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Disorders of Extreme Stress
(DESNOS) Symptoms Are
Associated With Type and
Severity of Interpersonal
Trauma Exposure in a Sample
of Healthy Young Women
Julian D. Ford
University of Connecticut School of Medicine
Patricia Stockton
Stacey Kaltman
Bonnie L. Green
Georgetown University Medical Center
Childhood abuse and other developmentally adverse interpersonal traumas may
put young adults at risk not only for posttraumatic stress disorder (PTSD) but
also for impairment in affective, cognitive, biological, and relational self-
regulation (“disorders of extreme stress not otherwise specified”; DESNOS).
Structured clinical interviews with 345 sophomore college women, most of
whom (84%) had experienced at least one traumatic event, indicated that the
DESNOS syndrome was rare (1% prevalence), but DESNOS symptoms were
reported by a majority of respondents. Controlling for PTSD and other anxiety
or affective disorders, DESNOS symptom severity was associated with a history
of single-incident interpersonal trauma and with more severe interpersonal trauma
in a dose-response manner. Noninterpersonal trauma was associated with ele-
vated prevalence of PTSD and dissociation but not with DESNOS severity.
Study findings indicate that persistent posttraumatic problems with self-regulation
warrant attention, even in relatively healthy young adult populations.
Keywords: childhood interpersonal trauma; self-regulation; young adults
Exposure to traumatic events is prevalent and often has a profound and last-
ing impact. More than half of the general population report experiencing
Journal of Interpersonal
Violence
Volume 21 Number 11
November 2006 1399-1416
© 2006 Sage Publications
10.1177/0886260506292992
http://jiv.sagepub.com
hosted at
http://online.sagepub.com
1399
Authors’ Note: This research was supported in part by National Institute of Mental Health
Grants RO1 MH50332 (Bonnie L. Green, PI) and K23 MH01889-01A (Julian D. Ford, PI).
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trauma at some point in their life (Kessler, Sonnega, Bromet, Hughes, &
Nelson, 1995). Between 10% and 25% of people exposed to psychological
trauma develop posttraumatic stress disorder (PTSD), which can be debili-
tating (Breslau, Davis, & Andreski, 1995; Kessler et al., 1995). When trauma
occurs at critical ages or developmental transitions (Cicchetti & Rogosch,
2001) and involves abuse in the form of “betrayal” by caregivers (Freyd,
1994) or violation of self (Herman, 1992) or core values (e.g., war atroci-
ties; Michultka, Blanchard, & Kalous, 1998), the risk of PTSD in adulthood
is high. Interpersonal violence or violation in childhood is associated with
particularly high (i.e., 50%-75%) risk of PTSD in adolescence or adulthood
(Kessler et al., 1995).
Moreover, interpersonal trauma in childhood is associated with chronic
problems in adulthood with biological and affective self-regulation (DeBellis,
2001; Manly, Kim, Rogosch, & Cicchetti, 2001) that place survivors at risk
for chronic medical illness (e.g., cardiovascular, metabolic, immunologic,
obesity; Schnurr & Green, 2004). Infants and young children exposed to
interpersonal trauma are at risk for regulatory, attachment, anxiety, and
affective disorders in infancy and childhood (Scheeringa & Zeanah, 2001).
Adolescents who were exposed to interpersonal trauma in childhood are at
risk for internalizing (Mazza & Reynolds, 1999), externalizing (Ford,
2002), and substance use (Gordon, 2002) disorders. Adult survivors of child
abuse and family violence are at risk not only for PTSD (Duncan, Saunders,
Kilpatrick, Hanson, & Resnick, 1996) but also for heightened anxiety
(McCauley et al., 1997; Stein et al., 1996), depression and suicidality (Dube
et al., 2001; Duncan et al., 1996; Felitti et al., 1998; McCauley et al., 1997),
addiction (Duncan et al., 1996; Felitti et al., 1998; Gordon, 2002; McCauley
et al., 1997), personality disorders (Zlotnick, Mattia, & Zimmerman, 2001),
mental illness (Leverich et al., 2002; Lysaker, Meyer, Evans, Clements, &
Marks, 2001), and sexual disorders (Felitti et al., 1998). Adult survivors of
child abuse also are at risk for revictimization (Follette, Polusny, Bechtle,
& Naugle, 1996; Whitfield, Anda, Dube, & Felitti, 2003).
