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DISCRETE BEHAVIORAL STATES THEORY Discrete Behavioral States/States of Being
Abstract
Discrete Behavioral States Theory (DBST) developed by Frank W. Putnam is a transtheoretical, translational rlieory of
/11111c1oa1111s cious11eTshs.i s chapter focuses on DBST particularly as it relates to psychological trauma, dissociation and
pomraumatic and dissociative disorders (DD). For a complete discussion of OBST see Putnam's book, Tlie Way We
Are:H ow States of Nlind Ii,jfoence Our Ide11titicsP, ersonalitya, nd Pote11tialfoCr hange( 2016).1
OBST elucidates human experience and behavior across myriad normal and pathological domains. Discrete states of
being (SoB) are so pervasive and ubiquitous as to be essentially invisible, unless they shift in dramatic, unexpected ways,
and, even then, we usually do not conceptualize these changes in terms of behavioral states - although we use the word
'·state" frequently. The "atheoretical" DSM-5 (American Psychiatric Association, 2013) uses the term "state/states·•
over 100 times in describing psychiatric symptoms and disorders. DID diagnostic criteria are founded on the constructs
of "identity state" and "personality state," in the DSM-IV-TR and DSM-5 (and DSM-111-R), respectively. The term
"state" appears frequently in writings about the DD, especially dissociative identity disorder (DID).
OBST is not a "perfect" theory. There are many areas that need to be refined, and it may not explain all aspects of
human consciousness. However, the power ofDBST is based in substantial support from numerous domains of research,
including human development, neurobiology, chronobiology, psychopathology, and many others - from subcellular to
social systems.
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( Lancet . 2018;392:1058–1070)
Postpartum depression is a common problem, with an overall prevalence in the United States of ∼11.5%. It is associated with impaired mother-infant attachment, increased maternal morbidity and poor outcomes for infants later in life, including lower academic achievement and an increased risk of depression. There is a need for improved pharmacological treatment options for mothers suffering from postpartum depression. Brexanolone is a soluble, intravenous, positive allosteric modulator of y-aminobutyric-acid type A (GABA A ) receptors. In a previous phase 2 clinical trial, this medication was found to have rapid and sustained antidepressant effects. The current article reports on 2 randomized double-blind phase 3 studies that aimed to assess the efficacy of brexanolone injection in women with moderate to severe postpartum depression.
Experimental studies of learning suggest that human temperament may depend on the molecular mechanisms for associative conditioning, which are highly conserved in animals. The main genetic pathways for associative conditioning are known in experimental animals, but have not been identified in prior genome-wide association studies (GWAS) of human temperament. We used a data-driven machine learning method for GWAS to uncover the complex genotypic–phenotypic networks and environmental interactions related to human temperament. In a discovery sample of 2149 healthy Finns, we identified sets of single-nucleotide polymorphisms (SNPs) that cluster within particular individuals (i.e., SNP sets) regardless of phenotype. Second, we identified 3 clusters of people with distinct temperament profiles measured by the Temperament and Character Inventory regardless of genotype. Third, we found 51 SNP sets that identified 736 gene loci and were significantly associated with temperament. The identified genes were enriched in pathways activated by associative conditioning in animals, including the ERK, PI3K, and PKC pathways. 74% of the identified genes were unique to a specific temperament profile. Environmental influences measured in childhood and adulthood had small but significant effects. We confirmed the replicability of the 51 Finnish SNP sets in healthy Korean (90%) and German samples (89%), as well as their associations with temperament. The identified SNPs explained nearly all the heritability expected in each sample (37–53%) despite variable cultures and environments. We conclude that human temperament is strongly influenced by more than 700 genes that modulate associative conditioning by molecular processes for synaptic plasticity and long-term memory.
The FK506 binding protein 5 gene ( FKBP5 ) has been associated with susceptibility to pathogenic effects of childhood trauma including dissociative symptoms. This study examines the impact of maltreatment on dissociative tendencies in adolescence as moderated by the FKBP5 gene. Dissociative symptoms and variation within FKBP5 were assessed in a high-risk, low socioeconomic status community sample of 279 maltreated and 171 nonmaltreated adolescents. Following the assignment of haplotypes across four single nucleotide polymorphisms (rs3800373, rs9296158, rs1360780, and rs9470080), individuals with one or more copies of the CATT haplotype ( N = 230) were grouped together and compared to individuals with zero copies of this haplotype ( N = 185). Analyses of covariance were conducted to test hypotheses regarding the effects of developmental timing and the chronicity of maltreatment and the CATT haplotype. We found a significant interactive effect of timing/chronicity of maltreatment and the CATT haplotype on dissociative symptoms. Among adolescents who had no copies of the CATT haplotype, dissociative symptoms were higher for chronically maltreated adolescents who had an infancy onset compared to those who were not maltreated or whose maltreatment experience was either relatively less chronic or not started in infancy. The groups did not differ significantly among subjects who carry one or more copies of the CATT haplotype.
