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Childhood trauma and perceived parental dysfunction in the etiology of dissociative symptoms in psychiatric inpatients

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Research on the etiology of dissociation in adults has focused primarily on childhood sexual abuse. The role of co-occurring childhood stressors and of more chronic adverse conditions such as neglect is less clear. This study examined the level of dissociation in relation to childhood trauma (sexual/physical abuse, witnessing interparental violence), early separation from a parent, and perceived parental dysfunction. One hundred sixty inpatients consecutively admitted to a general psychiatric hospital were administered the Dissociative Experiences Scale and the Structured Trauma Interview. The mean Dissociative Experiences Scale score was 17.4; 18.0% of the patients scored beyond 30. Early separation was reported by 26.4% of the patients; 30.1% had witnessed interparental violence; 23.6% reported physical abuse; 34.6% reported sexual abuse; 11.7% reported rape before age 16; and 42.1% reported sexual and/or physical abuse. The level of dissociation was primarily related to reported overwhelming childhood experiences (sexual and physical abuse). When sexual abuse was severe (involving penetration, several perpetrators, lasting more than 1 year), dissociative symptoms were even more prominent. Highest dissociation levels were found in patients reporting cumulative sexual trauma (intrafamilial and extrafamilial) or both sexual and physical abuse. In particular, maternal dysfunction was related to the level of dissociation. With control for gender and age, stepwise multiple regression analysis indicated that the severity of dissociative symptoms was best predicted by reported sexual abuse, physical abuse, and maternal dysfunction. These findings indicate that dissociation, although trauma-related, is neglect-related as well. This implies the importance of object relations and attachment in the diagnosis and treatment of patients with dissociative disorders.
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Am J Psychiatry 156:3, March 1999
379
Childhood Trauma and Perceived Parental Dysfunction
in the Etiology of Dissociative Symptoms
in Psychiatric Inpatients
Nel Draijer, Ph.D., and Willie Langeland, M.A.
Objective: Research on the etiology of dissociation in adults has focused primarily on
childhood sexual abuse. The role of co-occurring childhood stressors and of more chronic
adverse conditions such as neglect is less clear. This study examined the level of dissoci-
ation in relation to childhood trauma (sexual/physical abuse, witnessing interparental vio-
lence), early separation from a parent, and perceived parental dysfunction. Method: One
hundred sixty inpatients consecutively admitted to a general psychiatric hospital were ad-
ministered the Dissociative Experiences Scale and the Structured Trauma Interview. Re-
sults: The mean Dissociative Experiences Scale score was 17.4; 18.0% of the patients
scored beyond 30. Early separation was reported by 26.4% of the patients; 30.1% had wit-
nessed interparental violence; 23.6% reported physical abuse; 34.6% reported sexual
abuse; 11.7% reported rape before age 16; and 42.1% reported sexual and/or physical
abuse. The level of dissociation was primarily related to reported overwhelming childhood
experiences (sexual and physical abuse). When sexual abuse was severe (involving pene-
tration, several perpetrators, lasting more than 1 year), dissociative symptoms were even
more prominent. Highest dissociation levels were found in patients reporting cumulative
sexual trauma (intrafamilial and extrafamilial) or both sexual and physical abuse. In partic-
ular, maternal dysfunction was related to the level of dissociation. With control for gender
and age, stepwise multiple regression analysis indicated that the severity of dissociative
symptoms was best predicted by reported sexual abuse, physical abuse, and maternal
dysfunction. Conclusions: These findings indicate that dissociation, although trauma-re-
lated, is neglect-related as well. This implies the importance of object relations and attach-
ment in the diagnosis and treatment of patients with dissociative disorders.
(Am J Psychiatry 1999; 156:379–385)
Dissociative symptoms refer to disruptions in the
usually integrated functions of consciousness, such as
memory, identity, and perception of the environment
(DSM-IV, p. 477). The theoretical assumption that dis-
sociation is primarily a response to overwhelming ex-
periences, especially in childhood (1, 2), is currently
questioned (3–5). What is the empirical evidence for
this assumed relationship? And, if there is a relation-
ship, is the level of adult dissociation directly associ-
ated with early trauma per se, or are other pathogenic
factors in childhood relevant as mediators? The term
“trauma” is here restricted to psychologically over-
whelming experiences inducing fear and helplessness.
Empirical evidence supporting the relation between
trauma and dissociation is based on three sources: 1)
studies on the relation between dissociation and
trauma in adulthood, 2) research examining links be-
tween childhood trauma and adult dissociation, and
3) prospective studies of children. Regarding the first
source, elevations in the level of dissociation have
been demonstrated in adults during or shortly after a
traumatic event (6–10) as well as long after an over-
whelming event (11). Childhood trauma could be a
precursor for these dissociative tendencies, since
higher dissociation levels have been found in rape vic-
tims reporting childhood sexual abuse than in non-
abused rape victims (12).
Research examining the relation between childhood
trauma and adult dissociation has focused primarily
on sexual and physical abuse. In particular, sexual
Received July 28, 1997; revisions received Feb. 3 and July 17,
1998; accepted Aug. 18, 1998. From the Department of Psychia-
try, Vrije Universiteit. Address reprint requests to Dr. Draijer,
Department of Psychiatry, Vrije Universiteit, Valeriusplein 9, 1075
BG Amsterdam, The Netherlands.
Supported by a grant from the Dutch Ministry of Health, Welfare
and Sports.
The authors thank the Psychiatric Centre Joris in Delft for its
cooperation.
380
Am J Psychiatry 156:3, March 1999
PERCEIVED PARENTAL DYSFUNCTION
abuse, its severity, and its combination with physical
abuse have been found to be strongly related to adult
dissociation measured by either the Dissociative Expe-
riences Scale (13–20) or the Structured Clinical Inter-
view for DSM-III-R Dissociative Disorders (SCID-D)
(21, 22). Two studies (23, 24) indicated that physical
abuse was more important than sexual abuse in the ex-
planation of adult dissociation.