These complex posttraumatic impairments have been described as “disor-
ders of extreme stress not otherwise specified” (DESNOS) (Herman, 1992;
Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997; van der Kolk et al.,
1996). DESNOS has been assessed by structured interview (Pelcovitz et al.,
1997) in midlife and older adult community samples (Roth et al., 1997; van
der Kolk et al., 1996), in inpatient (Ford, 1999; Ford & Kidd, 1998) and
outpatient mental health (Roth et al., 1997; van der Kolk et al., 1996) and
substance abuse (Ford & Frisman, 2002) samples, and among homeless
adults (Ford & Frisman, 2002). DESNOS involves persistent alterations in
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seven aspects of self-regulation and psychosocial functioning following
exposure to traumatic stress: (a) affect and impulse regulation (i.e., persis-
tent distress, risky behavior or self-harm), (b) biological self-regulation (i.e.,
somatization—pain or physical symptoms or impairments that cannot be
fully medically explained), (c) attention or consciousness (i.e., dissociation),
(d) perception of perpetrator or perpetrators (e.g., idealization, preoccupa-
tion with revenge), (e) self-perception (e.g., self as damaged or ineffective,
profound shame or guilt), (f) relationships (e.g., inability to trust, revictim-
ization, avoidance of sexuality), and (g) systems of meaning or sustaining
beliefs (e.g., hopelessness, loss of faith).
DESNOS symptoms thus differ from PTSD’s symptoms of unwanted
memories (intrusive reexperiencing), excess arousal (hyperarousal and hyper-
vigilance), and conscious and automatic attempts to cope with these memories
and the excess arousal (avoidance and emotional numbing; American Psy-
chiatric Association, 1994). PTSD is an anxiety disorder, but DESNOS
involves a broader set of self-regulatory impairment that takes the form of
profound and enduring problems with overwhelming emotional distress,
periods of severe dissociation, loss of a basic sense of trust in relationships
and meaning in life, and chronic health problems that cannot be explained
by medical causes. This view of DESNOS as posttraumatic self-dysregulation
is consistent with findings which have been replicated with civilian clinical
samples (Roth et al., 1997; van der Kolk et al., 1996) and military clini-
cal samples (Ford, 1999) that DESNOS is most likely to occur following
(a) trauma in early childhood when many self capacities are formed or mal-
formed and (b) interpersonal violence or violation rather than noninterper-
sonal traumas such as serious accidents, disasters, or illnesses.
However, DESNOS has not been assessed among healthy young adults,
despite evidence that this relatively protected and resilient population may
be adversely affected by trauma exposure in childhood or adolescence (Green
et al., 2000; Krupnick et al., 2004; Lauterbach & Vrana, 2001; Scarpa et al.,
2002). Prior analyses with the present data set (Krupnick et al., 2004)
showed that exposure to interpersonal trauma in adolescence increased
young adults’ risk of Axis I diagnoses (including PTSD) and borderline
personality disorder (BPD) symptoms. BPD shares several features with
DESNOS, and the two syndromes were highly comorbid in a clinical sam-
ple of women (McLean & Gallop, 2003). Early childhood trauma exposure
was not examined in our prior studies, although it has been found to be pre-
dictive of both BPD and DESNOS (McLean & Gallop, 2003). Therefore,
the present study was designed to extend the research literature on DESNOS
and interpersonal trauma by examining the separate relationships of early
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childhood and adolescent interpersonal trauma on the risk of DESNOS in
healthy youth women. The rationale for restricting the sample to young adults
(who were not currently experiencing trauma) was that this enabled us to
examine the impact of childhood and adolescent trauma exposure in adult-
hood without the potential confound of exposure to trauma in adulthood.