The etiology of dissociative identity disorder (DID) remains a topic of debate. Proponents of the fantasy model and the trauma model of DID have both called for more empirical research. To this end, the current study presents new and extended data analyses of a previously published H2O positron emission tomography imaging study. This study included 29 subjects: 11 patients with DID and 10 high- and 8 low-fantasy-prone DID-simulating mentally healthy control subjects. All subjects underwent an autobiographical memory script-driven (neutral and trauma related) imagery paradigm in 2 (simulated) dissociative personality states (neutral and trauma related). Psychobiological and psychophysiological data were obtained. Results of the new post-hoc tests on the psychophysiological responses support the trauma model. New results of the brain imaging data did not support the fantasy model. This study extends previously published results by offering important new supporting data for the trauma model of DID.
This study was an investigation of the additional risk conferred by the experience of psychogenic amnesia for memories of childhood sexual abuse (CSA) on the likelihood of becoming a victim of sexual assault in later life. A total of 210 community respondents completed a retrospective web-based trauma survey. The majority of respondents were female (74.3%) and their ages ranged from 16 to 65 years, with a mean age of 33 years. Chi-squared analysis revealed that survivors of CSA demonstrated significantly greater risk (58%, χ44.461, p = 0.0005) of experiencing sexual assault in adolescence in comparison with their non-abused counterparts (13%). Furthermore, survivors who reported having been amnesic for their abuse-related memories demonstrated a higher rate of adolescent revictimisation (86%) than survivors who had retained continuous memories of their victimisation (48%, χ8.626, p = 0.003). Overall, once-amnesic survivors of CSA demonstrated 6.6 times the risk of sexual assault and an eight-fold risk for rape during adolescence in comparison with their non-abused counterparts. It is proposed that the elevated risk conferred by amnesia for CSA might be mediated by two distinct pathways, both of which are associated with the use of dissociation as a defence mechanism.
The purpose of this article is to examine how closely six theoretical models fit the empirical evidence reviewed in Part 1 on the relationship between trauma and dissociation and to apply the resulting conclusions to make recommendations about diagnostic criteria for PTSD. We describe six models for the relationships among traumatic stress, dissociation, and PTSD, including models for fantasy-proneness, mediation, comorbidity, interactional comorbidity, component, and subtype. The research reviewed strongly supports component and subtype models of the relationship between dissociation and PTSD, and recommendations are made for including dissociative symptoms in the diagnostic criteria for PTSD in ICD-11 and DSM-5 and adding either a dissociative subtype or a complex PTSD diagnosis in both diagnostic systems. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Dissociative symptoms, first-rank symptoms of schizophrenia, and delusions were assessed in 40 schizophrenia patients and 40 dissociative identity disorder (DID) patients with the Multidimensional Inventory of Dissociation (MID). Schizophrenia patients were diagnosed with the Structured Clinical Interview for the DSM-IV Axis I Disorders; DID patients were diagnosed with the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised. DID patients obtained significantly (a) higher dissociation scores; (b) higher passive-influence scores (first-rank symptoms); and (c) higher scores on scales that measure child voices, angry voices, persecutory voices, voices arguing, and voices commenting. Schizophrenia patients obtained significantly higher delusion scores than did DID patients. What is odd is that the dissociation scores of schizophrenia patients were unrelated to their reports of childhood maltreatment. Multiple regression analyses indicated that 81% of the variance in DID patients' dissociation scores was predicted by the MID's Ego-Alien Experiences Scale, whereas 92% of the variance in schizophrenia patients' dissociation scores was predicted by the MID's Voices Scale. We propose that schizophrenia patients' responses to the MID do not index the same pathology as do the responses of DID patients. We argue that neither phenomenological definitions of dissociation nor the current generation of dissociation instruments (which are uniformly phenomenological in nature) can distinguish between the dissociative phenomena of DID and what we suspect are just the dissociation-like phenomena of schizophrenia.
