Article

Suicidality in Childhood Abuse Survivors – The Contribution of identification with the aggressor

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Abstract

Objective Childhood abuse survivors are at risk for suicidal ideation and suicide attempts. Research has indicated that posttraumatic stress disorder (PTSD) symptoms and dissociation are related to elevated suicidal ideation and behavior (SIB) among this population. At the same time, although the theoretical and clinical literature in the trauma field have suggested that survivors’ pathological attachment to their perpetrators, known as identification with the aggressor, might explain SIB, this supposition has not been investigated to date. Method Filling this gap, this study explored the associations between identification with the aggressor, PTSD symptoms, dissociation, and SIB among 589 adult survivors of childhood abuse. Results Identification with the aggressor, PTSD symptoms, and dissociation were related to elevated levels in suicidal ideation and behavior. Furthermore, profile type (namely, having high versus medium or low levels of identification with the aggressor, PTSD symptoms, and dissociation) was implicated in participants’ SIB: Participants who adhered to a profile characterized by high levels of identification with the aggressor, PTSD symptoms, and dissociation had higher levels of suicide risk and suicidal ideation, as well as higher odds of reporting a history of suicide attempts, compared to participants who adhered to the other two profiles (i.e., characterized by medium or low levels of identification with the aggressor, PTSD symptoms, and dissociation). Limitations This study relied on convenience sampling and a cross-sectional design. Conclusions Identification with the aggressor might serve, alongside PTSD symptoms and dissociation, as a risk factor for suicidal ideation and behavior among childhood abuse survivors.

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... According to IWA theory, although IWA aims to promote survival during the abuse, it often continues to exist even after the abuse ends and has negative repercussions on survivors' well-being (Frankel, 2002;. Evidence from studies among childhood abuse survivors have landed support for this claim, indicating IWA to be related to elevated PTSD, dissociation, selfinjurious behavior, suicidality, and revictimization (Lahav, 2021b;Lahav et al., 2020;Lahav, Talmon, Ginzburg, & Spiegel, 2019). Additionally, a recent study among women reported being subjected to IPV at present or in the past indicated IWA to have unique contribution in explaining trauma-related distress and depressive symptoms above and beyond background characteristics and IPV features (Lahav, 2021a). ...
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This study explored the relation between guilt and identification with the aggressor (IWA) and the moderating role of IWA in the relation between intimate partner violence (IPV) and guilt. An online survey was conducted among a convenience sample of 700 women. IPV survivors demonstrated elevated guilt, and IWA was related to guilt. Furthermore, IWA moderated the relation between IPV and guilt: Among participants with low IWA levels, IPV was unrelated to guilt, but among participants with high IWA levels, IPV was related to guilt. These findings suggest that IWA may be a key element in explaining guilt among IPV survivors.
... Identification with the aggressor was associated with elevated trauma-related distress and depressive symptoms, and had a unique contribution in explaining these outcomes in women who reported current/previous IPV, above and beyond background characteristics and IPV features. The current results are consistent with previous evidence indicating associations between IWA and negative outcomes among childhood abuse survivors, such as guilt, dissociation, self-injurious behavior, re-victimization, PTSD symptoms, and suicidality (Lahav, 2021;Lahav et al., 2019bLahav et al., ,c, 2020, and suggest that the adverse qualities of IWA might also be applicable under conditions of past or present IPV. ...
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Intimate partner violence (IPV) is a global health problem that often results in a variety of mental health detriments, including trauma-related distress and depressive symptoms. According to the trauma literature, IPV victims may develop strong bonds with their perpetrators – a phenomenon known as identification with the aggressor (IWA) – in order to survive the abuse. Yet, this defensive reaction may endure after the abuse has ended, and may adversely affect victims' mental health. Nevertheless, research exploring these suppositions is lacking. Filling this void, this study investigated IWA in light of current versus past IPV as well as the relations between IWA, trauma-related distress, and depressive symptoms among a convenience sample of 297 women. Of them, 68 and 229 participants reported being subjected to IPV at present or in the past, respectively. Results indicated that whereas participants who reported current IPV had elevated trauma-related distress and depressive symptoms compared to participants who reported past IPV, no differences were found in IWA levels between the groups. Identification with the aggressor was related to trauma-related distress and depressive symptoms. Furthermore, IWA had a unique contribution in explaining trauma-related distress and depressive symptoms above and beyond background characteristics and IPV features. The findings of the current study suggest that IWA may mirror the unique relational dynamics that characterize IPV, which continue to exist even after the abuse ends, and may be implicated in IPV survivors’ psychological distress.
