How can self-regulation enhance our understanding of trauma and dissociation?

Is PTSD symptomatology a mechanism of emotional regulation? Insights from an interdisciplinary point of view

Post-traumatic stress disorder (PTSD) symptomatology has historically been considered a psychic ailment that is part of a mental disorder. However, it has often been proposed that it could play an adaptive role, in that it would prevent individuals from being exposed to content or situations that they would not be prepared to process. Within the literature on emotional regulation (ER), PTSD symptomatology has commonly been linked to the concept of emotional dysregulation (ED). However, some definitions open the possibility that traumatic symptomatology could be considered ER, from which delicate conclusions would follow. To resolve this dilemma, we turn to interdisciplinary dialogue, specifically with the aid of Thomistic anthropology, whose concepts allow us to understand precisely the relationship between voluntary and involuntary processes and the close relationship between the concepts of reason and regulation. Even though part of the PTSD symptomatology involves psychic mechanisms aimed at modifying emotional states, it is concluded that it is necessary to continue conceptualizing it as ED. The theoretical and practical implications of this discussion are reviewed.

Risk of Revictimization within Intimate Relationships among Women Survivors of Childhood Sexual Abuse: The Role of Cumulative Trauma and Self-Capacities Disturbances

Childhood sexual abuse, especially in the context of cumulative childhood interpersonal trauma (CCIT), is associated with an increased risk of revictimization by an intimate partner among women. The aim of the present study is to examine the role of self-capacities disturbances in the association between CCIT and revictimization by an intimate partner. The sample comprised of 247 adult women survivors consulting in sex therapy. Path analyses showed an indirect effect of self-capacities disturbances in the association between CCIT and revictimization (ORs = 1.49 and 1.62), demonstrating the importance of intervening in relational and affective difficulties among women survivors to prevent the risk of revictimization.

Trauma, Emotional Regulation, and Coping Styles in Individuals with and without Probable Dissociative Disorders in Hong Kong

Previous studies showed that dissociation and dissociative disorders (DDs) are prevalent and are associated with considerable individual and social consequences. There are ongoing debates regarding whether dissociation is a response to betrayal trauma across cultures and whether dissociation can be explained by maladaptive coping. Additionally, little is known about the clinical features of individuals with DDs in the Chinese context. This study aimed to investigate the relationship between trauma, emotional regulation, coping, and dissociation. We analyzed baseline data from a randomized controlled trial (N = 101). Participants with dissociative symptoms in Hong Kong completed self-report assessments. Structured interviews were also conducted subsequently. Participants with probable DDs reported more traumatic events (p = .009 to .017) and exhibited significantly higher levels of dysfunctional coping (p < .001) compared to those who reported dissociative symptoms but did not have a DD. Dissociative symptoms were more strongly associated with betrayal trauma than with non-betrayal trauma. Among different emotion regulation and coping strategies, dysfunctional coping was the only significant factor associated with dissociative symptoms (β = .309, p = .003). Dysfunctional coping was a statistically significant mediator that may explain the relationship between betrayal trauma and dissociative symptoms. Although other mediation paths are also possible and further longitudinal studies are required, our findings highlight the strong link between dysfunctional coping and dissociative symptoms and suggest that coping skills training should be incorporated into interventions for betrayal trauma survivors with dissociative symptoms. Additionally, this study provides evidence for the cross-cultural validity of the betrayal trauma theory. Further studies, however, are required.

Experiential avoidance, uncompassionate self-responding, and peritraumatic depersonalization/derealization: A novel mediation model for war-related PTSD symptomatology

OBJECTIVE

To explore a novel model for war-related posttraumatic stress disorder (PTSD) symptomatology including emotion regulation processes, namely experiential avoidance (EA) and uncompassionate self-responding (USR), mediating the impact of childhood threat memories, combat exposure distress, combat and noncombat threats, and peritraumatic depersonalization/derealization (PDD) on PTSD symptomatology.

METHOD

A sample of 650 male Portuguese Overseas War veterans filled self-report instruments.