The current state of the data concerned with psychopharmacologic interventions for multiple personality disorder (MPD) is reviewed. Common sense guidelines are provided for drug treatment of MPD. An overview is given for use of medications for specific symptoms commonly found in MPD patients, such as affective, posttraumatic stress disorder, and sleep disorder symptoms.
In contrast to trauma's relationship with the other dissociative disorders, the relationship of trauma to depersonalization disorder is unknown. The purpose of this study was to systematically investigate the role of childhood interpersonal trauma in depersonalization disorder.
Forty-nine subjects with DSM-IV depersonalization disorder and 26 healthy comparison subjects who were free of lifetime axis I and II disorders and of comparable age and gender were administered the Dissociative Experiences Scale and the Childhood Trauma Interview, which measures separation or loss, physical neglect, emotional abuse, physical abuse, witnessing of violence, and sexual abuse.
Childhood interpersonal trauma as a whole was highly predictive of both a diagnosis of depersonalization disorder and of scores denoting dissociation, pathological dissociation, and depersonalization. Emotional abuse, both in total score and in maximum severity, emerged as the most significant predictor both of a diagnosis of depersonalization disorder and of scores denoting depersonalization but not of general dissociation scores, which were better predicted by combined emotional and sexual abuse. The majority of the perpetrators of emotional abuse were either or both parents. Although different types of trauma were modestly correlated, only a few of these relationships were statistically significant, underscoring the importance of comprehensively considering different types of trauma in research studies.
Childhood interpersonal trauma and, in particular, emotional abuse may play a role in the pathogenesis of depersonalization disorder. Compared to other types of childhood trauma, emotional maltreatment is a relatively neglected entity in psychiatric research and merits more attention.
To examine relationships between childhood autobiographical memory disturbance (CAMD) and adverse childhood experiences (ACEs) which are defined as common forms of child maltreatment and related traumatic stressors.
We use the ACE score (an integer count of eight different categories of ACEs) as a measure of cumulative exposure to traumatic stress during childhood. In a cross sectional analysis we assess the relationship of the ACE score to the prevalence of CAMD in a sample of 9,460 relatively healthy adults evaluated for wellness care at a southern California health maintenance organization between August 1995 and March 1996. In addition, we examined possible secular influences by examining association among each of four birth cohorts. Logistic regression was used to obtain the adjusted relative odds of CAMD associated with increasing ACE score.
Overall, the age-standardized prevalence of CAMD was 18% (men: 15%; women: 19%). As the ACE score increased, the prevalence of CAMD increased in a graded fashion for both men and women (p for trend <.0001). After adjustment for age, sex, race/ethnicity, and education, adults with an ACE score >or=6 were 5.9 (95% CI, 4.4-7.9) times more likely to have CAMD compared to adults with an ACE score of 0. The prevalence of CAMD increased with each successive birth cohort, and graded relationships between the ACE score and CAMD were observed among each of the four birth cohorts though no statistical difference in the association was found across birth cohorts.
The accumulation of ACEs across several domains is associated CAMD among men and women and in each of four birth cohorts. Further research is needed that describes the prevalence of CAMD in population-based samples and that examines whether impaired memory is a marker for persons neurobiologically affected by multiple forms of child maltreatment and related traumatic stressors.
Clinicians have noted that childhood abuse survivors frequently report that they have forgotten large parts of their childhood. While memory for abusive experiences has attracted a great deal of attention from researchers, other types of memory disturbances may also accompany a history of childhood trauma. Many clinicians report that certain types of sexual abuse, and abuse at certain developmental stages, is more likely to result in reports of gaps in memory for the abuse. However, because information has been mainly collected in clinical populations, the possibility of confounding between abusive experiences and psychological disturbances cannot be ruled out. This article reports on data gathered from a large, epidemiologic study conducted within a health maintenance organization. A history of childhood physical or sexual abuse doubled the prevalence of general autobiographical memory loss for women, while for men, the rate increased 1.5 times over those with no abuse history. Higher rates of autobiographical memory loss were noted where both types of abuse were reported. Further, multiple incidents of sexual abuse, sexual abuse by a relative, and more severe sexual abuse increased reports of autobiographical memory loss. Theoretical perspectives on changes in the memory system that may affect trauma survivors are discussed.
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