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bibliography of dissociative disorders
Article
Childhood abuse and neglect are associated with dissociative symptoms in adulthood. However, empirical studies show heterogeneous results depending on the type of childhood abuse or neglect and other maltreatment characteristics. In this meta-analysis, we systematically investigated the relationship between childhood interpersonal maltreatment and dissociation in 65 studies with 7352 abused or neglected individuals using the Dissociative Experience Scale (DES). We extracted DES-scores for abused and non-abused populations as well as information about type of abuse/neglect, age of onset, duration of abuse, and relationship to the perpetrator. Random-effects models were used for data synthesis, and meta-regression was used to predict DES-scores in abused populations from maltreatment characteristics. The results revealed higher dissociation in victims of childhood abuse and neglect compared with non-abused or neglected subsamples sharing relevant population features ( MAbuse = 23.5, MNeglect = 18.8, MControl = 13.8) with highest scores for sexual and physical abuse. An earlier age of onset, a longer duration of abuse, and parental abuse significantly predicted higher dissociation scores. This meta-analysis underlines the importance of childhood abuse/neglect in the etiology of dissociation. The identified moderators may inform risk assessment and early intervention to prevent the development of dissociative symptoms.
Article
Over the past decade, the interpersonal theory of suicide has contributed to substantial advances in the scientific and clinical understanding of suicide and related conditions. The interpersonal theory of suicide posits that suicidal desire emerges when individuals experience intractable feelings of perceived burdensomeness and thwarted belongingness and near-lethal or lethal suicidal behavior occurs in the presence of suicidal desire and capability for suicide. A growing number of studies have tested these posited pathways in various samples; however, these findings have yet to be evaluated meta-analytically. This paper aimed to (a) conduct a systematic review of the unpublished and published, peer-reviewed literature examining the relationship between interpersonal theory constructs and suicidal thoughts and behaviors, (b) conduct meta-analyses testing the interpersonal theory hypotheses, and (c) evaluate the influence of various moderators on these relationships. Four electronic bibliographic databases were searched through the end of March, 2016: PubMed, Medline, PsycINFO, and Web of Science. Hypothesis-driven meta-analyses using random effects models were conducted using 122 distinct unpublished and published samples. Findings supported the interpersonal theory: the interaction between thwarted belongingness and perceived burdensomeness was significantly associated with suicidal ideation; and the interaction between thwarted belongingness, perceived burdensomeness, and capability for suicide was significantly related to a greater number of prior suicide attempts. However, effect sizes for these interactions were modest. Alternative configurations of theory variables were similarly useful for predicting suicide risk as theory-consistent pathways. We conclude with limitations and recommendations for the interpersonal theory as a framework for understanding the suicidal spectrum.
Article
Many individuals worldwide are exposed to continuous traumatic stress (CTS). However, the psychiatric sequela of CTS and the relevance of posttraumatic stress disorder (PTSD) diagnostic criteria in this situation have yet to be determined. Filling this gap, the present study assessed psychiatric reactions to CTS and the relationship between such reactions and functional impairment among two representative samples of adults exposed to ongoing shelling over 6 (n = 387) and 9 years (n = 468). Assessment included PTSD symptomatology (i.e., intrusion, avoidance, hyperarousal), anxiety, somatization, and depression. Profile categorization aimed to underscore variations in symptom clustering and severity, and determine whether or not a profile is dominated by PTSD symptoms. Latent Profile analyses (LPA) of sample I revealed four distinct symptoms profiles: (1) ‘symptomatically resilient’; (2) ‘symptomatically low-moderate’; (3) ‘symptomatically moderate-high’; and (4) ‘symptomatically overall high’. LPA of sample II revealed three distinct symptoms profiles: (1) ‘symptomatically resilient’; (2) ‘symptomatically low-moderate’; (3) “symptomatically moderate-high”. Moreover, profile variation was implicated in dysfunction. Consistent with studies focusing on single trauma exposure, the findings revealed that the most prevalent profile was the symptomatically resilient, indicating that most people exposed to CTS seem to evince a scarce number of psychiatric symptoms. Moreover, reactions to CTS proved broader than the existing PTSD symptomatology. Examining symptom dominance and severity in relation to impairment and dysfunction, and clinical considerations are discussed.