RESULTS

The model explained 59% of the variance of PTSD symptomatology. Both EA and USR mediated the effects of noncombat threats and PDD on PTSD. Additionally, EA mediated combat exposure distress and USR mediated childhood threat memories. Combat exposure distress, combat and noncombat threats, and PDD showed direct effects on PTSD symptomatology.

CONCLUSION

The findings help to better understand the relationship between predictive factors of war-related PTSD in clinical and research settings, providing novel insights on the effects of combat exposure distress, and the different effects of combat and noncombat-related threats on PTSD.

Victimization profiles in girls involved in the juvenile justice system: A latent class analysis

BACKGROUND

Previous research has demonstrated that youth involved in the juvenile justice system endorse diverse patterns of victimization. However, previous research investigating victimization profiles among youth involved in the juvenile justice system has primarily consisted of boys.

OBJECTIVE

This study investigated victimization profiles and correlates of victimization exposure, including posttraumatic stress symptoms and risk behaviors, in a sample of girls involved in the juvenile justice system.

PARTICIPANTS AND SETTING

Participants were 245 girls involved in the juvenile justice system (Mage = 15.57, SD = 1.13) participating in a dating violence prevention program. The sample was racially diverse, and 48 % self-identified as Hispanic/Latina.

METHOD

Prior to participating in the intervention, participants completed self-report measures of adversity and victimization exposure, posttraumatic stress symptoms, and risk behaviors.

RESULTS

Results of latent class analysis identified three distinct victimization profiles. The first class (n = 106) was characterized by low levels of victimization. The second class (n = 98) experienced predominantly emotional victimization (i.e., emotional dominant). The third class (n = 41) was characterized by exposure to polyvictimization (i.e., polyvictimization predominant). Girls categorized into the polyvictimization dominant class evidenced the greatest levels of posttraumatic stress symptoms, substance use, suicidal behaviors, and sexual risk behaviors.

CONCLUSIONS

Girls involved in the juvenile justice system report distinct patterns of victimization, which are differentially associated with posttraumatic stress symptoms and risk behaviors. The present study underscores the importance of implementing trauma-informed assessment and intervention practices within juvenile justice systems.

Emotion Dysregulation in Sexually Abused Preschoolers: Insights from a Story Completion Task

Child sexual abuse (CSA) during the preschool period can seriously undermine children's ability to develop emotional competency. Narrative tasks, such as the MacArthur Story Stem Battery (MSSB), are particularly adapted to gain a better understanding of young children's self-regulation processes. To explore the emotion regulation competencies of sexually abused preschoolers, we developed a coding grid and undertook a detailed analysis of abused and non-abused children's narratives using the MSSB. A sample of 62 sexually abused and 65 non-abused preschoolers 3½ to 6½ years old was recruited and children were presented with nine stories and an expressive vocabulary test. Analyses were performed to compare abused and non-abused children's narratives and to assess the contribution of CSA to children's narratives. CSA was associated with fewer demonstrations of empathy, help, and comfort, and less coherent and resolved stories. The narratives of CSA victims also included less emotions and emotional variations. The influence of CSA appeared the strongest in the stories involving fear. These findings suggest the presence of emotion dysregulation among sexually abused preschoolers, but also insecure attachment, and a sense of betrayal, isolation, and powerlessness.

Factor Structure, Reliability, and Validity of the Daily Self-Report Measure for Trauma-Related Sequelae (DSR-TRS)

