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Suicidality in Childhood Abuse Survivors – The Contribution of identification with the aggressor
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.
... Although identification with the aggressor may be an important survival mechanism during the abuse itself, it often continues after the abuse ends, at which point it becomes highly maladaptive (Frankel, 2002;Lahav, 2021). Identification with the aggressor has been found to be related to dissociation, guilt, and PTSD symptoms , as well as self-harm and inward aggression (Lahav et al., 2020) among adult childhood abuse survivors. ...
... It is possible that people with higher levels of identification with the aggressor are more suggestible and thereby more susceptible to social constructs regarding unattainable beauty standards. It has been shown that identification with the aggressor is related to dissociation (Lahav, 2021;Lahav et al., 2021), which in turn has been linked to suggestibility (Eisen & Lynn, 2001;Merckelbach et al., 2000). These putative links may support the assumption that shape and weight overevaluation and body dissatisfaction are a form of being hypersensitive not only to the perpetrator's needs, but also to malignant and harmful societal beauty standards. ...
... Thus, the association between identifying with the perpetrator's aggression and restrained eating may also be seen as a form of suicidal ideation and attempt, in contrast to non-suicidal self-injury, which reflects a way of regulating the pain rather than an intent to die (Klonsky, 2007). Suicidality was recently linked to identification with the aggressor (Lahav, 2021), possibly supporting this conceptualization of eating disorder symptoms as self-harming behaviors as well as a form of suicidal self-annihilation. ...
Background
Childhood abuse has been increasingly recognized as a risk factor for eating disorder symptoms. Additionally, it has been demonstrated that childhood abuse may lead to identification with the aggressor, an automatic defensive process, to survive the abuse. Although it has been clinically implied, the role of identification with the aggressor as a potential mechanism underlying the relation between childhood abuse and eating disorder symptoms has not yet been empirically explored.
Objective
This study examines the role of identification with the aggressor as mediator in the association between history of childhood abuse and eating disorder symptoms among adults.
Participants and methods
A convenience sample of 198 participants completed self-report questionnaires assessing history of childhood abuse, eating disorder symptoms, and the various facets of identification with the aggressor.
Results
Severity of childhood abuse was significantly associated with shape and weight overevaluation, body dissatisfaction, and binge eating, as well as with all components of identification with the aggressor. In addition, almost all components of identification with the aggressor were significantly associated with eating disorder symptoms. Finally, identifying with the perpetrator's aggression mediated the association between childhood abuse and eating disorder symptoms.
Conclusions
The findings may contribute to future clinical interventions by illuminating identification with the aggressor as an important aspect in treating eating disorders. Understanding the pervasive effects of identification with the aggressor on survivors' self and their interactions with others may point to the significance of the therapeutic relationship, through which survivors can reprocess and weaken its detrimental effects.
... The literature on this topic has addressed self-blame as a consequence of abusive incidents, which has far-reaching effects on the lives of children both in childhood and adulthood. Such findings have demonstrated that identification with the aggressor is implicated in a higher risk of PTSD, dissociation , revictimization (Lahav et al., 2019) and suicidality in adulthood (Lahav, 2021). From a different standpoint, Dorresteijn et al. (2019) demonstrated that childhood trauma was related to symptoms of anxiety, depression, and interpersonal sensitivity issues in adulthood due to the use of self-blame as a coping strategy. ...
Background:
The association between child maltreatment and polyvictimization has received growing attention since being identified by Finkelhor and colleagues in 2005.
Objective:
The current study was designed to explore the experiences and perceptions of children who reported polyvictimization during forensic interviews.
Methods:
This mixed-methods study sample comprised 117 children aged 5-14, referred for the first time to forensic interviews following suspected physical abuse by a parent. More than one-third of the children reported polyvictimization. A thematic analysis was carried out to spotlight these children's experiences.
Results:
The analysis identified three main themes: the way children comprehend the polyvictimization, the consequences of the polyvictimization regarding the children's negative self-attribution, and the way the polyvictimization was constructed through the dynamic with the forensic interviewers.
Conclusions:
The findings pointed to the importance of the forensic interview platform in assessing children's maltreatment burden. The current study also provided a glance into the possible involvement of the mechanics of self-blame among maltreated children. These findings have the potential to enhance our understanding of the excessive psychological toll taken on polyvictimized children.
... The greatest relevance in this study was the methodological choice to confirm this association. Most studies measure attachment retrospectively, questioning parents, adolescents, young people and adults and not children; and even when a longitudinal follow-up is achieved, when a non-infant population is at the baseline, they focus on a retrospective look at the assessment of suicidal and self-harm behavior during childhood and adolescence [9,11,32,68]. Thus, despite the losses obtained in this study, the possibility of prospectively monitoring these 316 children directing the Table 2 Total, direct, and indirect effects of non-secure attachment on the suicidal behavior/self-harm 1) a = exposure effect-> mediator; b = mediator effect; c = total effect; c' = ADE (average direct effects); a*b = indirect effect ou ACME (Average Causal Mediation Effects); c = c' + a*b = ADE (average direct effect) + ACME (Average Causal Mediation Effects) ...