Finally, in prospective research (25) sexually abused
girls had significantly higher initial and 1-year follow-
up dissociation levels than nonabused control subjects.
Little is known, however, about the effect of co-oc-
curring distressing circumstances such as parental loss
or separation, witnessing interparental violence, and
the more chronic adverse circumstances of neglect. Epi-
demiological research has demonstrated that neglect is
a risk factor for later psychopathology in general (26,
27) and that parental loss is a risk factor for adult de-
pression (28). Furthermore, in community samples of
women, parental dysfunction, interparental violence,
and separation from parents were related to sexual and
physical abuse as well as to general adult psychopathol-
ogy (29, 30). Parental dysfunction and sexual and phys-
ical abuse, both in childhood and in adulthood, have
been found to be independent predictors of adult psy-
chopathology (31). In addition, some writers consider
dissociative identity disorder primarily an attachment
disorder, highlighting the relevance of disturbed attach-
ment relationships in which a child grows up (32, 33).
Given the interrelationship among family pathology,
neglect, early separation, and childhood abuse, which
experiences are central in the etiology of dissociation?
Empirical findings on the importance of neglect com-
pared with abuse are inconclusive. In one study (5) the
relation between dissociation and sexual abuse disap-
peared when family pathology was controlled for. In a
nonclinical population, loss in the family and intrafa-
milial and extrafamilial sexual abuse, rather than
abuse alone, predicted the level of adult dissociation
(34). Early separation from parents was significantly
more often reported by patients with dissociative dis-
order than by control patients with other axis I diag-
noses but was reported as often by patients with clus-
ter B personality disorders; pathological dissociation
was strongly related to sexual and physical abuse but
only slightly related to early separation and witnessing
interparental violence (22). Among sexually abused fe-
male inpatients, physical neglect and witnessing sexual
abuse or physical abuse were associated with higher
levels of dissociative symptoms, but childhood stress-
ors involving loss were not. A close relationship with a
parent, sibling, or friend did not have a mediating ef-
fect (35). Nor did—in a nonclinical sample—perceived
availability of emotional support in childhood elimi-
nate the relation between childhood trauma and disso-
ciation (36). We may conclude that neglect (conceptu-
alized in a variety of ways) and separation from
parents, in addition to overwhelming intimate experi-
ences such as childhood abuse, may be precursors of
dissociation.
The present study was designed to examine the
predictive value of childhood trauma, prolonged sep-
aration, and neglect in the development of adult dis-
sociation. It was hypothesized that besides neglect
(conceptualized as parental dysfunction) and separa-
tion from a parent (due to divorce, illness, or death),
overwhelming childhood experiences (witnessing in-
terparental violence and, in particular, sexual and
physical abuse) would uniquely contribute to the level
of dissociative symptoms in an adult psychiatric inpa-
tient population.
METHOD
Instruments
The Dissociative Experiences Scale (13) is the most widely used
screening instrument for dissociative symptoms in clinical samples.
Good reliability and good clinical validity have been reported at dif-
ferent centers in North America (13, 37, 38) and in The Netherlands
(39, 40). The scale, a 28-item visual analogue self-report instrument,
contains items referring to amnesia, depersonalization, derealiza-
tion, absorption, and identity alteration.
The Structured Trauma Interview (41) is an adapted version for
psychiatric patients of the interview developed for a national survey
on the prevalence and sequelae of child sexual and physical abuse
and perceived neglect (29). It addresses childhood experiences
proven to be risk factors for adult psychopathology (early separa-
tion from parents, parental dysfunction, parental physical aggres-
sion, sexual abuse, witnessing interparental violence, and other
overwhelming experiences before age 16); “parents” includes step-
parents and adoptive parents. Adult sexual and physical assault is
addressed as well. Although the Structured Trauma Interview has
been used in several studies, no data on its validity have been pub-
lished yet.
Neglect was defined as parental dysfunction or unavailability re-
sulting from recurrent illness, nervousness, depression, alcohol mis-
use, and use of sedatives. The choice to conceptualize neglect in
terms of parental dysfunction is based on the fact that it refers to fac-
tual, observable behavior of the parents instead of more subjective
indications of their unavailability or lack of affection. Questions
were: “Was your (step/adoptive) mother often ill? Was she nervous,
tense? Was she depressed? Did she use a lot of alcohol? Did she use
sedatives, as far as you know?” The same questions were asked with
respect to fathers. Answers were coded in a yes/no format (unclear
answers were coded as no). A total score for each parental figure was
based on these questions; their internal consistency was reasonable
(Cronbach’s alpha for dysfunction of mother: 0.64; for dysfunction
of father: 0.65). This measure of neglect was validated by its relation
to lack of maternal and paternal affection as measured by the Paren-
tal Bonding Instrument (26) (Pearson’s r=–0.49 and –0.38, respec-
tively, N=1,054, p<0.0001) (29).
Early separation was defined as the loss of, or separation from, a
natural parent or caretaker by death, divorce, illness, foster care, or
other reasons before age 12 during a period of at least 6 months.
Physical abuse was defined as severe parental aggression. Parental
aggression included physical punishments by parental figures that
could have hurt the child physically. Questions were: “Sometimes
parents hit their children as a disciplinary measure or because they
lose their temper. If your parents wanted to punish you, what did they
do? How often do you remember that your parents hit you? If you try
to remember the occasions they hit you, which made the biggest im-
pression on you?” Frequency and severity of parent-to-child violence
before age 16 were assessed according to the Conflict Tactics Scales
(42). Instances of culturally accepted corporal punishment were not
rated as abusive. On the basis of a qualitative analysis comparing as-
pects of physical aggression (i.e., nature/severity of violence, fre-
quency, duration, injury), a severity index was constructed with
scores consisting of absent, mild, moderate, and severe. The mild cat-
Am J Psychiatry 156:3, March 1999
381
NEL DRAIJER AND WILLIE LANGELAND
egory included being incidentally hit or kicked, with no injuries. The
moderate category included being recurrently hit and/or kicked and
incidentally being hit with an object, sometimes leading to injuries
such as bruises. The term “physical abuse” was reserved for the cate-
gory of severe parental aggression. This included recurrent and
chronic forms of physical violence that frequently inflicted injuries,
such as repeatedly being kicked or hit with a fist or an object (e.g., a
stick or a belt), being tied up, or being thrown down stairs.