Article
This review examines posttraumatic stress disorder (PTSD) related to child maltreatment in adults, PTSD comorbidities, and complex PTSD, with a focus on emotion dysregulation. Adults maltreated as children report high rates of PTSD. Although all forms of child maltreatment are associated with increased PTSD risk, effects are stronger for child sexual and emotional abuse, abuse in the context of other adverse childhood experiences, and cumulative abuse. PTSD comorbidities that involve emotion dysregulation are examined, including substance use disorders, eating disorders, and borderline personality disorder. Emotion dysregulation appears to be a coalescent factor in the nexus of child maltreatment, PTSD, and other comorbidities. Treatment recommendations are made for adults with child maltreatment–related PTSD and comorbidities.
Article
Background: Relationships of some types of childhood maltreatment and suicidal behavior remain controversial and inconclusive. Methods: Medline, Embase, PsycINFO and Cochrane library were searched for eligible studies, and the results were synthesized in meta-analyses. Results: childhood maltreatment was associated positively with suicidal behavior in the total population and maltreatment subgroups. Emotional abuse had the strongest effect (OR = 2.33, SMD =0.660, P<0.001). Subgroup analyses showed that the effects of childhood abuse (OR = 1.55, SMD = 0.523) and neglect (OR =1.25, SMD = 0.31) were significant. According to the analysis of dichotomous outcomes, childhood maltreatment was associated positively with suicidal behavior in men and women (women: OR = 4.84, P<0.001; men: OR = 1.03, P<0.001). Among populations, childhood maltreatment had the strongest effect on suicidal behavior in the general population (OR = 3.78, P<0.001). However, the analysis of continuous outcomes showed that the effect was strongest in patients with chronic schizophrenia (SMD = 0.89, P<0.001). In addition, childhood maltreatment was associated positively with suicide attempt (OR = 1.11, SMD =0.48, P<0.001), but not with suicidal ideation. Limitations: Some subgroup samples were not sufficiently large. Conclusions: Childhood maltreatment increases the risk of suicidal behavior. Emotional abuse had the strongest effect among the five types of maltreatment. The risk of suicidal behavior is higher in the general population, women, and individuals with chronic schizophrenia who have histories of childhood maltreatment.
Article
Dissociative disorders (DD) are frequently associated with suicidal behaviors. We performed the first meta-analysis of studies comparing rates of suicide attempts (SA) and non-suicidal self-injury (NSSI) in psychiatric individuals with and without DD. We included: 1) studies comparing SA and NSSI rates in psychiatric individuals with and without DD; 2) studies comparing Dissociative Experiences Scale (DES) scores in both SA and NSSI psychiatric patients versus non SA and non NSSI ones. Cochrane Collaboration Review Manager Software and STROBE statement were used. Nineteen studies were included in the analyses. DD patients were more likely to report both previous SA and NSSI in comparison to non DD patients. Importantly, results remained highly significant in both outcomes but with no more heterogeneity when including studies using a DSM-based method to diagnose DD. Both SA and NSSI patients reported higher DES scores in comparison to non SA and non NSSI patients. The presence of DD diagnosis or higher DES scores seems to be related to both SA and NSSI in psychiatric patients. Hence, it may be reasonable to hypothesize the presence of a dissociative subtype in a subset of these patients, which should be considered as a transdiagnostic factor and should be carefully assessed.
Article
Early developmental trauma is imprinted in the psyche by survival fragmentation and dissociation. Traumatized patients need the analyst to be actively involved and allow for regression to dependence in order to strengthen, create and construct their psychic functioning and structure so that environmental failures will be contained and not rupture continuity of being. I suggest that Ferenczi's and Winnicott's ideas about regression to dependence in analysis are fundamental contributions to these quests, and that Ferenczi set the foundation, which Winnicott further explored and developed. I would like to focus on their clinical theory of treating early developmental trauma of the psyche, describing it in the less known language of Ferenczi, reviving his concept of Orpha and its functions. The complementarities of the two approaches can enrich and broaden our understanding of the clinical complications that arise in the analysis of such states.