Because studies have shown that repeated exposure to traumatic stressors is
associated with cumulative increases in the risk and severity of posttrau-
matic problems (Follette et al., 1996; Green et al., 2000; McCauley et al.,
1997; Whitfield et al., 2003), we also examined the association of DESNOS
with cumulative trauma exposure in two ways: (a) multiple incidents of
traumatic exposure (vs. a single trauma incident) and (b) multiple perpetra-
tors of interpersonal violence or violation (vs. one perpetrator).
We expected that clinically significant DESNOS would be rare in this
population but that the core features of DESNOS would occur with sufficient
frequency to determine if they were distinct from PTSD and other psychi-
atric disorders in their relationship to different types of past trauma expo-
sure. Based on the evidence summarized above, that DESNOS are the sequelae
of cumulative interpersonal trauma exposure in early childhood, we tested
the following primary hypothesis:
Hypothesis 1: The likelihood of meeting criteria for each DESNOS feature will
increase as the severity of trauma exposure increases successively from (a) no
past trauma, to (b) single-incident noninterpersonal trauma, to (c) single-incident
interpersonal trauma, to (d) ongoing (i.e., abuse) or multiple interpersonal trau-
mas by one perpetrator, and finally to (e) abuse by more than one perpetrator or
abuse plus one or more incidents of interpersonal trauma by another perpetrator.
Based on conflicting evidence that DESNOS may be either a complex
and severe form of PTSD (van der Kolk et al., 1996) or a syndrome distinct
from (although often comorbid with) PTSD and other anxiety and affective
disorders (Ford, 1999), we also tested the following hypothesis:
Hypothesis 2: DESNOS will be related to severity of trauma exposure independent
of the effects of (a) PTSD and (b) affective or other anxiety disorders.
Method
Sample and Procedure
As described in Green et al. (2000, 2001) and Krupnick et al. (2004), par-
ticipants were college women recruited via mailings sent to all sophomore
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women who were 24 years old or younger and were taking at least 9 credit
hours per semester at six colleges and universities in the Washington, D.C.,
area. The mailings were sent during four consecutive semesters during 2
successive years and included a detailed description of the study, an assur-
ance of confidentiality, and a packet of self-report questionnaires along
with a self-addressed, postage-paid envelope. A separate consent form was
provided for participants to indicate if they were interested in participating
in the next phase of the study. In total, 10,722 questionnaires were mailed
and 2,568 were returned (response rate = 24%). Of those returned, 65%
gave permission to be contacted for the next phase of the study if they met
study criteria. Approximately 700 women were interviewed by telephone to
screen for specific and mutually exclusive traumatic event exposure histo-
ries. From this second screening, 363 women were interviewed in person.
Women signed a separate consent form for the 2.5- to 3-hour interview and
were paid $25 for their time.
Interviewers were 6 women graduate clinical psychology students and 2
bachelor’s-level female research assistants. Interviewers were trained to
reliably conduct the Structured Clinical Interview for DSM-IV (SCID) and
the Structured Interview for Disorders of Extreme Stress (SIDES) for
DESNOS with training tapes, observation of skilled interviewers, practice
with feedback, and supervision with careful review of each interview.
Based on listwise deletion, 18 respondents were not included in the final
data sample because of missing data on one or more of the measures.
Excluded respondents did not differ from the 345 for whom analyses will
be reported on any demographic or study variables. Five participant sub-
groups were defined to reflect trauma severity based on a structured trauma
history interview (see below). Only events or experiences that met criteria
of the fourth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) for PTSD Criterion A were used to define participant
subgroups. Abuse was defined as sexual or physical assault occurring at
least five times by the same perpetrator within any 12-month period. For
children, age 11 years old or younger sexual assault had to be by an indi-
vidual at least 5 years older. At age 12 or older, unless the perpetrator was
a family member, sexual assault had to involve physical force or physical
threat (including a weapon) against the respondent’s will or while she was
helpless. Physical assault had to involve intentional harm by another person
that caused demonstrable injury, threat with a potentially lethal weapon, or
infliction of extreme pain (e.g., exposure to extremes of heat or cold).
Fights between peers younger than 12 and fights or assaults by siblings
were excluded.