Sexual abuse was defined as any pressured or forced sexual con-
tact before age 16, ranging from fondling to penetration. The ques-
tion was: “Nowadays it is clear that many women, but men as well,
have had negative sexual experiences in their childhood. Do you
know if something like this happened to you?” If the answer was
positive, the interviewer inquired about perpetrators, sexual activi-
ties, force or pressure, frequency, age at onset, and how upsetting
these experiences were at the time. Rape was defined as sexual abuse
including penetration. If a patient was sexually abused by more than
one perpetrator at different times, the most important incident was
chosen by the subject for more detailed inquiry.
Experiences of witnessing physical or sexual violence between
parents before age 16 were rated as childhood witnessing of interpa-
rental violence.
Procedure
During 18 months all consecutively admitted adult inpatients of a
general psychiatric hospital were invited by staff members to partic-
ipate in the study. According to the national records that follow the
ICD, this inpatient population matches the national inpatient popu-
lation diagnostically. Multiple admissions were treated as one case.
Criteria for eligibility included fluency in Dutch, freedom from or-
ganic dysfunction, and stabilization that was adequate for giving in-
formed consent. After complete description of the study to the sub-
jects, both written and verbal informed consent was obtained.
The Dissociative Experiences Scale was administered along with
other self-report instruments. Participants were interviewed about
childhood experiences independently. Interviewers were trained psy-
chiatric nurses, a social worker, and a psychologist who were super-
vised on countertransference issues during data gathering. Unless pa-
tients expressed the wish to share the information with their treating
clinicians, research data were kept confidential.
Data Analysis
A series of bivariate analyses were conducted to examine the pre-
dictive value of selected childhood experiences. Chi-square tests with
Yates’s correction and two-tailed t tests were used where appropri-
ate. When cell sizes were 5 or less, we used Fisher’s exact test of
probability. Multivariate stepwise regression analysis was used to
examine the relative importance of childhood trauma for the expla-
nation of the variance in dissociation.
RESULTS
Of 313 admitted patients, 182 were willing and able
to participate. However, 15 patients refused to partici-
pate during data gathering, and another seven partici-
pated as “pilot subjects,” leaving 160 subjects
(51.1%). The main reasons for nonparticipation were
a hospital stay that was too short to administer all in-
struments (39%), refusal (35%), and permission not
granted by the treating clinician (19%).
More women (N=94) than men (N=66) participated
(χ
2
=10.08, df=1, p<0.005), fewer participants lived
alone (43%, versus 59% of the nonparticipants; χ
2
=
14.70, df=4, p<0.005), and fewer were unemployed
(53%, versus 71% of the nonparticipants; χ
2
=34.34,
df=3, p<0.0001). The participants were slightly
younger than the nonparticipants (mean age=35.6
years, SD=12.0, and mean=38.5 years, SD=14.0, re-
spectively; t=1.97, df=310, p<0.05). They did not dif-
fer in the number of psychiatric hospitalizations.
Some demographic differences may be explained by
the fact that patients suffering from psychosis or
schizophrenia were often considered unable to partici-
pate by their treating clinician; 36% of the participants
suffered from psychotic symptoms, compared with
62% of the nonparticipants (χ
2
=17.13, df=1, p<
0.0001). More participants (41%) than nonpartici-
pants (25%) met the criteria for a DSM-III-R axis II di-
agnosis (χ
2
=7.98, df=2, p<0.05). As axis II diagnoses
are made over time, this difference could be a bias re-
sulting from the short hospital stays among the non-
participants. Thus, the study group was selective
mainly toward including more nonpsychotic patients.
This bias is inherent to clinical research.
No adverse consequences of the standardized inter-
view were observed.
Table 1 presents both characteristics of childhood
trauma and their prevalence. To a certain extent, child-
hood experiences were interrelated: early separation
from a parent was related to sexual abuse (r=0.20, N=
147, p<0.05), to physical abuse (r=0.17, N=148, p<
0.05), and to witnessing interparental violence (r=
0.25, N=143, p<0.01); sexual and physical abuse were
related (r=0.18, N=147, p<0.05); and physical abuse
was related to witnessing interparental violence (r=
0.25, N=143, p<0.05), but sexual abuse was not.
The nature and frequency of parental dysfunction
are shown in table 2. Except for alcohol misuse, moth-
ers were reported to have been dysfunctional more of-
ten than fathers. Total scores for each parental figure
were only slightly related (Pearson’s r=0.15, N=136,
p<0.10). Perceived maternal dysfunction was more
closely related to childhood trauma than perceived pa-
ternal dysfunction. The level of maternal dysfunction
was associated with early separation (r=0.33, N=144,
p<0.0001), witnessing interparental violence (r=0.29,
N=140, p<0.0001), and sexual abuse (r=0.18, N=143,
p<0.05). However, the level of paternal dysfunction
was only related to witnessing interparental violence
(r=0.25, N=137, p<0.01).
The mean Dissociative Experiences Scale score was
17.4 (SD=16.8, median=12.1, N=139); 25.2% (N=35)
of the patients scored beyond 25, and 18.0% (N=25)
beyond 30. The scores of male and female patients did
not differ. Younger patients scored somewhat higher
(r=–0.18, N=139, p<0.05).
The severity of dissociative symptoms was signifi-
cantly related to reported physical abuse and sexual
abuse but not to early separation (table 1). The severity
of sexual abuse (penetration and duration longer than
1 year) was strongly related to the level of dissociation.
Highest dissociation scores came from patients who
were sexually abused both inside and outside the fam-
ily or who were both sexually and physically abused.