Background:
Attachment influences the development and the formation of the self and subjectivity and, just as early adverse events, may be related to the occurrence of mental disorders, suicidal behavior, and self-harm throughout life. This study aimed to analyze the effect of mental representation of attachment in children on suicidal behavior and self-harm throughout childhood and adolescence, considering the mediating role of internalizing problems.
Methods:
Based on a cohort of 500 students (mean age 8 years, SD 1.2) sampled from public schools in a Brazilian southeastern metropolis, 316 children were followed for eight years in three waves (2006, 2008, 2012). The following data from the research baseline (2005) were used: family drawing, maternal and family variables, and sociodemographic data. The mental representation of attachment (independent variable) was measured by the Family Drawing Global Scale, discriminating between secure attachment and non-secure attachment. Suicidal behavior/self-harm (dependent variable) and internalizing problems were evaluated in three research waves through CBCL and YSR (ASEBA). Descriptive analysis, calculation of frequencies and p-values of the variables of interest, as well as modeling of structural equations, were performed.
Results:
The prevalence throughout the study was: 17.1% [CI 13.3-20.8] for suicidal ideation and 8.9% [CI 5.6 - 12.2] for self-harm; there was a recurrence at one time in 16.5% [IC 12.6 - 20.3] and in two or more moments in 4.1% [CI 2.0 - 6.3] of the sample. Female gender (p = 0.035), internalizing disorders (p < 0.01), and non-secure attachment (p = 0.035) were associated with the occurrence of suicidal behavior/self-harm. The modeling indicated that 92,2% of the total effect of attachment (p = 0.069) on suicidal behavior/self-harm was due to direct effect, the other 7,8% of the effect being mediated by internalizing problems, adjusted for the confounding variables sex, skin color/race, and social stratum. The total effect showed a positive value, which indicates an increase in suicidal behavior/self-harm when the non-secure attachment is present. The approximate OR of non-secure attachment on the total effect (direct + indirect) was 1.15, indicating that, when adjusting for confounding variables, there was a 15% increase in suicidal behavior/self-injury from non-secure attachment.
Conclusions:
The study supports the hypothesis that there is a relationship between disruptive attachment patterns (non-secure attachment) developed during infancy and suicidal and self-harm behavior during childhood and adolescence. These findings validate the concern about the first thousand days of childhood as a critical period for child growth and development, but also for the mental health of children and adolescents.
... The person's (dissociated) self-states that identify with the aggressor lose their own agency and connection to their own wants and needs, become submissive, and undergo mental fusion with the perpetrators via an adoption of the perpetrators' point of view concerning the abuse (Amir, 2016;Coates & Moore, 1997;Lahav, Allende, et al., 2020;. Although this type of identification is assumed to be an automatic reaction that has advantageous effects in terms of promoting survival during the abuse (Frankel, 2002), it often becomes entrenched in victims' mentality and continues to exist long after the abuse has ended (Lahav, 2021b;. Thus, adult survivors of childhood abuse might view their traumatic past from their perpetrators' perspectives and not only deny and minimize the abuse, but also attribute to it beneficial aspects as reflected in reports of PTG (Lahav, Seligman, et al., 2017). ...
Childhood abuse puts individuals at risk for psychopathology and psychiatric symptoms such as posttraumatic stress disorder (PTSD) and anxiety symptoms. At the same time, research has indicated that some survivors report positive transformations in the aftermath of their trauma, known as posttraumatic growth (PTG). Yet the essence of PTG reports is questionable, and some scholars claim that it may reflect maladaptive illusory qualities. Furthermore, according to a recent theoretical model, PTG might be dissociation-based and related to survivors' bonds with their perpetrators. This study aimed to explore these claims by assessing PTG, dissociation, and identification with the aggressor (IWA), as well as PTSD and anxiety symptoms. An online survey was conducted among 597 adult childhood abuse survivors. Study variables were assessed via self-report measures. Analyses indicated positive associations between PTG, dissociation, and IWA. Three distinct profiles were found, reflecting high, medium, and low scores on PTG, dissociation, and IWA. Profile type explained PTSD and anxiety symptoms above and beyond gender, age, and abuse severity. These findings suggest that whereas some childhood abuse survivors might experience a positive transformation subsequent to their trauma, others' PTG reports might reflect dissociative mechanisms and pathological attachments to their perpetrators , and thus might be maladaptive. ARTICLE HISTORY
... 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). ...