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A no trauma (NT) subgroup (n= 56) included participants who reported
no past traumatic events on the screening questionnaire or in the subsequent
interview. A single-incident noninterpersonal (SNI) subgroup (n= 33) included
participants who reported one accidental injury or bereavement trauma (loss
of a family member or very close friend by homicide, suicide, or accident)
in childhood or adolescence and no other trauma events. A single-incident
interpersonal trauma (SIT) subgroup included participants (n= 76) who
reported a single incident of physical or sexual assault. An ongoing or mul-
tiple interpersonal trauma (OMIT) subgroup (n= 104) included participants
who reported past physical or sexual abuse, or multiple assaults, with only
one perpetrator. A cumulative abuse trauma (CAT) subgroup (n= 76) included
participants reporting past physical and/or sexual abuse by more than one
perpetrator (11%) or abuse by one perpetrator and at least one other incident
of interpersonal trauma by a different perpetrator (89%).
Measures
Stressful Life Events Screening Questionnaire (SLESQ). The 13-item
SLESQ (Goodman, Corcoran, Turner, Yuan, & Green, 1998) screens for
past Criterion A1 stressor events—“actual or threatened death or serious
injury, or a threat to the physical integrity of self or others” (American
Psychiatric Association, 1994, p. 427)—plus one item for traumatic loss.
SLESQ items do not assess Criterion A2 (reactions to exposure). The retest
correlation for number of events reported by a sample of 140 male and
female college students when the SLESQ was readministered 2 weeks after
a first testing was .89, and individual item kappa coefficients for retest reli-
ability ranged from .31 to 1.00 (Mdn = .73). Criterion validity was sup-
ported by a .77 correlation between the total number of events identified on
the SLESQ and in a face-to-face interview covering the same events, with
item kappas ranging from .26 to .90 (Mdn = .64).
SIDES. The SIDES (Pelcovitz et al., 1997) structured interview assesses
the presence of 48 symptoms by asking if the participant had experienced
the symptom “since the event or for as long as you can remember.” A total
score, seven subscale scores, and a dichotomous classification score (pre-
sent vs. absent) can be calculated using rules described by Pelcovitz et al.
(1997). The SIDES subscales correspond to the seven DESNOS features
described above. In this study, respondents in the NT and SNI groups had
no perpetrator, so the fourth SIDES subscale (Altered Perceptions of
Perpetrators) was not utilized. Pelcovitz et al. reported evidence of adequate
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interrater reliability and internal consistency for the SIDES total score and
subscale scores in community and clinical samples.
SCID-NP. Lifetime anxiety (including PTSD) and affective disorders
were assessed using the SCID (First, Spitzer, Gibbon, & Williams, 1996),
a structured interview that follows diagnostic criteria defined by the DSM-
IV of the American Psychiatric Association (1994). Reliability for diagno-
sis ratings was conducted on a sample of 52 interviews from this study in
which one interviewer conducted the interview and a second observed and
rated. Kappas for the reliability of the ratings for lifetime disorders were .81
for acute stress disorder, 1.00 for PTSD, .92 for major depressive disorder,
.78 for alcohol abuse, .79 for alcohol dependence, and .48 to 1.00 for all
other diagnoses.
Data Analyses
First, summary statistics, bivariate correlations of the SIDES subscales,
and comparisons of the prevalence of DESNOS subscales for respondents
with or without a history of PTSD were calculated. To test Hypothesis 1,
cross-tabulations and chi-square analyses were conducted to test the relative
likelihood of meeting criteria for PTSD and each DESNOS feature across all
five trauma subgroups. As a further test of Hypothesis 1, a series of logistic
regression analyses were conducted comparing pairs of trauma subgroups
on the relative likelihood of meeting criteria for PTSD and each DESNOS
feature. To test Hypothesis 2, we conducted a general linear model analysis
of variance (ANOVA) and subsequent analyses of covariance (ANCOVA) to
determine if different types of trauma exposure were associated with level of
DESNOS symptoms after controlling for the effects of lifetime diagnosis of
(a) PTSD and (b) any affective or other anxiety disorder.
