in interidentity amnesia. Neurobiological differences have been demonstrated between dissociative identities within patients with DID and between patients with DID and controls. Given the current evidence, DID as a diagnostic entity cannot be explained as a phenomenon created by iatrogenic influences, suggestibility, malingering, or social role-taking. On the contrary, DID is an empirically robust chronic psychiatric disorder based on neurobiological, cognitive, and interpersonal non-integration as a response to unbearable stress. While current evidence is sufficient to firmly establish this etiological stance, given the wide opportunities for innovative research, the disorder is still understudied. Comparison of well-selected samples of DID patients with non-dissociative subjects who have other psychiatric disorders would further delineate the neurobiological and cognitive features of the disorder, whereas genetic research on DID would further illuminate the interaction of the individual with environmental stress. As such, DID may be seen as an exemplary disease model of the biopsychosocial paradigm in psychiatry.

Is high hypnotizability a necessary diathesis for pathological dissociation?

During the 19th century, high hypnotizability was considered to be a form of psychopathology that was inseparable from hysteria. Today, hypnotizability is considered to be a normal trait that has no meaningful relationship with psychopathology. Psychiatric patients generally manifest medium to low hypnotizability. Nevertheless, several psychiatric diagnoses are marked by an unexpectedly large proportion of patients with high hypnotizability. This is especially true of the diagnostic categories that were subsumed by the 19th-century concept of hysteria: dissociative identity disorder, somatization disorder, and complex conversion disorders. These hysteria-related modern diagnoses are also highly dissociative. A review and analysis of the literature regarding the relationship between hypnotizability and dissociation indicates that high hypnotizability is almost certainly a necessary diathesis for the development of a severe dissociative disorder. Such a diathesis has significant implications for (a) the psychiatric nosologies of the American Psychiatric Association and the World Health Organization, (b) the hypnosis field, and (c) the etiology and construct validity of dissociative identity disorder and other severe dissociative disorders. Specifically, the dissociative disorders (excepting depersonalization disorder, which is not classified as a dissociative disorder by the World Health Organization) are manifestations of hypnotic pathology.

Dissociation is associated with emotional maltreatment in a sample of traumatized women with a history of child abuse

Theories of dissociation emphasize that symptoms of dissociation are correlated with traumatic events. Although the association of dissociative symptoms and retrospective reports of child abuse with a focus on mainly sexual and physical abuse has been well documented, investigation of the contribution of emotional or psychological types of maltreatment to the prediction of dissociation has been neglected to a great extent. The aim of this study was to determine the differential impact of different types of maltreatment on dissociative symptoms in a sample of 203 female residential patients treated for posttraumatic stress disorder linked to child maltreatment. Moreover, it was examined whether the link between dissociation and child maltreatment is direct or indirect. Subjects completed questionnaires on child maltreatment, posttraumatic stress, and dissociative symptoms. Although all types of maltreatment were related to dissociative symptoms, emotional abuse was the strongest and most direct predictor of dissociation in multivariate hierarchical analyses with the influence of other trauma types being confounded by emotional abuse. This study highlights the importance of emotional types of maltreatment for the genesis of dissociative symptoms in patients with posttraumatic stress disorder.

Cumulative Effects of Stressful Childhood Experiences on Delusions and Hallucinations

The association between stressful childhood experiences (SCE) and psychotic symptoms is still not clearly understood, and different causal pathways have been proposed. Generalized estimating equation modeling was used to test the dose-response relationship between SCE and delusions and hallucinations at baseline and follow-up periods and the possible confounding effects of dissociation on this relationship. The prevalence of SCE in individuals with psychotic disorders was high, with more co-occurring SCE categories being positively associated with more types of delusions and hallucinations. Each additional SCE was associated with a 1.20 increase in the incidence rate ratio (95% confidence interval [CI; 1.09, 1.32]) for hallucinations and a 1.19 increase (CI [1.09, 1.29]) for delusions, supporting a dose-response association. After we controlled for the mediating effects of dissociative symptoms at follow-up, SCE remained independently associated with delusions. We propose that cumulative SCE can result in complex trauma reactions that present with a broad range of symptomatology, including dissociative, posttraumatic stress disorder, and psychotic symptoms.