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. ...
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.
Objectives
To compare mortality, comorbidities and causes of death in people with psychogenic non-epileptic seizures (PNES), epilepsy and the general population.
Methods
Using linkage of multiple Swedish national registers, we identified individuals with incident diagnosis of PNES, epilepsy and conversion disorder with motor symptoms or deficits, and 10 controls for each. Main outcome was all-cause mortality. Causes of death were categorised into non-natural (eg, suicide, injuries) and natural. Conditional Cox regression models were used to estimate HRs and 95% CIs for mortality. HRs were adjusted for socioeconomic factors and psychiatric comorbidities.
Results
Included were 885 individuals with PNES, 50 663 with epilepsy and 1057 with conversion disorder and motor symptoms or deficits. We found 32 (3.6%) deaths among individuals with PNES, compared with 46 (0.5%) deaths in controls, giving an adjusted HR of 5.5 (95% CI 2.8 to 10.8). Patients with epilepsy had a 6.7 times higher risk of death (95% CI 6.4 to 7.0) compared with individuals without epilepsy. The association between conversion disorder with motor symptoms or deficits was non-significant after adjusting for psychiatric comorbidities. PNES carried a higher risk of natural (HR 8.1, 95% CI 4.0 to 16.4) and non-natural causes of death (HR 15.3, 95% CI 3.0 to 78.6). Suicide ranked high in patients with PNES (18.8%) and conversion disorder with motor symptoms and deficits. The association between PNES diagnosis and all-cause mortality varied with age and time since diagnosis.
Conclusion
Like epilepsy, PNES carries a higher than expected risk of both natural and non-natural causes of death. The high proportion of suicides requires further investigation.
Background
Suicide and suicidal behaviour are global health concerns with complex aetiologies. Given the recent research and policy focus on loneliness, this systematic review aimed to determine the extent to which loneliness predicts suicidal ideation and/or behaviour (SIB) over time.
Methods
A keyword search of five major databases (CINHAL, Medline, PsychArticles, PsychInfo and Web of Knowledge) was conducted. Papers for inclusion were limited to those using a prospective longitudinal design, written in English and which measured loneliness at baseline and SIB at a later time-point.
Results
After duplicates were removed, 947 original potential papers were identified, with 22 studies meeting the review criteria. Meta-analysis revealed loneliness was a significant predictor of both suicidal ideation and behaviour and there was evidence that depression acted as a mediator. Furthermore, studies which consisted of predominantly female participants were more likely to report a significant relationship, as were studies where participants were aged 16-20 or >55 years at baseline.
Limitations
There was considerable variability in measures, samples and methodologies used across the studies. Middle-aged adults were under-represented, as were individuals from minority ethnic backgrounds. All studies were conducted in countries where self-reliance and independence (i.e. individualism) are the cultural norm.
Conclusions
Loneliness predicts later SIB in select populations. However, due to the heterogeneity of the studies further research is needed to draw more robust conclusions. Suicide death also needs to be included as an outcome measure. A focus on more collectivist countries is also required.
Background
: Dissociative symptoms are documented in diverse clinical and non-clinical populations and associated with poorer mental health outcomes. Yet, research on dissociative symptoms is frequently limited to PTSD samples, and therefore little is known about the prevalence, clinical correlates, and risk factors related to dissociative symptoms in broader, representative trauma-exposed populations.
Methods
: The current study assessed dissociative symptoms in a contemporary, nationally representative sample of trauma-exposed U.S. veterans irrespective of PTSD diagnostic status. We compared sociodemographic, military, and psychiatric characteristics, trauma histories, level of functioning, and quality of life in veterans with dissociative symptoms to those without dissociative symptoms; and determined the incremental effect of dissociative symptoms on suicidality, functioning, and quality of life, independent of comorbidities.
Results
: Veterans with dissociative symptoms were more likely to be non-white, male, in financial distress, and lacking social support, with greater likelihood of psychiatric comorbidity, lower quality of life, and poorer cognitive and emotional functioning than those without dissociative symptoms, even after accounting for comorbid PTSD, anxiety, and depression. Dissociative symptoms were also related to a 5-fold greater likelihood of current suicidal ideation and 4-fold greater likelihood of lifetime suicide attempt history.
Limitations
: Cross-sectional data limit inference of the directionality of findings, and our sample may not generalize to the non-veteran population.
Conclusions
: Dissociation may be an important transdiagnostic clinical symptom and marker of heightened risk for suicidality and psychiatric comorbidities. There may be clinical utility in assessing for dissociative symptoms in veterans outside of the context of PTSD.