Results
As expected, full DESNOS was rare (3 cases; <1% prevalence). Affect
dysregulation was the least commonly endorsed SIDES feature (Table 1).
Somatization, altered self-perceptions, and dissociation also were endorsed by
fewer than half the respondents. Alterations in relationships and sustaining
beliefs each was endorsed by about half the sample. The SIDES features were
moderately intercorrelated (Table 1), sharing up to 17% variance (r2). Affect
dysregulation and somatization were particularly distinct, sharing between 1%
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and 10% variance with each other subscale. Thus, although interrelated, the
DESNOS features were relatively independent of one another in this sample.
One in 9 (n= 38, 11%) respondents met criteria for lifetime (i.e., current
or past) PTSD diagnosis, comparable to prevalence figures reported for
women in community samples (Breslau et al., 1995; Kessler et al., 1995;
Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). The fact that this rel-
atively normative prevalence level was observed despite oversampling of
respondents with a trauma history may reflect the protective influence of
education on PTSD risk (Ullmann & Brecklin, 2002). The relatively low
proportion of the sample with retraumatization and chronicity most likely
reflects the sampling strategy, which was designed to oversample respon-
dents with a single trauma episode. More than one third (n= 125) of the
sample met criteria for lifetime affective (i.e., major depression, dysthymic
disorder) or other anxiety (i.e., panic, agoraphobia, social phobia, obsessive-
compulsive disorder, generalized anxiety disorder) disorders.
Although the low prevalence of full DESNOS does not permit us to
examine the convergence or divergence of full DESNOS and PTSD, bivari-
ate correlations showed that a history of PTSD was most strongly related to
altered self-perceptions and significantly, but less strongly, related to each
other DESNOS feature (Table 1). Cross-tabulations were done to compare
respondents for whom lifetime PTSD and each DESNOS subscale were
present or absent (Table 2). Concordance was particularly strong for the
least prevalent DESNOS features, affect dysregulation, somatization, and
altered self-perceptions. At least 80% of respondents showed a correspon-
dence between lifetime PTSD and each of these three DESNOS features.
The more prevalent DESNOS features frequently were discordant with
(i.e., occurred in the absence of) PTSD: dissociation (32% discordance) and
altered relationships and systems of meaning (42%-43% discordance).
Thus, although there is a great deal of overlap between PTSD and each
DESNOS feature, DESNOS features often occurred separately from PTSD
and may constitute distinct subclinical posttraumatic sequelae (Ford, 1999).
Cross-tabulations comparing the five trauma subgroups resulted in sta-
tistically significant differences in the likelihood of lifetime PTSD and each
DESNOS feature: χ2(df = 4) = 12.1-56.4, p <.015. As shown in Table 3, the
prevalence of lifetime PTSD was between 9% and 10% for the SNI, SIT,
and OMIT groups but 20% for the CAT group. In logistic regression analy-
ses testing the likelihood of PTSD, the NT, SNI, SIT, and OMIT groups did
not differ, but CAT participants were significantly more likely than OMIT
participants to meet PTSD diagnostic criteria (odds ratio, OR = 3.23, 95%
confidence interval, CI = 1.35-7.70), χ2(df = 2) = 6.9, p <.01.
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Table 1
Prevalence and Bivariate Correlations of DESNOS Subscales
Variable Prevalence (%) I II III V VI VII
I. SIDES affect dysregulation 8 —
II. SIDES somatization 17 .27*** —
III. SIDES dissociation 36 .19*** .28*** —
V. SIDES altered self-perception 25 .22*** .33*** .38*** —
VI. SIDES altered relationships 50 .10 .27*** .30*** .41*** —
VII. SIDES altered sustaining beliefs 47 .19*** .19*** .35*** .33*** .23*** —
Lifetime PTSD 11 .21*** .24*** .28*** .38*** .22*** .21***
Note: N= 334 for all variables (listwise deletion of missing data). SIDES = Structured Interview for Disorders of Extreme Stress; PTSD = posttrau-
matic stress disorder.