The severity of dissociative symptoms was also re-
lated to perceived parental dysfunction (table 2): per-
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PERCEIVED PARENTAL DYSFUNCTION
ceived maternal dysfunction due to illness, nervousness,
depression, and alcohol misuse and perceived paternal
dysfunction due to nervousness, alcohol misuse, and use
of sedatives. Highest levels of dissociation were shown
by patients who reported having mothers who were
heavy drinkers. In terms of the combined total score,
maternal dysfunction was associated with dissociation
(r=0.32, N=130, p<0.0001); paternal dysfunction was
correlated not as strongly (r=0.24, N=126, p<0.01).
Multivariate stepwise regression analysis, using gender
and age as control variables, indicated that all trauma
and neglect variables together accounted for 23% of the
variance in the Dissociative Experiences Scale scores.
Physical abuse and sexual abuse were the strongest pre-
dictors (both betas=0.24, p<0.01), but maternal dysfunc-
tion was significant as well (beta=0.21, p<0.05).
DISCUSSION
Our central question was, What is the predictive
value of childhood trauma, in the sense of over-
whelming experiences, compared with prolonged sep-
aration and neglect due to parental dysfunction in the
development of adult dissociation? Although mater-
nal dysfunction in particular turned out to be impor-
tant in this prediction, sexual and physical abuse each
made an independent contribution to the level of
adult dissociation.
Given the theoretical overlap between the concepts
of abuse and neglect, the correlations between the two
were not so strong as to consider abuse and neglect
(conceptualized as parental dysfunction) as co-occur-
ring phenomena. Collinearity, though expected, was
not really present.
Our findings—indicating that childhood stressors in
the form of either severe physical or sexual abuse or re-
petitive sexual trauma were associated with a higher
degree of dissociative symptoms—support previous
findings (14, 16–20, 25). Multiple victimization, in
particular in intimate relationships, seems to reinforce
the dissociative response.
Contrary to our expectation, witnessing violence
and early separation from a parent did not contribute
TABLE 1. Prevalence of Traumatic Childhood Experiences and Scores on the Dissociative Experiences Scale of 160 Psychiatric
Inpatients
Type of Experience N %
Score on the
Dissociative
Experiences
Scale Analysis
a
Mean SD F df p
Separation from parent before age 12 (N=148)
Yes 39 26.4 20.88 17.92
No 109 73.6 14.74 15.35
Witnessed interparental violence before age 16 (N=143)
Yes 43 30.1 20.05 18.07
No 100 69.9 14.52 15.40
Physical abuse before age 16 (N=140)
b
Yes 35 25.0 26.71 21.61
Abuse by mother (N=145) 18 12.4 28.22 18.06
Abuse by father (N=141) 23 16.3 25.76 22.38
No 105 75.0 13.26 13.06
Sexual abuse before age 16 (N=155)
c
Yes 55 35.5 26.07 18.57
Sexual activity (N=137)
d
10.44 2, 136 <0.0001
Fondling only 24 17.5 26.37 21.40
Penetration (rape) 16 11.7 28.28 18.89
Duration more than 1 year (N=148)
e
18 12.2 25.96 16.00 3.72 2, 124 <0.05
Perpetrator (N=140)
Intrafamilial only 17 12.1 23.60 21.20
Extrafamilial only 21 15.0 21.03 15.75
Intra- and extrafamilial 5 3.6 30.72 20.02 6.31 2, 134 <0.0001
No 100 64.5 12.80 12.95
Sexual abuse and/or physical abuse (N=147) 10.51 3, 127 <0.0001
Ye s 6 2 4 2 . 2
Physical abuse only 19 12.9 16.24 12.78
Sexual abuse only 28 19.0 18.17 12.71
Both
f
15 10.2 34.51 22.32
No 85 57.8 11.92 12.75
a
Significant difference between the scores of patients with and without the type of experience.
b
Significant difference between the scores of patients with and without the type of experience (t=4.15, df=124, p<0.0001).
c
Significant difference between the scores of patients with and without the type of experience (t=4.84, df=130, p<0.0001).
d
Categories for analysis: absent, fondling, penetration.
e
Categories for analysis: absent, duration <1 year, duration 1 year.
f
A Scheffé post hoc comparison procedure was applied to this analysis of variance: the mean Dissociative Experiences Scale scores of
the category “both physical and sexual abuse” differed significantly from all other categories (p<0.05).
Am J Psychiatry 156:3, March 1999
383
NEL DRAIJER AND WILLIE LANGELAND
independently to the level of dissociation when com-
pared with parental dysfunction and other overwhelm-
ing childhood experiences. Experiences of parental loss
or separation were not related to greater severity of
dissociative symptoms, confirming earlier clinical data
based on a similar dissociation measure and similar
definition of loss (35), but contradicting results based
on different instruments in a nonclinical sample (34,
36). Apparently, our study needs replication in a non-
clinical population.
One explanation for why sexual abuse and physical
abuse are related to the level of adult dissociation, and
loss or separation are not, may be the secrecy and de-
nial associated with these forms of abuse. Subjectively,
the child lives in a fragmented reality, and social sup-
port is limited because traumatization occurs through
exactly the persons on whom the child is dependent.
The fact that maternal dysfunction is important in
the explanation of adult dissociation disconfirms the
theoretical assumption of a sheer trauma-related eti-
ology of dissociation. We suppose that dysfunction
and unavailability of caretakers contribute to a lack
of soothing capacities in the child (43) and thus to
the vulnerability to overwhelming feelings and the
use of dissociation as a defense against them. In the
early stages of treatment of the dissociative patient,
strengthening of the self-soothing capacities or coping
skills is very important.
Our findings provide support for the clinical obser-
vation that patterns of insecure/disorganized attach-
ment are related to increased levels of dissociation
(31, 32, 44). They also support findings in nonclinical
samples that the quality of the object relations (mea-
sured by similar parental availability measures and
the Parental Bonding Instrument) is a major factor in
adult outcome (28, 30). They support the notion that
perceived availability of emotional support in child-
hood is an important mediator in adult proneness to
dissociation (36).