Dissociation is a lack of the normal integration of thoughts, feelings, and experiences into the stream of consciousness and memory. Dissociation occurs to some degree in normal individuals and is thought to be more prevalent in persons with major mental illnesses. The Dissociative Experiences Scale (DES) has been developed to offer a means of reliably measuring dissociation in normal and clinical populations. Scale items were developed using clinical data and interviews, scales involving memory loss, and consultations with experts in dissociation. Pilot testing was performed to refine the wording and format of the scale. The scale is a 28-item self-report questionnaire. Subjects were asked to make slashes on 100-mm lines to indicate where they fall on a continuum for each question. In addition, demographic information (age, sex, occupation, and level of education) was collected so that the connection between these variables and scale scores could be examined. The mean of all item scores ranges from 0 to 100 and is called the DES score. The scale was administered to between 10 and 39 subjects in each of the following populations: normal adults, late adolescent college students, and persons suffering from alcoholism, agoraphobia, phobic-anxious disorders, posttraumatic stress disorder, schizophrenia, and multiple personality disorder. Reliability testing of the scale showed that the scale had good test-retest and good split-half reliability. Item-scale score correlations were all significant, indicating good internal consistency and construct validity. A Kruskal-Wallis test. and post hoc comparisons of the scores of the eight populations provided evidence of the scale's criterion-referenced validity. The scale was able to distinguish between subjects with a dissociative disorder (multiple personality) and all other subjects.
This comprehensive systematic review and meta-analysis aimed to quantify the association between different types of childhood maltreatment and suicidality. We searched five bibliographic databases, including Medline, PsychINFO, Embase, Web of Science and CINAHL, until January 2018. Random-effects meta-analysis was employed followed by univariable and multivariable meta-regressions. Heterogeneity was quantified using the I2 statistic and formal publication bias tests were undertaken. The methodological quality of the studies was critically appraised and accounted in the meta-regression analyses. Data from sixty-eight studies based on n = 261.660 adults were pooled. All different types of childhood maltreatment including sexual abuse (OR = 3.17, 95% CI = 2.76 to 3.64), physical abuse (OR = 2.52, 95% CI = 2.09 to 3.04) and emotional abuse (OR = 2.49, 95% CI = 1.64 to 3.77) were associated with 2 to 3-fold increased risk for suicide attempts. Similar results were found for the association between childhood maltreatment and suicidal ideation. Complex childhood abuse was associated with a particularly high risk for suicide attempts in adults (OR= 5.18, 95% CI = 2.52 to 10.63). Variations across the studies in terms of demographic and clinical characteristics of the participants and other core methodological factors did not affect the findings of the main analyses. We conclude that there is solid evidence that childhood maltreatment is associated with increased odds for suicidality in adults. The main outstanding challenge is to better understand the mechanisms which underpin the development of suicidality in people exposed to childhood maltreatment because current evidence is scarce.
Background: One of the main obstacles in studying suicide risk factors is the difference between cases in which the individual died by suicide and those in which the individual engaged in suicidal behavior. A promising strategy that overcomes this obstacle is the study of survivors of serious suicide attempt (SSA), i.e. an attempt that would have been fatal had it not been for the provision of rapid and effective emergency treatment. Serious suicide attempters are epidemiologically very similar to those who died by suicide, and thus may serve as valid proxies for studying suicides. This paper aims to define the specific risk factors of SSAs by conducting a qualitative data synthesis of existing studies.
Methods: In accordance with PRISMA guidelines, we conducted a systematic search of the literature in PubMed, ProQuest and Psychlit electronic research-literature databases. Search terms were “serious” “OR” “near lethal,” combined with the Boolean “AND” operator with “suicide*.” In addition, a manual search of the literature on Google Scholar was performed, for further studies not yet identified.
Results: Initial search identified 683 citations. A total of 39 research reports met the predefined criteria and were analyzed. Mental pain, communication difficulties, decision-making impulsivity, and aggression, as well as several demographic variables, were found to be major risk factors for SSAs.
Limitations: We found a variability of definitions for SSA that hamper the ability to draw a model for the risk factors and processes that facilitate it. Moreover, the role of suicide intent and planning in SSA is still unclear. Further studies should aim to clarify and refine the concepts and measures of SSA, thereby enabling more specific and concrete modelling of the psychological element in its formation.
Conclusions: SSA is a distinguishable phenomenon that needs to be addressed specifically within the scope of suicidal behavior. Interpersonal problems, as well as impulsivity and aggression, seem to facilitate SSA when mental pain serves as a secondary factor. Healthcare professionals should to be aware of SSA, and familiar with its specific risk factors. Moreover, psychological and suicidal risk assessment should include a designated evaluation of these risk factors as part of intervention and prevention models for SSA.