The structure and psychometrics of daily self-report measures have only rarely been empirically tested. We developed the Daily Self-Report of Trauma-Related Sequelae (DSR-TRS), comprised of items assessing, in the past day: (1) posttraumatic stress disorder (PTSD) symptoms: (2) symptoms of affective-, behavioral-, relational-, somatic-, dissociative-, and self-dysregulation; and (3) stressors, mood, coping strategies, and drug and alcohol use. Psychometric analyses were conducted with data from 141 women who participated in a randomized clinical trial of two present-centered therapies for PTSD or a wait-list condition and completed at least one DSR-TRS during two 30-day periods at baseline and posttreatment/wait-list. Five DSR-TRS subscales were created based on a series of exploratory, confirmatory, and multilevel factor analyses: Positive Affect, Negative Affect, Self-Regulation, Dysregulation, and PTSD symptoms. DSR-TRS subscales had acceptable within-person and between-person reliability. Convergent and discriminant validity were supported at baseline and posttest in relation to questionnaire and interview assessment measures. Implications for research on daily self-report measures such as the DSR-TRS with trauma survivors are discussed.

From Fight or Flight, Freeze or Faint, to "Flow": Identifying a Concept to Express a Positive Embodied Outcome of Trauma Recovery

BACKGROUND

The lifespan effects of adverse childhood experiences and their complex posttraumatic sequelae include early physical morbidity and mortality. Attention to physical sequelae and recovery is gaining clinical and research momentum. However, patient-centered communication in health care is hampered by lack of a common concept and word for a positive subjective, embodied outcome of trauma recovery.

OBJECTIVE

To address this gap in theory, research, and practice vocabulary.

DESIGN

We applied the six-step concept identification method described by Morse.

RESULTS

The concept we identified is distinct from the trauma-reactive states of "fight or flight" and "freeze or faint." We call it "flow."

CONCLUSIONS

Further deductive or inductive work to validate the concept would be useful as a step toward instrument development, followed by validation of its utility as a self-report proxy endpoint for patient centered health outcomes research. Qualitative research could be useful to elucidate the process of attaining "posttraumatic flow."

Derealization and self-harm strategies are used to regulate disgust, fear, and sadness in adult survivors of childhood sexual abuse

Emotion regulation (ER) difficulties have been identified as an important target for clinical intervention in the treatment of post-traumatic stress disorder (PTSD) symptoms in survivors of childhood sexual abuse (CSA). However, there is limited research regarding the use of specific strategies to regulate specific emotions following exposure to traumatic events. The aim of the current study was to investigate the indirect effects of four trauma-related emotions (anger, sadness, disgust, and fear) on PTSD severity via two mediators: derealization and self-harm. In particular, we tested that if the two hypothetical mediators operate sequentially, derealization precedes self-harm and/or self-harm precedes derealization. A predominate female clinical sample (N = 109) of CSA survivors completed measures of experience of emotions, ER, and post-traumatic stress. Bivariate and serial mediation analyses were conducted to test the direct and indirect effects of trauma-related emotions on PTSD severity. Serial mediation analyses indicated that there were significant total effects of all trauma-related emotions on PTSD severity. Three trauma-related emotions (sadness, disgust, and fear) were indirectly associated to PTSD severity via derealization and self-harm and via self-harm and derealization. Results indicate that difficulties in regulating the emotions of sadness, disgust, and fear may result in more severe derealization and self-harm as coping strategies, which in turn lead to greater PTSD severity. The sequence of mediators does not hold great importance in these pathways. Overall, our findings suggest that therapeutically targeting derealization and self-harm might enable the reduction of PTSD among CSA survivors.

Polyvictimization in childhood and its adverse impacts across the lifespan: Introduction to the special issue

Although much empirical work has focused on the adverse impact of specific types of childhood victimization (e.g., sexual, physical, or emotional abuse), researchers and clinicians increasingly are recognizing the prevalence of polyvictimization, or exposure to multiple types of victimization. Polyvictimization during formative developmental periods may have detrimental and potentially lifelong biopsychosocial impacts over and above the effects of exposure to specific types of adversity. In this guest editorial, we summarize the key questions and findings for six empirical studies on polyvictimization included in this Special Issue of the Journal of Trauma & Dissociation. These empirical studies further our understanding of the nature, consequences, and assessment of polyvictimization. We conclude with recommendations for continued scientific research and clinical inquiry on polyvictimization.