The Evolving Construct of Posttraumatic Stress Disorder (PTSD): DSM-5 Criteria Changes and Legal Implications

In the DSM-5, the diagnosis of posttraumatic stress disorder (PTSD) has undergone multiple, albeit minor, changes. These changes include shifting PTSD placement from within the anxiety disorders into a new category of traumatic and stressor-related disorders, alterations in the definition of a traumatic event, shifting of the symptom cluster structure from three to four clusters, the addition of new symptoms including persistent negative beliefs and expectations about oneself or the world, persistent distorted blame of self or others, persistent negative trauma-related emotions, and risky or reckless behaviors, and the addition of a dissociative specifier. The evidence or lack thereof behind each of these changes is briefly reviewed. These changes, although not likely to change overall prevalence, have the potential to increase the heterogeneity of individuals receiving a PTSD diagnosis both by altering what qualifies as a traumatic event and by adding symptoms commonly occurring in other disorders such as depression, borderline personality disorder, and dissociative disorders. Legal implications of these changes include continued confusion regarding what constitutes a traumatic stressor, difficulties with differential diagnosis, increased ease in malingering, and improper linking of symptoms to causes of behavior. These PTSD changes are discussed within the broader context of DSM reliability and validity concerns.

Positive affect, childhood adversity, and psychopathology in psychiatric inpatients

BACKGROUND

Low positive affect is closely related to common pathological responses to childhood adversity, including posttraumatic stress disorder (PTSD) and depression, but little is known about how the characteristics of early adversity experiences might be related to positive affect in adulthood.

OBJECTIVE

This study aimed to explore whether low positive affect is related to specific childhood adversities, including abuse, neglect, caretaker dysfunction, and low childhood social support.

METHOD

Using structured interviews and self-report measure data collected from 173 adult psychiatric inpatients, this study examined the relationship between positive affect and symptoms of psychopathology, as well as how the number of types of abuse experienced, severity of adversity types (physical abuse and sexual abuse), childhood environment (childhood social support, neglect, and caretaker dysfunction), and number of non-abuse traumas related to positive affect.

RESULTS

Positive affect was significantly negatively related to several symptoms of psychopathology, including depression, dissociation, self-destructive behavior, PTSD, and global psychopathology. Individuals who experienced both physical and sexual abuse reported significantly less positive affect than those with only physical or no abuse experiences. Lower positive affect was predicted by lower childhood social support and greater severity of sexual abuse, with both factors accounting for unique variance in positive affect.

CONCLUSION

These results suggest that individuals who experience multiple types of early adversity, more severe sexual abuse experiences, and less social support are at risk of psychological difficulties. Given the relatively strong association between positive affect and childhood social support, interventions to foster social support may be a means of increasing positive affect among individuals exposed to childhood adversity.

Development and initial validation of the Structured Interview for Self-Destructive Behaviors

This article describes the initial validation of the Structured Interview for Self-Destructive Behaviors (SI-SDB), a brief interview assessing suicidality, self-injury, substance abuse, disordered eating, and risky sexual behaviors. Self-destructive behaviors present clinical and practical challenges for mental health treatment providers. Participants were 217 psychiatric inpatients with a wide variety of diagnoses who completed the SI-SDB and other measures of psychiatric symptoms, trauma exposure, and other childhood experiences. Internal validity analyses revealed an internally consistent measure with 2 major factors. External validity analyses indicated that the Substance Abuse and Disordered Eating scales were predictive of related psychiatric diagnoses. All scales except Substance Abuse were significantly correlated with psychiatric symptoms and childhood abuse. These findings indicate that the SI-SDB is a valid means of assessing 5 significant domains of dangerous behaviors in clinical and research settings. Further research on the reliability of reports over time, interrater consistency, and convergent validity with longer measures of the SI-SDB domains is needed.

Evidence for a dissociative subtype of PTSD by latent profile and confirmatory factor analyses in a civilian sample

BACKGROUND

Dissociative symptoms are increasingly recognized in individuals with posttraumatic stress disorder (PTSD). The aim of this study was to investigate the prevalence of derealization and depersonalization symptoms via latent profile analyses (LPAs) in a civilian PTSD sample and examine the relationship between PTSD and dissociative symptoms via factor analytic methods.

METHODS

A civilian sample of individuals with PTSD predominantly related to childhood abuse (n = 134) completed a diagnostic interview for PTSD and comorbid psychiatric disorders. LPAs and confirmatory factor analyses (CFAs) were performed on the severity scores for PTSD, derealization, and depersonalization symptoms.

RESULTS

LPAs extracted three groups, one of which was uniquely characterized by high derealization and depersonalization symptoms, and accounted for 25% of the sample. Individuals in the dissociative subgroup also showed a higher number of comorbid Axis I disorders and a more significant history of childhood abuse and neglect. CFAs suggested the acceptance of a five factor solution in which dissociative symptoms are distinct from but correlate significantly with the core PTSD symptom clusters.