To determine the number of clusters in the clustering analysis that has a broad range of applied sciences, such as physics, chemistry, biology, engineering, economics etc., many methods have been proposed in the literature. The aim of this paper is to determine the number of clusters of a dataset in a model-based clustering by using an Analytic Hierarchy Process (AHP). In this study, the AHP model has been created by using the information criteria Akaike's Information Criterion (AIC), Approximate Weight of Evidence (AWE), Bayesian Information Criterion (BIC), Classification Likelihood Criterion (CLC), and Kullback Information Criterion (KIC). The achievement of the proposed approach has been tested on common real and synthetic datasets. The proposed approach based on the corresponding information criteria has produced accurate results. The currently produced results have been seen to be more accurate than those corresponding to the information criteria.
This paper focuses on a unique variant of the mechanism of identification with the aggressor. The term "hermetic narrative" refers to a condition in which the trauma victim creates a hermetically sealed narrative of witnessing, which becomes an addictive and subjugating object in itself, while obstructing natural processes of thinking. This paper examines the ways in which the hermetic narrative reconstructs victim-aggressor relations both within the individual and in the analytic relationship. It further discusses the risk of creating a "false analysis" that is based on a malignant cooperation of the analyst and patient with the internalized traumatic object.
This study examined the psychometric properties of the posttraumatic stress disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5; Weathers, Litz, et al., 2013b) in 2 independent samples of veterans receiving care at a Veterans Affairs Medical Center (N = 468). A subsample of these participants (n = 140) was used to define a valid diagnostic cutoff score for the instrument using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013) as the reference standard. The PCL-5 test scores demonstrated good internal consistency (α = .96), test-retest reliability (r = .84), and convergent and discriminant validity. Consistent with previous studies (Armour et al., 2015; Liu et al., 2014), confirmatory factor analysis revealed that the data were best explained by a 6-factor anhedonia model and a 7-factor hybrid model. Signal detection analyses using the CAPS-5 revealed that PCL-5 scores of 31 to 33 were optimally efficient for diagnosing PTSD (κ(.5) = .58). Overall, the findings suggest that the PCL-5 is a psychometrically sound instrument that can be used effectively with veterans. Further, by determining a valid cutoff score using the CAPS-5, the PCL-5 can now be used to identify veterans with probable PTSD. However, findings also suggest the need for research to evaluate cluster structure of DSM-5. (PsycINFO Database Record
We review research on the relationship of exposure to psychological trauma, with non-suicidal self-injury (NSSI) and suicidality (suicidal ideation [SI], and suicide attempts [SA]) in individuals with dissociative disorders and posttraumatic stress disorder (PTSD). The review provides a context for the Special Issue of the Journal of Trauma and Dissociation on these topics. Exposure to childhood sexual abuse was the most consistent traumatic antecedent of self-harm, although traumatic violence in childhood (particularly physical abuse) and adulthood (particularly domestic violence) and exposure to multiple types of traumatic stressors also were associated with NSSI and SI/SA. Dissociative disorders and PTSD are consistently associated with increased NSSI and SA/SI. There is preliminary cross-sectional evidence that dissociation and posttraumatic stress disorders may mediate the relationship between psychological trauma and NSSI and SI/SA. Research on emotion dysregulation as a potential cross-cutting mechanism linking dissociation, PTSD, and self-harm is also reviewed. We conclude with discussion of implications for clinical practice and future directions for scientific research.
We conducted a latent class analysis (LCA) on 249 recent motor vehicle accident (MVA) victims to examine subgroups that differed in posttraumatic stress disorder (PTSD) symptom severity, current major depressive disorder and alcohol/other drug use disorders (MDD/AoDs), gender, and interpersonal trauma history 6-weeks post-MVA. A 4-class model best fit the data with a resilient class displaying asymptomatic PTSD symptom levels/low levels of comorbid disorders; a mild psychopathology class displaying mild PTSD symptom severity and current MDD; a moderate psychopathology class displaying severe PTSD symptom severity and current MDD/AoDs; and a severe psychopathology class displaying extreme PTSD symptom severity and current MDD. Classes also differed with respect to gender composition and history of interpersonal trauma experience. These findings may aid in the development of targeted interventions for recent MVA victims through the identification of subgroups distinguished by different patterns of psychiatric problems experienced 6-weeks post-MVA.