Polyvictimization and Girls' Involvement in the Juvenile Justice System: Investigating Gender-Differentiated Patterns of Risk, Recidivism, and Resilience

A recent dramatic rise in girls' arrests has increased our need to examine whether our models of youth justice system involvement need to be differentiated by gender. Polyvictimization, in particular, has been implicated as a powerful predictor of youth problem behavior. However, recent research suggests that polyvictimization is associated with youth involvement in the justice system in ways that differ for girls at the levels of the independent variables (i.e., the sources of risk), the dependent variables (i.e., youth outcomes), and the mediators of these associations (i.e., the purported mechanisms that account for these relations). The present critique describes growth points in the current research with the goal of suggesting promising directions for future investigations. In particular, gaps are noted regarding our understanding of the specific forms of polyvictimization that affect traumatized girls' development, especially given the highly disproportionate prevalence of sexual abuse among justice-involved girls. In addition, increased attention is needed to gender differences in the timing of victimization and the onset of risky behavior, as well as the nature of trauma-linked youth offenses and recidivism, which research also suggests may differ for boys and girls. Furthermore, a new body of research on psychophysiological reactivity promises to shed light on gender differences in trauma response, resilience, and risk. Finally, the importance acknowledging the intersection of polyvictimization, gender, and race is noted. The article ends with a discussion of the ways in which understanding gender differences and similarities can inform gender-responsive approaches to prevention and intervention efforts.

Cumulative childhood trauma, emotion regulation, dissociation, and behavior problems in school-aged sexual abuse victims

BACKGROUND

Child sexual abuse is associated with a plethora of devastating repercussions. A significant number of sexually abused children are likely to experience other forms of maltreatment that can seriously affect their emotion regulation abilities and impede on their development. The aim of the study was to test emotion regulation and dissociation as mediators in the association between cumulative childhood trauma and internalized and externalized behavior problems in child victims of sexual abuse.

METHODS

Participants were 309 sexually abused children (203 girls and 106 boys; Mean age = 9.07) and their non-offending parent. Medical and clinical files were coded for cumulative childhood trauma. At initial evaluation (T1), parents completed measures assessing children's emotion regulation abilities and dissociation. At Time 2 (T2), parents completed a measure assessing children's behavior problems. Mediation analyses were conducted with emotion regulation and dissociation as sequential mediators using Mplus software.

RESULTS

Findings revealed that cumulative childhood trauma affects both internalized and externalized behavior problems through three mediation paths: emotion regulation alone, dissociation alone, and through a path combining emotion regulation and dissociation.

LIMITATIONS

Both emotion regulation and dissociation were assessed at T1 and thus the temporal sequencing of mediators remains to be ascertained through a longitudinal design. All measures were completed by the parents.

CONCLUSIONS

Clinicians should routinely screen for other childhood trauma in vulnerable clienteles. In order to tackle behavior problems, clinical interventions for sexually abused youth need to address emotion regulation competencies and dissociation.

Dissociation mediates the relationship between sexual abuse and child psychological difficulties

The aim of the present study was to evaluate, using structural equation modeling, a theoretical model in which dissociation is a core process mediating the relationship between childhood sexual abuse (CSA) and internalizing, externalizing, and sexualized behaviour difficulties in children. A total of 290 children aged 2-12 participated in this study in Québec, Canada from 1998 to 2004, including 138 children with histories of CSA and 152 non-abused children. To assess child dissociative symptoms, internalizing and externalizing difficulties, as well as sexualized behaviour difficulties, the Child Dissociative Checklist, the Child Behaviour Checklist and the Child Sexualized Behaviour Inventory were completed by parents. Dissociation mediated the relationship between CSA and internalizing, externalizing, and sexualized behaviour difficulties, with the model explaining respectively 42.5%, 49.9% and 33.9% of the variance of these difficulties. Findings are consistent with a model where dissociation is a common pathway linking CSA and child psycho-sexual difficulties.