***p<.001, two-tailed.
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Affect dysregulation and somatization were the least frequently reported
DESNOS features overall (Table 3), showing a pattern of relationships to
the trauma groups similar to that of PTSD: no occurrences in the NT group,
low levels for the SNI, SIT, and OMIT groups (except that somatization
was reported by more than 20% of the OMIT group), and higher levels of
occurrence in the CAT group. Altered self-perceptions were also uncom-
mon but were most frequently reported by participants with an abuse
history (i.e., either OMIT or CAT). Dissociation, altered relationships, and
altered sustaining beliefs were relatively rare (but not absent) in the NT
group, more common in the SNI and SIT groups, and most often reported
by both the OMIT and CAT groups.
Logistic regression analyses comparing pairs of trauma groups sequen-
tially showed that the SNI group was more likely than the NT group to report
dissociation (OR = 4.00, 95% CI = 1.23-13.03), χ2(df = 1) = 5.3, p <.05. The
SNI and SIT groups did not differ significantly on any DESNOS feature.
The OMIT group was more likely than the SIT group to report dissociation
(OR = 1.98, 95% CI = 1.05-3.83), χ2(df = 1) = 4.5, p <.05, altered relation-
ships (OR = 2.08, 95% CI = 1.16-3.97), χ2(df = 1) = 6.1, p <.01, and altered
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Table 2
Co-Occurrence of Lifetime PTSD and Each DESNOS Feature
Lifetime Lifetime
DESNOS Subscale PTSD Absent PTSD Present
I. SIDES affect dysregulation Absent (%) 83 8
Present (%) 63
II. SIDES somatization Absent (%) 77 6
Present (%) 12 5
III. SIDES dissociation Absent (%) 60 3
Present (%) 29 8
V. SIDES altered self-perception Absent (%) 72 3
Present (%) 17 8
VI. SIDES altered relationships Absent (%) 48 2
Present (%) 41 9
VII. SIDES altered sustaining beliefs Absent (%) 50 3
Present (%) 39 8
SIDES symptom count M5.4 14.9
SD 5.7 7.7
Note: N= 345 for all variables based on listwise deletion of missing data. DESNOS = disor-
ders of extreme stress not otherwise specified; PTSD = posttraumatic stress disorder; SIDES =
Structured Interview for Disorders of Extreme Stress. Percentages in bold represent a dis-
crepancy between PTSD and the DESNOS feature.
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Table 3
Posttraumatic Stress Sequelae of Different Types of Trauma Exposure
V. Altered VII. Altered
I. Affect II. III. Self- VI. Altered Sustaining DESNOS
Lifetime PTSD Dysregulation % Somatization % Dissociation % Perception % Relations % Beliefs % Features% MSD
All respondents 11 8 17 36 25 50 47 7.2 5.4
No traumaa0 0 0 9 4 14 24 1.2 1.8
Single-incident noninterpersonal 9 3 12 30 9 27 42 3.4 3.4
traumab
Single-incident interpersonal 10 6 11 31 21 42 35 5.2 5.1
traumac
Ongoing/multiple interpersonal 10 9 21 47 33 65 54 8.2 7.3
traumad
Cumulative abuse traumac20 16 30 48 36 72 70 10.6 7.0
Note: DESNOS = disorders of extreme stress not otherwise specified; PTSD = posttraumatic stress disorder.
a. n= 56.
b. n= 33.
c. n= 76.
d. n= 104.
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sustaining beliefs (OR = 2.10, 95% CI = 1.19-4.02), χ2(df = 1) = 6.4, p <.01.
The CAT group was more likely than the OMIT group to report altered sus-
taining beliefs (OR = 1.92, 95% CI = 1.03-3.57), χ2(df = 1) = 4.3, p <.05.