Article
This paper explores the clinical utility of conducting an intersubjective psychoanalysis with an adult survivor of childhood sexual abuse. Specifically, psychoanalysis guided by intersubjectivity theory views the process of all clinical work as a constantly unfolding illumination of the phenomena that emerge within a psychological field constituted by two subjectivities. The focus of this treatment is to continually provide a shared understanding of the historical trauma and its past, present, and still unfolding contexts. The clinical example in this paper is a report of a still continuing psychoanalysis.
Article
Disorganized attachment has been proposed as a mediating mechanism in the relation between childhood abuse and dissociation. However, support for mediation has been mixed when using interview or self-report measures of attachment. In the current work, relations among severity of abuse, attachment disorganization, and dissociation were assessed in young adulthood using both interview and interaction-based measures of attachment. One hundred and twelve low-income young adults were assessed for socioeconomic stresses, abusive experiences in childhood, and attachment disorganization at age 20. Attachment disorganization was assessed with the Adult Attachment Interview, coded independently for Unresolved states of mind and for Hostile-Helpless (HH) states of mind. Attachment disorganization was also measured using a newly validated assessment of young adult-parent interaction during a conflict discussion. Mediational analyses revealed that the link between childhood abuse and dissociation was partially explained by disturbances in young adult-parent interaction. Narrative disturbances on the Adult Attachment Interview were related to abuse and to dissociation but did not mediate the link between the two. Results are discussed in relation to the role of parent-child communication processes in pathways to dissociation.
Article
IMPORTANCE: The US Army experienced a sharp increase in soldier suicides beginning in 2004. Administrative data reveal that among those at highest risk are soldiers in the 12 months after inpatient treatment of a psychiatric disorder. OBJECTIVE: To develop an actuarial risk algorithm predicting suicide in the 12 months after US Army soldier inpatient treatment of a psychiatricdisorder to target expanded posthospitalization care. DESIGN, SETTING, AND PARTICIPANTS: There were 53 769 hospitalizations of active duty soldiers from January 1, 2004, through December 31, 2009, with International Classification of Diseases, Ninth Revision, Clinical Modification psychiatric admission diagnoses. Administrative data available before hospital discharge abstracted from a wide range of data systems (sociodemographic, US Army career, criminal justice, and medical or pharmacy) were used to predict suicides in the subsequent 12 months using machine learning methods (regression trees and penalized regressions) designed to evaluate cross-validated linear, nonlinear, and interactive predictive associations. MAIN OUTCOMES AND MEASURES: Suicides of soldiers hospitalized with psychiatric disorders in the 12 months after hospital discharge. RESULTS: Sixty-eight soldiers died by suicide within 12 months of hospital discharge (12.0% of all US Army suicides), equivalent to 263.9 suicidesper 100 000 person-years compared with 18.5 suicides per 100 000 person-years in the total US Army. The strongest predictors included sociodemographics (male sex [odds ratio (OR), 7.9; 95% CI, 1.9-32.6] and late age of enlistment [OR, 1.9; 95% CI, 1.0-3.5]), criminal offenses (verbal violence [OR, 2.2; 95% CI, 1.2-4.0] and weapons possession [OR, 5.6; 95% CI, 1.7-18.3]), prior suicidality [OR, 2.9; 95% CI, 1.7-4.9], aspects of prior psychiatric inpatient and outpatient treatment (eg, number of antidepressant prescriptions filled in the past 12 months [OR, 1.3; 95% CI, 1.1-1.7]), and disorders diagnosed during the focal hospitalizations (eg, nonaffective psychosis [OR, 2.9; 95% CI, 1.2-7.0]). A total of 52.9% of posthospitalization suicides occurred after the 5% of hospitalizations with highest predicted suicide risk (3824.1 suicides per 100 000 person-years). These highest-risk hospitalizations also accounted for significantly elevated proportions of several other adverse posthospitalization outcomes (unintentional injury deaths, suicide attempts, and subsequent hospitalizations). CONCLUSIONS AND RELEVANCE: The high concentration of risk of suicide and other adverse outcomes might justify targeting expanded posthospitalization interventions to soldiers classified as having highest posthospitalization suicide risk, although final determination requires careful consideration of intervention costs, comparative effectiveness, and possible adverse effects.