CONCLUSIONS

The results from LPAs and CFAs are concordant with the concept of a dissociative subtype in patients with PTSD and suggest that symptoms of derealization-depersonalization and the core symptoms of PTSD are positively correlated. Thought should be given to including a dissociative subtype of PTSD in the DSM-5.

The dissociative subtype of posttraumatic stress disorder: rationale, clinical and neurobiological evidence, and implications

BACKGROUND

Clinical and neurobiological evidence for a dissociative subtype of posttraumatic stress disorder (PTSD) has recently been documented. A dissociative subtype of PTSD is being considered for inclusion in the forthcoming Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) to address the symptoms of depersonalization and derealization found among a subset of patients with PTSD. This article reviews research related to the dissociative subtype including antecedent, concurrent, and predictive validators as well as the rationale for recommending the dissociative subtype.

METHODS

The relevant literature pertaining to the dissociative subtype of PTSD was reviewed.

RESULTS

Latent class analyses point toward a specific subtype of PTSD consisting of symptoms of depersonalization and derealization in both veteran and civilian samples of PTSD. Compared to individuals with PTSD, those with the dissociative subtype of PTSD also exhibit a different pattern of neurobiological response to symptom provocation as well as a differential response to current cognitive behavioral treatment designed for PTSD.

CONCLUSIONS

We recommend that consideration be given to adding a dissociative subtype of PTSD in the revision of the DSM. This facilitates more accurate analysis of different phenotypes of PTSD, assist in treatment planning that is informed by considering the degree of patients' dissociativity, will improve treatment outcome, and will lead to much-needed research about the prevalence, symptomatology, neurobiology, and treatment of individuals with the dissociative subtype of PTSD.

Psychoform and somatoform dissociation and PTSD in deaf adults

Both deafness and dissociation disconnect people from certain aspects of the external environment. Dissociation among the deaf population has been largely neglected as an area of scientific investigation. The purpose of this study was twofold: first, to examine the psychometrics of 2 dissociation measures--the Dissociation scale of the Trauma Symptom Inventory (TSI) and the Somatoform Dissociation Questionnaire-20 (SDQ-20); and second, to evaluate the relationship between dissociation and posttraumatic stress disorder (PTSD) in deaf adults. A diverse sample of 79 deaf adults was assessed using the Clinician-Administered PTSD Scale, the TSI, and the SDQ-20. Results provided support for the concept of psychoform dissociation, as measured by the TSI Dissociation scale, in deaf adults. However, somatoform dissociation, as measured by the SDQ-20, showed lower internal consistency. The SDQ-5, a shortened version of the SDQ-20, was unreliable in the current sample. Deaf adults were significantly higher on psychoform dissociation than the norm samples of hearing adults. As in hearing samples, dissociation--both psychoform and somatoform--was significantly related to PTSD symptoms. In addition, those with dissociative PTSD displayed significantly more symptoms of depression, anger, impaired self-reference, tension reduction behavior, and somatoform dissociation than did the nondissociative PTSD group.

Development and validation of a brief self-report measure of trauma exposure: the Trauma History Screen

Although information about individuals' exposure to highly stressful events such as traumatic stressors is often very useful for clinicians and researchers, available measures are too long and complex for use in many settings. The Trauma History Screen (THS) was developed to provide a very brief and easy-to-complete self-report measure of exposure to high magnitude stressor (HMS) events and of events associated with significant and persisting posttraumatic distress (PPD). The measure assesses the frequency of HMS and PPD events, and it provides detailed information about PPD events. Test-retest reliability was studied in four samples, and temporal stability was good to excellent for items and trauma types and excellent for overall HMS and PPD scores. Comprehensibility of items was supported by expert ratings of how well items appeared to be understood by participants with relatively low reading levels. In five samples, construct validity was supported by findings of strong convergent validity with a longer measure of trauma exposure and by correlations of HMS and PPD scores with posttraumatic stress disorder (PTSD) symptoms. The psychometric properties of the THS appear to be comparable or better than longer and more complex measures of trauma exposure.

Understanding social support's role in the relationship between maltreatment and depression in youth with foster care experience

This study investigated whether more complex maltreatment experiences predicted higher levels of depressive symptomatology for young adults and examined the role of social support during late adolescence in that association. Specifically, the study tested whether social support had a direct effect on depression and whether it mediated and/or moderated the relationship between self-reported maltreatment and depression in a sample of 513 youth exiting the child welfare system. Indices of maltreatment types (neglect and physical, sexual, psychological abuse) experienced during two periods (precare and during-care) were used in conjunction with a measure of perceived social support (reflecting support availability and social network sufficiency) in negative binomial regression models predicting depressive symptoms. Both precare and during-care maltreatment were associated with depressive symptoms as a young adult. Social support had a direct effect on depressive symptoms as well as moderation and partial mediation effects on the relationship between maltreatment and depression. Social support's buffering effect was stronger for those experiencing fewer types of maltreatment. This buffering effect appears to diminish as maltreatment histories become more complex.