Our data do not support the view expressed by Nash
et al. (5) that sexual abuse, compared with neglect due
to family pathology, is irrelevant in the etiology of
adult dissociative symptoms. An explanation of this
discrepancy could lie in the weak and unusual depen-
dent measure used in that particular study: scores on
two MMPI-based measures of dissociative experiences
and the Dissociation Content Scale. In addition, Nash
et al. used rather specific criteria for sexual abuse—i.e.,
involving at least genital manipulation to orgasm of or
by the child. Furthermore, the method of statistical
analysis they used (analysis of covariance instead of re-
TABLE 2. Prevalence of Parental Dysfunctions and Scores on the Dissociative Experiences Scale of 160 Psychiatric Inpatients
Parental Dysfunction N %
Score on the
Dissociative
Experiences Scale Analysis
a
Mean SD t (two-tailed) df p
Mother
Recurrently ill (N=147) 1.98 130 <0.05
Yes 48 32.7 20.40 18.15
No 99 67.3 14.49 14.98
Often nervous (N=146) 3.11 128 <0.005
Yes 78 53.4 20.49 18.79
No 68 46.6 11.89 11.36
Often depressed (N=146) 3.24 128 <0.005
Yes 37 25.3 24.66 17.39
No 109 74.7 14.08 15.21
Abused alcohol (N=147) 3.12 130 <0.005
Yes 13 8.8 29.93 18.48
No 134 91.2 15.07 15.46
Used sedatives (N=145)
Yes 30 20.7 17.72 15.21
No 115 79.3 16.17 16.61
Father
Recurrently ill (N=143)
Yes 30 21.0 16.31 13.68
No 113 79.0 16.35 17.11
Often nervous (N=144) 2.51 126 <0.05
Yes 43 29.9 21.72 18.41
No 101 70.1 13.94 14.94
Often depressed (N=143)
Yes 25 17.5 16.85 16.48
No 118 82.5 16.10 16.41
Abused alcohol (N=143) 2.55 126 <0.05
Yes 37 25.9 22.42 18.03
No 106 74.1 14.11 15.19
Used sedatives (N=142) 2.27 124 <0.05
Yes 14 9.9 25.95 19.62
No 128 90.1 15.20 15.80
a
Significant difference between the scores of patients with and without the parental dysfunction.
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PERCEIVED PARENTAL DYSFUNCTION
gression analysis) does not allow the inferences that
were made (45).
We may presume that the inconclusive findings thus
far on the prediction of dissociation are probably due
to weaknesses in the abuse measures and neglect mea-
sures as well as in the dissociation measures used.
Some limitations of our study should be noted. It
was based on retrospection. The context of family dys-
function may be a risk factor for sexual and physical
abuse, but it may also be an artifact resulting from the
retrospective projections of helplessness and isolation
of abused patients (46). Nevertheless, it is striking that
mothers are perceived as less available than fathers and
that the perception of their unavailability is more im-
portant in the prediction of adult pathology (26). As-
signing causality is problematic, though, because of the
cross-sectional method we used. Also, memory bias
could be present among highly dissociative patients:
one could hypothesize both underreporting of trauma
due to dissociative amnesia and overreporting due to
high suggestibility in those patients, although suggest-
ibility has been found not to be related to the level of
dissociation (47). Because of the need for confidential-
ity, no independent corroborating evidence was sought
for any self-reported case of childhood abuse. There-
fore, the validity of abuse reports cannot be ensured.
Although the bias in the study group (skewed toward
less psychotic patients) is a general problem in clinical
research, the results should be considered with some
reservations. Only 23% of the variance was explained
by childhood trauma and perceived parental dysfunc-
tion. This suggests that the severity of dissociative
symptoms might be accounted for by other factors,
such as recent traumatic experiences (6, 8–10), stress
caused by a psychiatric admission, general distress
that made an admission necessary, or other influ-
ences. Inpatients in general present high levels of dis-
sociation, of which some are trauma-related and oth-
ers are not (Friedl and Draijer, manuscript submitted
for publication).
The current questions being raised about the etiol-
ogy and phenomenology of dissociation (4) should af-
fect the choice, conceptualization, and operationaliza-
tion of both criterion and predictor variables in
empirical research on the precursors of adult dissocia-
tion. The limited prediction of the level of dissociation
may be partly due to the criterion, the Dissociative Ex-
periences Scale score. The clinical validity of the Disso-
ciative Experiences Scale has been questioned (3, 4);
some of the items of the scale refer to nonpathological
dissociation, such as absorption, automatic daily be-
havior, and imaginative involvement, whereas other
items, such as amnesia, depersonalization, and identity
alteration, refer to pathological changes in conscious-
ness. Therefore, in future research on the etiology of
dissociation, instruments focusing on pathological dis-
sociation, such as a structured clinical interview
(SCID-D) (21) or the Dissociative Experiences Scale-T
(48), should be preferred. Recent stressors should be
taken into account as well. The assessment of neglect
could be improved by using standardized instruments,
such as the Parental Bonding Instrument (26).
CONCLUSIONS
This study shows that sexual and physical abuse
make a unique contribution to the severity of adult dis-
sociative symptoms, compared with neglect due to per-
ceived parental dysfunction. In particular, perceived
dysfunction of the mother—her unavailability—seems
to be important. Assuming that retrospective percep-
tions of parental availability refer to a certain extent to
external reality, these results could be interpreted as
pointing to the importance of early attachments be-
tween parent and child, the quality of object relations
in early development, or supportive relationships at
the time or after the abuse took place. These results
call for an integrative approach to the treatment of dis-
sociative patients, combining psychodynamic and
trauma theory. They stress the importance of rela-
tional issues, such as the necessity of support, the per-
sistence of distrust, and related transference and coun-
tertransference issues. We conclude that the criticism
of the superficial interpretation of sexual abuse as the
sole explanation of a diversity of psychiatric symp-
toms is correct (49).