Article
When we feel overwhelmed by an inescapable threat, we "identify with the aggressor" (Ferenczi, 1933). Hoping to survive, we sense and "become" precisely what the attacker expects of us--in our behavior, perceptions, emotions, and thoughts. Identification with the aggressor is closely coordinated with other responses to trauma, including dissociation. Over the long run, it can become habitual and can lead to masochism, chronic hypervigilance, and other personality distortions. But habitual identification with the aggressor also frequently occurs in people who have not suffered severe trauma, which raises the possibility that certain events not generally considered to constitute trauma are often experienced as traumatic. Following Ferenczi, I suggest that emotional abandonment or isolation, and being subject to a greater power, are such events. In addition, identification with the aggressor is a tactic typical of people in a weak position; as such, it plays an important role in social interaction in general.
Article
Background Post-traumatic stress disorder (PTSD) confers risk for suicidal ideation and suicide attempts but a link with suicide is not yet established. Prior analyses of users of the Veterans health administration (VHA) Health System suggest that other mental disorders strongly influence the association between PTSD and suicide in this population. We examined the association between PTSD and suicide in VHA users, with a focus on the influence of other mental disorders. Methods Data were based on linkage of VA National Patient Care Database records and the Centers for Disease Control and Prevention׳s National Death Index, with data from fiscal year 2007–2008. Analyses were based on multivariate logistic regression and structural equation models. Results Among users of VHA services studied (N=5,913,648), 0.6% (N=3620) died by suicide, including 423 who had had been diagnosed with PTSD. In unadjusted analysis, PTSD was associated with increased risk for suicide, with odds ratio, OR (95% confidence interval, 95% CI)=1.34 (1.21, 1.48). Similar results were obtained after adjustment for demographic variables and veteran characteristics. After adjustment for multiple other mental disorder diagnoses, PTSD was associated with decreased risk for suicide, OR (95% CI)=0.77 (0.69, 0.86). Major depressive disorder (MDD) had the largest influence on the association between PTSD and suicide. Limitations The analyses were cross-sectional. VHA users were studied, with unclear relevance to other populations. Conclusion The findings suggest the importance of identifying and treating comorbid MDD and other mental disorders in VHA users diagnosed with PTSD in suicide prevention efforts.
Article
Data from the 2010 Minnesota Student Survey was analyzed to identify risk and protective factors that distinguished adolescents across three groups: no suicidality, suicidal ideation only, and suicide attempt. The population-based sample included 70,022 students in grades 9 and 12. Hopelessness and depressive symptoms emerged as important risk factors to distinguish youth who reported suicidal ideation or behavior from those without a history of suicidality. However, these factors were not as important in differentiating adolescents who attempted suicidal from those who considered suicide but did not act on their thoughts. Instead, for both genders, self-injury represented the most important factor to distinguish these youth. Other risk factors that differentiated the latter groups, but not the former groups, for males were dating violence victimization and cigarette smoking, and for females was a same-sex sexual experience. Running away from home also seemed to increase the risk of a suicide attempt among youth in this study. Parent connectedness and academic achievement emerged as important protective factors to differentiate all the groups, yet neighborhood safety appeared to protect against the transition from suicidal thoughts to behavior. Findings from this study suggest risk and protective factors practitioners should target in clinical assessments and intervention programs to help prevent suicidal behavior among youth at greatest risk.
Article
Ferenczi's (1933) surprisingly unknown concept of identification with the aggressor – an abuse victim's ‘eliminating’ her own subjectivity and ‘becoming’ precisely what an attacker needs her to be – has radical implications for our understanding of analytic technique. Its very frequent occurrence also forces us to broaden our understanding of what constitutes trauma. Ferenczi saw the experience of ‘traumatic aloneness’ or ‘emotional abandonment’ as the key element of trauma, since this is what enforces the traumatic responses of dissociation and identification with the aggressor. Identification with the aggressor operates in the analytic relationship in both patient and analyst. This has various consequences, including the structuring of the relationship through unconscious collusions – mutually coordinated, defensive identifications designed to help both participants feel secure. This view of the analytic relationship has clinical implications in at least four areas: the understanding of the patient's free associations, which may reflect the patient's compliance with the analyst's wishes rather than the contents of the patient's own unconscious; the need for some kind of mutuality of analysis; the traumatizing potential of the analyst's authority; and the tendency of some patients to take blame and responsibility reflexively, as a way of protecting the analyst.