Quality of early care and childhood trauma: a prospective study of developmental pathways to dissociation

Kihlstrom (2005) has recently called attention to the need for prospective longitudinal studies of dissociation. The present study assesses quality of early care and childhood trauma as predictors of dissociation in a sample of 56 low-income young adults followed from infancy to age 19. Dissociation was assessed with the Dissociative Experiences Scale; quality of early care was assessed by observer ratings of mother-infant interaction at home and in the laboratory; and childhood trauma was indexed by state-documented maltreatment, self-report, and interviewer ratings of participants' narratives. Regression analysis indicated that dissociation in young adulthood was significantly predicted by observed lack of parental responsiveness in infancy, while childhood verbal abuse was the only type of trauma that added to the prediction of dissociation. Implications are discussed in the context of previous prospective work also pointing to the important contribution of parental emotional unresponsiveness in the development of dissociation.

The relationship between childhood support and later emergence of PTSD

The authors examine the relationship between three sources of social support (maternal, paternal, and peer) and the development of posttraumatic stress disorder (PTSD). This study utilized data from the National Comorbidity Survey (NCS), a large (N = 5,877) nationally representative population survey. Persons with and without a lifetime history of PTSD and those with and without a history of trauma exposure were compared on levels of social support received prior to age 15. Persons with a history of PTSD reported that they received less maternal, paternal, and peer support as children than those without PTSD. Importantly, persons who developed PTSD after the age of 17 reported lower levels of early childhood support from their fathers.

Relationship of personality to dissociation and childhood trauma in borderline personality disorder

BACKGROUND

Dissociation is a prominent feature in some individuals with borderline personality disorder (BPD), yet our understanding of the meanings and implications of prominent dissociation in BPD remains limited. The purpose of this study was to investigate the relationship between dissociation and childhood trauma in BPD and to explore the relationships of dissociation and trauma to various personality features of BPD.

METHODS

Twenty BPD subjects and 24 healthy comparison subjects of similar age and gender were administered the Dissociative Experiences Scale, the Childhood Trauma Questionnaire-short form, the Tridimensional Personality Questionnaire, the Defense Style Questionnaire, the Relationship Style Questionnaire, and the Schema Questionnaire.

RESULTS

The BPD group exhibited greater dissociation and childhood trauma, as well as greater pathology in most personality variables, compared with the healthy group. Dissociation in BPD was not significantly related to total childhood trauma, but only to emotional neglect, which accounted for 23% of the variance in dissociation scores.

CONCLUSION

Within the BPD group, dissociation was associated with fearful attachment and immature defenses, while total childhood trauma and emotional neglect were associated with overconnection and disconnection schemata. This is a preliminary study with a small sample size, yet the correlates of dissociation in BPD merit further investigation.

Assessing experiences and responses of crime victims

This paper reviews strategies and methods for assessing crime victims with an emphasis on assessments for clinical purposes. In terms of outcomes, this paper primarily focuses on assessing posttraumatic symptoms of PTSD, dissociation, and traumatic grief as these are all quite disabling and may be mediators of other responses. Additional topics reviewed include reasons to assess experiences and responses of crime victims, issues to bear in mind when conducting assessments for different purposes, considerations for use of various sources of information about a client, characteristics of measures and of clients to take into account when selecting measures, recommended domains of experiences and symptoms to assess, and suggestions about the process of administering measures and conducting therapeutic assessments.

Psychometric study of a brief screen for PTSD: assessing the impact of multiple traumatic events

Most measures of posttraumatic stress disorder (PTSD) symptoms are limited in that they focus on a single traumatic event and cannot be used to assess symptoms in persons who report no traumatic events. The utility of the brief PTSD measures that do not key to a single trauma is limited by lengthiness and high reading levels. The Screen for Posttraumatic Stress Symptoms (SPTSS) is a brief, self-report screening instrument for PTSD symptoms that overcomes these limitations by assessing PTSD symptoms using a low reading level and without keying them to a specific traumatic event. In a sample of 136 psychiatric inpatients, the SPTSS showed good internal consistency, a high sensitivity rate, and a moderate specificity rate. The concurrent and construct validity of the SPTSS were supported by strong correlations with symptom and trauma experience measures and by comparisons of SPTSS scores of groups with different trauma histories.