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... whilst childhood emotional abuse (CEA) has received little attention until recently. In studies of adults, links of CPA and CSA with dissociation scores have been widely reported in clinical groups (Chu & Dill, 1990;Chu, Frey, Ganzel, & Matthews, 1999;Draijer & Langeland, 1999;Kirby, Chu, & Dill, 1993;Lipschitz, Kaplan, Sorkenn, Chomey, & Asnis, 1996), non-clinical groups of undergraduates (DiTomasso & Routh, 1993;Eisen & Carlson, 1999;Sandberg & Lynn, 1992), and general population samples (Mulder et al., 1998;Vanderlinden et al., 1993). Furthermore, a dose-response relationship of dissociation to abuse is a very robust finding. ...
... Fearful attachment was more correlated with dissociation than were other attachment styles. Draijer and Langeland (1999) found that both abuse variables and maternal dysfunction contributed independently to the variance in dissociation scores. Again, it may be difficult to separate the effects of attachment and abuse, as the two variables may be integrally related. ...
... Disorganized attachment may contribute to a lack of ability to self-soothe, making the child more vulnerable to overwhelming feelings and hence more likely to use dissociation to cope with trauma (Draijer & Langeland, 1999). ...
Thesis
p>The majority of research on dissociation focuses on adulthood, although adolescence is thought to be a transitional time in the development of dissociation. This dissertation consists of two papers, both of which emphasize the importance of investigating dissociation during adolescence. A literature review of dissociation in adolescence was carried out. Recent conceptualizations of dissociation were firstly evaluated, followed by a review of studies investigating the developmental course of dissociation. The relationship between normal adolescent processes and dissociation was explored and the evidence for a relationship between dissociation and adolescent psychopathology was examined. Subsequently, the empirical evidence and theoretical basis for childhood trauma and disorganized attachment leading to dissociation were evaluated. It was argued that the developmental tasks of adolescence may provoke pathological dissociation in vulnerable young people. Finally, the clinical and research implications of a greater understanding of dissociation in adolescence were outlined. The research paper investigated the psychometric properties of the Adolescent Dissociative Experiences Scale and changes in the frequency of dissociative experiences during adolescence, as well as exploring the relationship between dissociation and psychological symptomatology in adolescence, particularly in females with anorexia. Dissociation was highly correlated with psychological symptomatology in non-clinical, mixed clinical and anorexic adolescent females and appeared to relate in a specific way to symptomatology in anorexia. The clinical and research implications of these findings were discussed.</p
... The cluster of diagnostic features that characterized the accused fit well into the literature that has linked childhood abuse with dissociative symptomatology and with psychopathy (e.g., Draijer & Langeland, 1999;Hyland et al., 2017;Kirby et al., 1993;Kong et al., 2018;Poythress et al., 2006;Vonderlin et al., 2018). Importantly, the extant research links sexual and physical trauma, as well as neglect and verbal abuse, to dissociation (Draijer & Langeland, 1999;Kong et al., 2018;Vonderlin et al., 2018). ...
... The cluster of diagnostic features that characterized the accused fit well into the literature that has linked childhood abuse with dissociative symptomatology and with psychopathy (e.g., Draijer & Langeland, 1999;Hyland et al., 2017;Kirby et al., 1993;Kong et al., 2018;Poythress et al., 2006;Vonderlin et al., 2018). Importantly, the extant research links sexual and physical trauma, as well as neglect and verbal abuse, to dissociation (Draijer & Langeland, 1999;Kong et al., 2018;Vonderlin et al., 2018). Terr (1991) divided childhood trauma into two types: Type I trauma occurs after a single shock and includes full detailed memories, omens, and misperceptions, while type II trauma follows multiple blows and includes denial and numbing, self-hypnosis, dissociation, and rage. ...
... This author conceptualizes childhood trauma as an etiologic determinant of a complex set of adult symptoms including character problems, psychotic thinking, violence, dissociation, extremes of passivity, self-mutilation, and a variety of anxiety disturbances. Draijer and Langeland (1999) reported that maternal dysfunction contributed to the level of dissociation in adults raised by abusive parents. ...
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This case study demonstrates the procedures and the complementary function and contribution of the Rorschach within a multi-method forensic mental health evaluation. This particular case addressed the state of mind of a perpetrator and related traumatic reactions and the possibility of Posttraumatic Stress Disorder (PTSD) associated with violent attacks involving rape. The verbatim Rorschach record contained repeated and troubled images of splitting and ripping, and of transitions from cooperative and pleasing to darkness and evil representations, that likely reflected the individual’s distressed perception of his own dissociation. A previous review of the research of the Rorschach and post-traumatic reactions (Viglione et al., 2012) provided the main structure for applying the Rorschach in this case. The resultant Rorschach interpretations were consistent with the outcome of self-report assessments including measures of mental status and trauma reactions, as well as with additional familial declarations and forensic and clinical interviews. The full battery of tests provided the image of a criminal suffering from chronic, complex PTSD with dissociative symptoms reflecting opposing affiliative and aggressive traits; his fluctuating aggressive behavior was consistent with features of antisocial personality disorder.
... In the research, maltreatment and abuse have been indicated as a vulnerability to develop disorganized attachment in childhood and possible dissociative behaviors (Main and Hesse, 1990;Liotti, 1992;Carlson and Sroufe, 1995;Draijer and Langeland, 1999;Ainsworth and Eichberg, 2006). In addition, it creates a dissociated personality and internalized victim/persecutor dyad (refer to Kernberg, 1967;Fonagy and Bateman, 2007;Mucci, 2018a) where one identifies with the victim and the related effects (low self-esteem, blame, shame, guilt), yet also identifies with as an internal persecutor position of which the subject is not aware, and identifies with the effects of the persecutor which include violence, hate, and aggressiveness (often revolving around one's body). ...