Sleep problems and dissociation in preschool victims of sexual abuse

OBJECTIVE

Child sexual abuse (CSA) is associated with a host of deleterious impacts, yet little is known about the short-term correlates in children. This study aimed to investigate the association between dissociation and sleep problems in a sample of preschool-age sexual abuse victims while controlling for potentially confounding variables, including gender, age, polytrauma, CSA characteristics, and parental distress.

METHOD

The sample consisted of 179 children (ages 3-6 years) and their non-offending parents. Parents completed questionnaires assessing their child's dissociative symptoms and sleep problems as well as their own level of psychological distress.

RESULTS

Regression analyses revealed that sleep problems were significantly associated with dissociative symptoms over and above all other control variables (children's gender and age, polytrauma, and parental distress). A longer duration of sexual abuse also predicted greater dissociative symptoms in preschool children.

CONCLUSION

Findings highlight the association between sleep problems and dissociation in preschool-age victims of CSA. Further research is needed to understand their impact on children's development to design appropriate treatment and prevention initiatives aimed at fostering resilience in young vulnerable children.

Examining Cognitive Processes and Drinking Urge in PTSD

Despite their centrality to learning theories, strikingly little attention has been paid to the role of cognitions in efforts to understand associations between posttraumatic stress disorder (PTSD) and alcohol drinking. In the present study, we sought to examine information processing pathways for trauma and alcohol information, and the effects of posttraumatic stress and trauma cue exposure on these pathways. Participants were college students (N = 232; 49% female; Mage = 19.56,SD = 1.44) categorized into three diagnostic groups based on current PTSD status determined by structured clinical interview. These students then were exposed to a personalized trauma or neutral cue script, followed by a Stroop task modified to include trauma, alcohol, and contrast words. Indices of mood and urge to drink alcohol were administered throughout the task. Findings revealed that those with PTSD who were exposed to the personalized trauma cue showed a general response slowing across all stimuli types on the Stroop task. Intriguingly, this slowing effect was significantly associated with urge to drink alcohol for only those PTSD participants who were exposed to the trauma cues. In contrast, we did not find support for the hypothesis that trauma cues would lead to attention bias to trauma and alcohol specific Stroop stimuli among participants with PTSD, nor did slower RT for specific word types predict unique variance in urge to drink alcohol. Findings suggest that individual (PTSD) and environmental (cue) circumstances may work conjointly to precipitate changes in cognitive processing - changes that may have implications for drinking motivation. Given the importance of cognition in the etiology of both PTSD and drinking, this is a mechanism that warrants further investigation.

The roles of emotion dysregulation and dissociation in the association between sexual abuse and self-injury among juvenile justice-involved youth

To date, scholars have established associations among nonsuicidal self-injury and sexual abuse, posttraumatic stress symptoms, and dissociation. However, leading theoretical models of the mechanisms underlying the association between trauma and negative outcomes suggest a more parsimonious explanation in that deficits in emotion regulation may underlie these various risk factors for self-injury. This study examined whether sexual abuse was differentially associated with nonsuicidal self-injury over and above other forms of traumatic experiences and whether the association between sexual abuse and self-injury was statistically mediated by emotion dysregulation and dissociation. Participants included 525 youth (392 boys, 133 girls) recruited from the U.S. juvenile justice system who completed measures of self-reported trauma exposure, posttraumatic stress symptoms, dissociation, and emotion dysregulation. Results of a hierarchical regression demonstrated that sexual abuse predicted posttraumatic stress symptoms and self-injury over and above other forms of traumatic experiences. Results of bootstrapped mediation analyses indicated that emotion dysregulation and dissociation in combination were implicated in self-injury among youth. The results suggest that youth in the juvenile justice system who experience sexual abuse may be at risk for higher rates of posttraumatic stress symptoms and that self-injury may be particularly salient for youth who experience sexual abuse. Furthermore, the results shed light on the role that dissociation and emotion dysregulation play in the relation between sexual abuse and self-injury, suggesting that a larger framework of self-regulation may have both empirical and clinical utility in helping to understand the underlying processes at play in these associations.