Article
Background: Although the proposal for a dissociative subtype of posttraumatic stress disorder (PTSD) in DSM-5 is supported by considerable clinical and neurobiological evidence, this evidence comes mostly from referred samples in Western countries. Cross-national population epidemiologic surveys were analyzed to evaluate generalizability of the subtype in more diverse samples. Methods: Interviews were administered to 25,018 respondents in 16 countries in the World Health Organization World Mental Health Surveys. The Composite International Diagnostic Interview was used to assess 12-month DSM-IV PTSD and other common DSM-IV disorders. Items from a checklist of past-month nonspecific psychological distress were used to assess dissociative symptoms of depersonalization and derealization. Differences between PTSD with and without these dissociative symptoms were examined across a variety of domains, including index trauma characteristics, prior trauma history, childhood adversity, sociodemographic characteristics, psychiatric comorbidity, functional impairment, and treatment seeking. Results: Dissociative symptoms were present in 14.4% of respondents with 12-month DSM-IV/Composite International Diagnostic Interview PTSD and did not differ between high and low/middle income countries. Symptoms of dissociation in PTSD were associated with high counts of re-experiencing symptoms and net of these symptom counts with male sex, childhood onset of PTSD, high exposure to prior (to the onset of PTSD) traumatic events and childhood adversities, prior histories of separation anxiety disorder and specific phobia, severe role impairment, and suicidality. Conclusion: These results provide community epidemiologic data documenting the value of the dissociative subtype in distinguishing a meaningful proportion of severe and impairing cases of PTSD that have distinct correlates across a diverse set of countries.
Article
We examined hopelessness and suicidal ideation in association with subthreshold and threshold posttraumatic stress disorder (PTSD) in a sample of Iraq and Afghanistan War Veterans (U.S., N = 275) assessed within a specialty VA postdeployment health clinic. Veterans completed paper-and-pencil questionnaires at intake. The military version of the PTSD Checklist was used to determine PTSD levels (No PTSD; subthreshold PTSD; PTSD), and endorsement of hopelessness or suicidal ideation were used as markers of elevated suicide risk. Veterans were also asked if they received mental health treatment in the prior 6 months. Veterans reporting subthreshold PTSD were 3 times more likely to endorse these markers of elevated suicide risk relative to the Veterans without PTSD. We found no significant differences in likelihood of endorsing hopelessness or suicidal ideation comparing subthreshold and threshold PTSD groups, although the subthreshold PTSD group was less likely to report prior mental health treatment. Clinicians should be attentive to suicide risk in returned Veterans reporting both subthreshold and threshold PTSD.
Article
Objectives: To examine the prevalence of childhood maltreatment and adult revictimization in migraineurs and the association with sociodemographic factors, depression and anxiety. Background: Population and practice-based studies have demonstrated an association of childhood abuse and headache in adults, although further details on headache diagnoses, characteristics, and comorbid conditions are lacking. There are mounting data suggesting substantial impact of early maltreatment on adult physical and mental health. Methods: Electronic surveys were completed by patients seeking treatment in 11 headache centers across the United States and Canada. Physicians determined the primary headache diagnoses based on the International Classification of Headache Disorders-2 criteria and average monthly headache frequency. Self-reported information on demographics (including body mass index), social history, and physician-diagnosed depression and anxiety was collected. The survey also included validated screening measures for current depression (Patient Health Questionnaire-9) and anxiety (The Beck Anxiety Inventory). History and severity of childhood (<18 years) abuse (sexual, emotional, and physical) and neglect (emotional and physical) was gathered using the Childhood Trauma Questionnaire. There were also queries regarding adult physical and sexual abuse, including age of occurrence. Analysis includes all persons with migraine with aura, and migraine without aura. Results: A total of 1348 migraineurs (88% women) were included (mean age 41 years). Diagnosis of migraine with aura was recorded in 40% and chronic headache (>or=15 days/month) was reported by 34%. The prevalence of childhood maltreatment types was as follows: physical abuse 21%, sexual abuse 25%, emotional abuse 38%, physical neglect 22%, and emotional neglect 38%. Nine percent reported all 3 categories of childhood abuse (physical, sexual, and emotional) and 17% reported both physical and emotional neglect. Overlap between maltreatment