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The sense of self has always been a topic of high interest in both psychoanalysis and most recently in neuroscience. Nowadays, there is an agreement in psychoanalysis that the self emerges from the relationship with the other (e.g., the caregiver) in terms of his/her capacity to attune, regulate, and synchronize with the emergent self of the infant. The outcome of this relational/intersubjective synchronization is the development of the sense of self and its regulatory processes both in dynamic psychology and neuroscience. In this work, we propose that synchrony is a fundamental biobehavioral factor in these dialectical processes between self and others which shapes the brain–body–mind system of the individuals, including their sense of self. Recently in neuroscience, it has been proposed by the research group around Northo􀀀 that the self is constituted by a brain-based nested hierarchical three-layer structure, including interoceptive, proprio-exteroceptive, and mental layers of self. This may be disrupted, though, when traumatic experiences occur. Following the three levels of trauma theorized by Mucci, we here suggest how di􀀀erent levels of traumatic experiences might have an enduring e􀀀ect in yielding a trauma-based topographic and dynamic re-organization of the nestedmodel of self featured by dissociation. In conclusion, we propose that di􀀀erent levels and degrees of traumatic experience are related to corresponding disruptions in the topography and dynamic of the brain-based three-layer hierarchical structure of the self.
... Childhood abuse, isolation, neglect, and maternal separation (MS) are significant factors that chronically lead to depression (Draijer and Langeland 1999;Banihashemi et al. 2015). In this context, MS is a considerable risk factor that leads to depression via hyperactivation of the hypothalamus-pituitary-adrenal axis (HPA axis) and oxidative stress (Aisa et al. 2007;Crombie et al. 2021). ...
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Depression and coronary heart diseases are the common comorbid disorder affecting humans globally. The present study evaluated the effectiveness of rosmarinic acid (RA) against myocardial infarction (MI) in comorbid depression induced by maternal separation in rats. Maternal stress is one of the childhood crises that may be a potential risk factor for coronary heart disease in later part of life. As per protocol, 70-80% of pups were separated daily for 3 h between postnatal day 1 (PND1) and postnatal day 21 (PND21). Forced-swim test, sucrose preference test, and electrocardiography were performed during the experiment. Body weight was measured on PND0, PND35, and PND55. Orally rosmarinic acid (25 mg/kg and 50 mg/kg) and fluoxetine (10 mg/kg) was done from PND35 to PND55. On PND53 and PND54, isoproterenol (100 mg/kg, subcutaneously) was administered to induce myocardial infarction. On PND55, blood was collected and animals sacrificed, and plasma corticosterone, brain-derived neurotrophic factor, cardiac biomarkers, interleukine-10, and anti-oxidant parameters were measured. Rosmarinic acid and fluoxetine ameliorated the maternal separation-induced increase in immobility period, anhedonia, body weight, ST elevation, corticosterone, creatine kinase-MB (CK-MB), and lactate dehydrogenase (LDH). At the same time, both drugs elevated the tissue levels of BDNF, IL-10, glutathione, and superoxide dismutase activity. This study provides the first experimental evidence that maternal stress is an independent risk factor of cardiac abnormalities in rats. Moreover, maternal stress synergistically increases the severity of cardiac abnormalities induced by isoproterenol. Interestingly, fluoxetine and rosmarinic acid effectively ameliorated behavioral anomalies and myocardial infarction in maternally separated rats. Schematic representation of possible molecular mechanism of action of rosmarinic acid against MS-induced myocardial infarction. RA, rosmarinic acid; MS, maternal separation; PND, postnatal days; ISO, isoproterenol; BDNF, brain-derived neurotrophic factor; GSH, glutathione; SOD, superoxide dismutase; IL-10, interleukin-10; MI, myocardial infarction.
... Another study reported that emotional neglect by parents was related to later symptoms of dissociation (Wright, Crawford, & Del Castillo, 2009). On the other hand, disrupted attachment, involving childhood trauma and parental maltreatment, may play an important role in the later development of dissociation (Draijer & Langeland, 1999;Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006). Disorganized attachment is reported to mediate the association between child sexual abuse and dissociation (Hebert, Langevin, & Charest, 2020), and it may also influence in the association between trauma and dissociation. ...
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... The second level (developed by Mucci, 2013Mucci, , 2016Mucci, , 2017Mucci, , 2018a on the basis of Ferenczi's clinical observations, e.g., Clinical Diary, Ferenczi, 1932a) adds to this first one, the non-intentional disattunement of the caregiver, the additional stress and dynamic consequences of severe abuse or maltreatment and severe deprivation. Maltreatment and abuse have been indicated in research as the cause of vulnerability toward developing disorganized attachment in the child and possible dissociative behaviors (Ainsworth & Eichenberg, 1991;Carlson & Sroufe, 1995;Draijer & Langeland, 1999;Liotti, 1992;Main & Hesse, 1990). In addition it creates in the personality a dissociated and internalized (see Fonagy & Batemen 2007;Kernberg, 1977;Mucci, 2018a) with a part of oneself as victim identified with the victim affects (low self esteem, blame, shame, guilt) and a part of oneself identified with an internal persecutor of which the subject is not aware, identified with the affects of the persecutor, violence, hate, aggressiveness (often revolving around one's body). ...
Article
Trauma-related disorders and their related phenomena remain a fundamental quibble in the psychopathological diagnosis. Only the Psychodynamic Diagnostic Manual-2 recognizes the long time enduring effects of trauma of human hand as distinct from accidents or natural catastrophes, while the Diagnostic and Statistical Manual of Mental Disorders–5 (DSM-5) does not. A response to trauma of human hand with effects on the mind–body–brain system is dissociation, a psychic mechanism denied for many years from Freud but reprised by the work of Janet and Ferenczi. Departing from psychoanalysis in a dialect relationship with neuroscientific research, we aim to highlight how dissociation is only in trauma of human agency and found its etiology in the three levels of interpersonal traumatization as proposed by Clara Mucci’s interdisciplinary and clinical observations. Trauma and dissociation couple the neuronal and abnormal functioning of brain and leave traces in body and on the implicit internalized past relationship from attachment. Clinicians and psychotherapists need to move beyond diagnosis and address all the implicit relational dissociative psychic states in order to re-establish a “physiological secure base” to maintain a cohesive and extended sense of self and relatedness.