No one has described more passionately than Ferenczi the traumatic induction of dissociative trance with its resulting fragmentation of the personality. Ferenczi introduced the concept and term, identification with the aggressor in his seminal "Confusion of Tongues" paper, in which he described how the abused child becomes transfixed and robbed of his senses. Having been traumatically overwhelmed, the child becomes hypnotically transfixed by the aggressor's wishes and behavior, automatically identifying by mimicry rather than by a purposeful identification with the aggressor's role. To expand upon Ferenczi's observations, identification with the aggressor can be understood as a two-stage process. The first stage is automatic and initiated by trauma, but the second stage is defensive and purposeful. While identification with the aggressor begins as an automatic organismic process, with repeated activation and use, gradually it becomes a defensive process. Broadly, as a dissociative defense, it has two enacted relational parts, the part of the victim and the part of the aggressor. This paper describes the intrapersonal aspects (how aggressor and victim self-states interrelate in the internal world), as well as the interpersonal aspects (how these become enacted in the external). This formulation has relevance to understanding the broad spectrum of the dissociative structure of mind, borderline personality disorder, and dissociative identity disorder.
Suicidal behavior is highly complex and multifaceted. Consequent to the pioneering work of Durkheim and Freud, theoreticians have attempted to explain the biological, social and psychological nature of suicide. The present work presents an overview and critical discussion of the most influential theoretical models of the psychological mechanisms underlying the development of suicidal behavior. All have been tested to varying degrees and have important implications for the development of therapeutic and preventive interventions. Broader and more in-depth approaches are still needed to further our understanding of suicidal phenomena.
The independent and combined roles of childhood maltreatment (physical abuse, sexual abuse, emotional abuse, emotional neglect, and physical neglect) and current post-traumatic stress disorder (PTSD) were examined in predicting nonfatal suicide attempts among 335 African American women. It was hypothesized that suicide attempters (n = 157) would evidence higher rates of all forms of childhood maltreatment and higher rates of current PTSD than controls (n = 178). The authors predicted that women with both current PTSD and a lifetime history of child maltreatment would be at greatest risk for making a nonfatal suicide attempt. Results revealed that current PTSD and all five forms of childhood maltreatment were independently related to risk for suicide attempts. PTSD in combination with any of the five forms of childhood maltreatment increased a woman's risk for making a nonfatal suicide attempt. This suggests interventions designed to reduce suicidal behavior should focus on women with PTSD and a history of child maltreatment.
This study investigated the predictive utility of a six-dimensional conceptualization of emotion dysregu-lation for suicidal ideation, as well as its ability to distin-guish among individuals with differing histories of suicidality. Young adults (N = 96) with current suicidal ideation but no suicide attempt history (n = 17), a history of a single (n = 20) or multiple attempts (n = 17), or no current ideation/no past attempts (n = 42) completed measures of emotion dysregulation, suicidal ideation, depression, hopelessness, and a diagnostic interview. Multiple suicide attempters differed from participants with no suicidal ideation/no past attempts on two emotion dys-regulation dimensions—nonacceptance of emotional responses and perceived limited access to emotion regu-lation strategies. After adjusting for depression symptoms and the presence of a mood or anxiety diagnosis, limited access to emotion regulation strategies significantly pre-dicted current suicidal ideation, a relation that was found to be statistically mediated by hopelessness.
Objective:
Longitudinal data on adolescent self-injury are rare. Little is known regarding the associations between various forms of self-injurious thoughts and behaviors over time, particularly within community samples that are most relevant for prevention efforts. This study examined nonsuicidal self-injury (NSSI) as a time-invariant, prospective predictor of adolescent suicide ideation, threats or gestures, and attempts over a 2.5-year interval.
Method:
A diverse (55% female; 51% non-White) adolescent community sample (n = 399) reported depressive symptoms, frequency of NSSI, suicide ideation, threats or gestures, and attempts in 9th grade (i.e., baseline) and at 4 subsequent time points. Generalized estimating equations and logistic regressions were conducted to reveal the associations between baseline NSSI and the likelihood of each suicidal self-injury outcome postbaseline while controlling for depressive symptoms and related indices of suicidal self-injury as competing predictors.
Results:
Baseline NSSI was significantly, prospectively associated with elevated levels of suicide ideation and suicide attempts, but not threats or gestures. Neither gender nor ethnicity moderated results.
Conclusions:
Above and beyond established risk factors such as depressive symptoms and previous suicidality, adolescent NSSI may be an especially important factor to assess when determining risk for later suicidality.
There is a gap in the literature regarding suicide risk among traumatized individuals with post-traumatic stress disorder (PTSD) and this article aims to systematically review literature on the relationship between PTSD and suicidal behavior and ideation. A meta-analysis of 50 articles that examined the association between PTSD and past and current suicidal ideation and behavior was conducted. There was no evidence for an increased risk of completed suicide in individuals with PTSD. PTSD was associated with an increased incidence of prior attempted suicide and prior and current suicidal ideation. Controlling for other psychiatric disorders (including depression) weakened, but did not eliminate, this association. The evidence indicates that there is an association between PTSD and suicidality with several factors, such as concurrent depression and the pre-trauma psychiatric condition, possibly mediating this relationship. There are significant clinical implications of the reported relationship for suicide risk assessment and therapy, and further studies might help to understand the mediating pathways between PTSD and increased suicide risk.