types ranged between 40% and 81%. Of those reporting childhood abuse, 43% reported abuse in adulthood, but infrequently (17%) over the age of 30 years. In logistic regression models adjusted for sociodemographic variables, current depression was associated with physical (P = .003), sexual (P = .007), and emotional abuse (P < .001), and physical and emotional neglect (P = .001 for both). Current anxiety was also associated with all childhood abuse and neglect categories (P < .001 for all). A graded relationship was observed between the number of childhood maltreatment types and remote or current depression and anxiety. In adjusted logistic regression analysis, migraineurs reporting 3 or more categories of childhood trauma were more likely to have received diagnoses of both depression and anxiety (odds ratios [OR] = 6.91, 95% confidence interval [CI]: 3.97-12.03), or either depression or anxiety (OR = 3.66, 95% CI: 2.28-5.88) as compared with those without childhood abuse or neglect. Conclusion: Reports of childhood maltreatment, especially emotional abuse and neglect, are prevalent in outpatients with migraine. There is extensive overlap of maltreatment types and a high rate of revictimization in adulthood. All types of childhood abuse and neglect are strongly associated with remote and current depression and anxiety, and the relationship strengthens with an increasing number of maltreatment types.
Article
In the half-century since his death, the Hungarian analyst Sándor Ferenczi has amassed an influential following within the psychoanalytic community. During his lifetime Ferenczi, a respected associate and intimate of Freud, unleashed widely disputed ideas that influenced greatly the evolution of modern psychoanalytic technique and practice. In a sequence of short, condensed entries, Sándor Ferenczi's Diary records self-critical reflections on conventional theory--as well as criticisms of Ferenczi's own experiments with technique--and his obstinate struggle to divest himself and psychoanalysis of professional hypocrisy. From these pages emerges a hitherto unheard voice, speaking to his heirs with startling candor and forceful originality--a voice that still resonates in the continuing debates over the nature of the relationship in psychoanalytic practice. Reviews of this book: "Compelling...Ferenczi was an innovator, an experimenter, someone who was always trying new approaches to the treatment of mental illness, even when his unorthodox techniques placed him in opposition to his analyst and mentor, Sigmund Freud." --Stuart Schneiderman, New York Times Book Review "Allows the public to assess, far better than before, the range of [Ferenczi's] professional gifts and the depth of his psychological vulnerability...A welcome addition to the growing number of significant texts illuminating the history of psychoanalysis." --Peter Gay, London Review of Books "The Diary is the work of a sane mind in full possession of its powers and gives us insight into the day-to-day thoughts of a practitioner whose status as a creative innovator is probably unsurpassed since Freud. It is a very moving book. One is continually amazed by the courage of the man." --Peter Lomas, Times Literary Supplement "Freud criticised his one-time favourite son for advocating the 'kissing technique', Ferenzci believed that 'only sympathy heals'. This is the 1932 record of his analyses. His work was faltering, doubting, and quite possibly, healing." --David Flusfeder, The Week [UK]
Article
The hypothesis of this paper states that at least some suicidal individuals are characterized by a disposition toward dissociation manifested in relative insensitivity to physical pain and indifference to their bodies. Three main topics are discussed: dissociation and suicide, psychological aspects of pain, and pain and suicide. Various theoretical and experimental studies suggest that certain stress conditions lead to the development of dissociative tendencies, and that once these tendencies are established, they become an integral part of suicidal behavior. Psychological variables that affect pain tolerance are presented and they include perception, motivation, emotions, and behavioral and cognitive strategies of pain control. These can increase tolerance of pain in suicidal individuals, making the suicidal act possible. The specific relationships of pain and suicide are then introduced through an examination of pain analgesia in the phenomenon of self-harm. The integration of the material suggests that early and continuous stress lead to the simultaneous development of dissociative tendencies (including indifference to the body and pain) and heightened vulnerability to stress. These dispositions may facilitate suicidal behavior in the face of mounting intolerable stress, helplessness, and hopelessness. Preliminary empirical support for the present hypothesis is cited. This hypothesis shifts the focus of attention from the question of what causes suicide to what facilitates suicide, and in so doing suggests new directions for research and therapy.