... Dissociative disorders are most closely related to sexual abuse (Draijer, & Langeland, 1999). ...
Thesis
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... Using the five item dissociation scale of the Childhood abuse as a predictor of dissociation 4 Trauma Symptom Checklist (TSC; Elliott & Briere, 1992), Wright et al. (2009) found sexual abuse coupled with child emotional neglect predicted 34% of the variance in dissociation scores; and Runtz and Roche (1999) found sexual abuse characteristics predicted 15% of the variance. This is consistent with other research that finds the abuse type most associated with DDs is sexual abuse (Draijer & Langeland, 1999). However, a review by Kate (2018) found the link between dissociation and sexual abuse status tended to be weak or not significant in studies using the Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986), which is the most commonly used screening tool for identifying pathological levels of dissociation. ...
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This Australian study explores a person’s self-reported exposure to childhood abuse to identify the characteristics that are predictive of clinical levels of dissociation in adulthood. The final sample comprised 303 participants, including 26 inpatients and outpatients (24 females and two males) receiving treatment for a dissociative disorder (DD), and 277 university participants, including 220 controls (186 females, 34 males), 31 with elevated levels of dissociation consistent with a DD or posttraumatic stress disorder (27 females and four males), and 26 with clinical levels of dissociation (20 females and six males). The findings demonstrate clinical levels of dissociation and DDs occur in individuals reporting a history of childhood abuse, particularly sexual abuse and experiences that are potentially life-threatening to a child, such as choking, smothering, and physical injury that breaks bones or teeth, or that compromise the child’s survival needs, including threats of abandonment and deprivation of basic needs. Females who disclosed being sexual abused in addition to being choked or smothered had a 106-fold risk of clinical levels of dissociation. As expected, self-reported amnesia was prevalent in the dissociative groups. Yet, even in the control group, one-third of those disclosing sexual abuse reported an unclear memory of it. Strong similarities in abuse experiences were found between the clinical sample and those in the university sample with clinical levels of dissociation (which is unlikely to have previously been diagnosed). The dissociative groups reported higher rates of corroboration of their abusive experiences. The findings support the traumatic etiology of dissociation.
... Using the five item dissociation scale of the Trauma Symptom Checklist (TSC; Elliott & Briere, 1992), Wilgus et al., 2016) found sexual abuse coupled with child emotional neglect predicted 34% of the variance in dissociation scores; and Runtz and Roche (1999) found sexual abuse characteristics predicted 15% of the variance. This is consistent with other research that finds the abuse type most associated with DDs is sexual abuse (Draijer & Langeland, 1999). However, a review by Kate (2018) found the link between dissociation and sexual abuse status tended to be weak or not significant in studies using the Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986), which is the most commonly used screening tool for identifying pathological levels of dissociation. ...
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This Australian study explores a person’s self-reported exposure to childhood abuse to identify the characteristics that are predictive of clinical levels of dissociation in adulthood. The final sample comprised 303 participants, including 26 inpatients and outpatients (24 females and two males) receiving treatment for a dissociative disorder (DD), and 277 university participants, including 220 controls (186 females, 34 males), 31 with elevated levels of dissociation consistent with a DD or posttraumatic stress disorder (27 females and four males), and 26 with clinical levels of dissociation (20 females and six males). The findings demonstrate clinical levels of dissociation and DDs occur in individuals reporting a history of childhood abuse, particularly sexual abuse and experiences that are potentially life-threatening to a child, such as choking, smothering, and physical injury that breaks bones or teeth, or that compromise the child’s survival needs, including threats of abandonment and deprivation of basic needs. Females who disclosed being sexual abused in addition to being choked or smothered had a 106-fold risk of clinical levels of dissociation. As expected, self-reported amnesia was prevalent in the dissociative groups. Yet, even in the control group, one-third of those disclosing sexual abuse reported an unclear memory of it. Strong similarities in abuse experiences were found between the clinical sample and those in the university sample with clinical levels of dissociation (which is unlikely to have previously been diagnosed). The dissociative groups reported higher rates of corroboration of their abusive experiences. The findings support the traumatic etiology of dissociation.
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Reviews recent findings concerning disorganized disoriented attachment in infants and its correlates in unresolved parental traumas. It is proposed that such attachment in infancy may lead to increased vulnerability to dissociative disorders via a linking mechanism proposed by M. Main and E. Hesse (1990, 1992): parental frightened and/or frightening behavior. Mothers of dissociative patients were reported much more often than mothers of other psychiatric patients to have suffered the loss through death of a significant other in the 2 yrs before–2 yrs after the patient's birth. This finding supports the hypothesis that many dissociative patients may have been infants attached in a disorganized/disoriented way to at least 1 attachment figure. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Among 88 women patients in an adult inpatient setting, 81% reported a history of sexual abuse physical abuse, or both. The scores on the Dissociative Experiences Scale (DES) and on the anxiety, hostility, and psychoticism scales of the Symptom Checklist 90-Revised (SCL 90-R) early in hospitalization were significantly higher among those who reported a history of abuse than among those who reported no such history. Also, those with a DSM-III-R diagnosis of a dissociative disorder had significantly higher scores on the DES. Reported abuse also was associated with higher scores on the borderline, antisocial, schizoid, and self-defeating personality disorder scales of the Personality Disorder Questionnaire (PDQ-R).
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Clinical reports and recent investigations indicate that depressed patients report that when they were children their parents were insensitive, unavailable, or overly intrusive and unable to tolerate the child's autonomy and independence. Using both an open-ended description of parents and a more structured rating procedure (Osgood semantic differential), the present study assessed the relation of descriptions of parents to aspects of depression in 121 undergraduates. Ratings of parents on the semantic differential as negative figures correlated significantly with several measures of depression. Intensity of depression and types of depressive experiences were also significantly related to the qualities attributed to the parents and the conceptual level with which the parents were described in the open-end procedure. The data offer support for the contention that the content and the cognitive level of parental representations may be a central dimension in depression. (26 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)