Trauma can be repeated on behavioral, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering. Anger directed against the self or others is always a central problem in the lives of people who have been violated and this is itself a repetitive re-enactment of real events from the past. People need a "safe base" for normal social and biologic development. Traumatization occurs when both internal and external resources are inadequate to cope with external threat. Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of external danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Assaults lead to hyperarousal states for which the memory can be state-dependent or dissociated, and this memory only returns fully during renewed terror. This interferes with good judgment about these relationships and allows longing for attachment to overcome realistic fears. All primates subjected to early abuse and deprivation are vulnerable to engage in violent relationships with peers as adults. Males tend to be hyperaggressive, and females fail to protect themselves and their offspring against danger. Chronic physiologic hyperarousal persists, particularly to stimuli reminiscent of the trauma. Later stresses tend to be experienced as somatic states, rather than as specific events that require specific means of coping. Thus, victims of trauma may respond to contemporary stimuli as a return of the trauma, without conscious awareness that past injury rather than current stress is the basis of their physiologic emergency responses. Hyperarousal interferes with the ability to make rational assessments and prevents resolution and integration of the trauma. Disturbances in the catecholamine, serotonin, and endogenous opioid systems have been implicated in this persistence of all-or-none responses. People who have been exposed to highly stressful stimuli develop long-term potentiation of memory tracts that are reactivated at times of subsequent arousal. This activation explains how current stress is experienced as a return of the trauma; it causes a return to earlier behavior patterns. Ordinarily, people will choose the most pleasant of two alternatives. High arousal causes people to engage in familiar behavior, regardless of the rewards. As novel stimuli are anxiety provoking, under stress, previously traumatized people tend return to familiar patterns, even if they cause pain.(ABSTRACT TRUNCATED AT 400 WORDS)
Dissociation is a lack of the normal integration of thoughts, feelings, and experiences into the stream of consciousness and memory. Dissociation occurs to some degree in normal individuals and is thought to be more prevalent in persons with major mental illnesses. The Dissociative Experiences Scale (DES) has been developed to offer a means of reliably measuring dissociation in normal and clinical populations. Scale items were developed using clinical data and interviews, scales involving memory loss, and consultations with experts in dissociation. Pilot testing was performed to refine the wording and format of the scale. The scale is a 28-item self-report questionnaire. Subjects were asked to make slashes on 100-mm lines to indicate where they fall on a continuum for each question. In addition, demographic information (age, sex, occupation, and level of education) was collected so that the connection between these variables and scale scores could be examined. The mean of all item scores ranges from 0 to 100 and is called the DES score. The scale was administered to between 10 and 39 subjects in each of the following populations: normal adults, late adolescent college students, and persons suffering from alcoholism, agoraphobia, phobic-anxious disorders, posttraumatic stress disorder, schizophrenia, and multiple personality disorder. Reliability testing of the scale showed that the scale had good test-retest and good split-half reliability. Item-scale score correlations were all significant, indicating good internal consistency and construct validity. A Kruskal-Wallis test and post hoc comparisons of the scores of the eight populations provided evidence of the scale's criterion-referenced validity.(ABSTRACT TRUNCATED AT 250 WORDS)
Childhood abuse survivors may display both inward and outward aggression
manifested in self-injurious behavior (SIB) and violent acts toward others.
Scrutinizing the literature reveals that the relational dynamics between
victims and their perpetrators might be involved in these phenomena. Yet,
research on this subject matter has been sparse. Filling this gap, this study
investigated the contribution of the singular bonds between victims and
their perpetrators, known as identification with the aggressor, in explaining
survivors’ aggression. The study was conducted among 306 Israeli college/
university students who reported a history of childhood abuse. Results
revealed that levels of adopting the perpetrator’s experience, identifying
with the perpetrator’s aggression, and replacing one’s agency with that of
the perpetrator were significantly associated with survivors’ inward and
outward aggression. Moreover, profile type—that is, having high versus low
levels of identification with the aggressor—was implicated in participants’
SIBs, urge to harm others, and violent acts toward others, above and beyond
the effects of gender and posttraumatic stress disorder (PTSD) symptoms.
The present findings suggest that identification with the aggressor might
make survivors prone to the re-enactment of past abusive dynamics, which,
in turn, could eventuate in aggression toward themselves and others.
Childhood abuse survivors may display both inward and outward aggression manifested in self-injurious behavior (SIB) and violent acts toward others. Scrutinizing the literature reveals that the relational dynamics between victims and their perpetrators might be involved in these phenomena. Yet, research on this subject matter has been sparse. Filling this gap, this study investigated the contribution of the singular bonds between victims and their perpetrators, known as identification with the aggressor, in explaining survivors’ aggression. The study was conducted among 306 Israeli college/university students who reported a history of childhood abuse. Results revealed that levels of adopting the perpetrator’s experience, identifying with the perpetrator’s aggression, and replacing one’s agency with that of the perpetrator were significantly associated with survivors’ inward and outward aggression. Moreover, profile type—that is, having high versus low levels of identification with the aggressor—was implicated in participants’ SIBs, urge to harm others, and violent acts toward others, above and beyond the effects of gender and posttraumatic stress disorder (PTSD) symptoms. The present findings suggest that identification with the aggressor might make survivors prone to the re-enactment of past abusive dynamics, which, in turn, could eventuate in aggression toward themselves and others.
Pain tolerance and dissociation have individually been shown to be risk factors for suicidal behaviors. The aim of the current study was to investigate how dissociation and physiological pain tolerance influence the relation between suicidal thoughts and behaviors. The sample consisted of 70 undergraduate college students who completed self-report measures of suicidality and dissociation and an electrical stimulation task to measure physiological pain tolerance. Results showed that dissociation and suicidal ideation, but not pain tolerance, were independently associated with increased suicide attempts. A three-way interaction of suicidal ideation, physiological pain tolerance, and dissociation statistically predicted number of suicide attempts, with an increased number of suicide attempts associated with high suicidal ideation and dissociation, regardless of pain tolerance. These results suggest that dissociation plays a significant role in predicting suicide attempts, perhaps by engendering a state of disconnect from one's body.
Identifying with the aggressor is a process wherein victims of abuse, particularly during childhood, take on their perpetrator’s experience. The victim defers to the perpetrator and adopts the perpetrator’s experience, learns the perpetrator’s desires and needs, and gratifies them. Although the clinical and theoretical literature suggests that identification with the aggressor occurs in the aftermath of abuse and has negative long-term implications, to date this concept has not been empirically investigated. To facilitate an exploration of this subject, the current study evaluated the psychometric properties of a new measure: the Identification With the Aggressor Scale (IAS). The study was conducted among convenience samples of students using online surveys. In Study 1, the IAS was administered to 318 students. In Study 2, the IAS, and a battery of questionnaires assessing features of abuse, dissociation, posttraumatic stress disorder (PTSD) symptoms, and posttraumatic guilt were administered to a convenience sample of 368 students. Four reliable IAS factors emerged from Study 1: Adopting the perpetrator’s experience concerning the abuse, identifying with the perpetrator’s aggression, replacing one’s agency with that of the perpetrator, and becoming hypersensitive to the perpetrator. In Study 2, a confirmatory factor analysis confirmed the scale’s underlying factor structure. A history of childhood abuse, recurrence and severity of abuse, and the perpetrator being a parental figure were all associated with higher IAS scores. In addition, IAS scores were correlated with dissociation, PTSD symptoms, and posttraumatic guilt. The present findings indicate that the IAS has good psychometric properties, making it useful as an assessment tool in future research.
Childhood sexual abuse (CSA) poses a risk for sexual revictimization.
Additionally, according to theory CSA may lead to
identification with the aggressor, expressed by adopting the
perpetrator’s experience concerning the abuse; identifying
with the perpetrator’s aggression; replacing one’s agency
with that of the perpetrator; and becoming hyper-sensitive to
the perpetrator. Although clinical impressions suggest that
identification with the aggressor underlies reenactment of
trauma, this linkage between identification with the aggressor
and sexual revictimization remains largely uninvestigated. This
study assessed (a) the relationship between identification with
the aggressor (total score and four subscales) and sexual revictimization;
(b) the unique associations between identification
with the aggressor (total score and four subscales) and sexual
revictimization, above and beyond chronicity of abuse and
PTSD symptoms. Participants were Israeli women students
who reported a history of CSA (n = 174). Analyses indicated
significant correlations between two subscales of identification
with the aggressor – replacing one’s agency with that of the
perpetrator and becoming hyper-sensitive to the perpetrator –
and sexual revictimization. These subscales of identification
with the aggressor were associated with sexual revictimization,
above and beyond the effects of chronicity of the abuse and
PTSD symptoms. Nevertheless, these associations were in
opposite directions – while replacing one’s agency with that
of the perpetrator was related with higher occurrence of sexual
revictimization, becoming hyper-sensitive to the perpetrator
was related with lower levels of revictimization. These results
imply that identification with the aggressor may serve as
a multifaceted phenomenon in the context of sexual revictimization,
comprised of both adaptive and maladaptive aspects.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
In the half-century since his death, the Hungarian analyst SÃÆándor 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, SÃÆándor 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]
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.