The ANOVA comparing the five trauma groups on overall DESNOS
symptoms yielded a significant finding, F(4, 340) = 26.2, p<.001. Post hoc
Tukey honestly significant difference tests (p<.05) showed that the CAT
and OMIT groups did not differ from each other (Table 3) but had higher
levels of DESNOS symptoms than the SIT, SNI, and NT groups. In addition,
the SIT group’s mean level of DESNOS symptoms was greater than that for
the NT group. The SIT and SNI groups were comparable, as were the SNI
and NT groups. The ANCOVA comparing the five trauma groups on the
number of DESNOS symptoms while controlling for the presence of a life-
time PTSD or other Axis I psychiatric disorder also produced a significant
finding, F(4, 338) = 12.0, p<.001. The adjusted mean numbers of DESNOS
symptoms still were comparable and significantly higher for CAT (8.7) and
OMIT (7.8) than for SIT (5.6), SNI (4.3), and NT (3.1). SIT participants had
significantly more DESNOS symptoms than NT participants, whereas the
SNI group was comparable to both the SIT and NT participants.
Discussion
Our results suggest that well-educated young women who experienced
trauma in childhood or adolescence—particularly as abuse or by multiple
perpetrators—may suffer from complex forms of posttraumatic biopsy-
chosocial dysregulation that are independent of either PTSD or other Axis I
psychiatric disorders. Independent of the effects of PTSD and other Axis I
psychiatric disorders, even a single incident of interpersonal trauma was suf-
ficient to be associated with elevated levels of DESNOS symptoms (com-
pared to no trauma), but a single incident of noninterpersonal trauma was
not. The finding that few respondents met all DESNOS criteria suggests that
posttraumatic dysregulation is not pervasive or debilitating for most of these
young, educated, and relatively resource-rich women even if they were sub-
jected to abuse or other interpersonal trauma earlier in their lives. However,
subclinical problems with self-regulation were common among these
women if they had experienced abuse or multiple perpetrator interpersonal
violence and more common if they had experienced even a single interper-
sonal assault than if they had no history of trauma.
Subclinical problems with self-regulation have been shown to occur and
cause impairment among young adults who have been exposed to childhood
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abuse (Miltenburg & Singer, 1999), especially following abuse by multiple
perpetrators (Cole-Detke & Kobak, 1998) or abuse combined with other
interpersonal trauma. There also is evidence that subthreshold PTSD is asso-
ciated with significant psychosocial (Stein, Walker, Hazen, & Forde, 1997)
and physical health (Schnurr & Green, 2004) impairment and that subclini-
cal psychiatric symptomatology is associated with both current impairment
and risk of future psychiatric morbidity (Katzelnick et al., 2001; Pearson
et al., 1999). Therefore, research is needed to determine if the DESNOS
symptomatology reported by many of the respondents is sufficient to cause
either current impairment or place them at risk of future clinically sig-
nificant problems. Prospective longitudinal follow-up studies also are
needed to determine if and for whom these self-regulatory problems persist
and if chronicity of DESNOS into and through adulthood is associated with
increasing psychosocial impairment—and if predictors of resilience and
recovery can be identified (Binder, McNiel, & Goldstone, 1996).
Our results suggest that interpersonal violence or violation (abuse) or
multiple interpersonal traumas each are more strongly associated with prob-
lems in self-regulation than either a single episode of noninterpersonal or
interpersonal trauma. This finding replicates results of prior studies of
DESNOS with other populations (Ford, 1999; Ford & Kidd, 1998; van der
Kolk et al., 1996) and is consistent with evidence that child abuse is asso-
ciated with serious biopsychosocial dysregulation (Cicchetti & Rogosch,
2001; DeBellis, 2001; Heim & Nemeroff, 2001; Kaufman, Plotsky, Nemeroff,
& Charney, 2000; Perry & Pollard, 1998). Our findings extend this research
literature by suggesting that this dysregulation may be present early in adult-
hood even among women who have sufficient resources and coping skills
(Binder et al., 1996) to be able to achieve ongoing college attendance.
The impact of persistent or repeated childhood or adolescent abuse is indi-
cated by the finding that the CAT subgroup reported the most DESNOS symp-
toms overall (although not significantly different from the OMIT group because
of substantial within-group variances). The CAT subgroup also was most likely
to have altered sustaining beliefs, had the highest prevalence of lifetime PTSD,
and was associated with high levels of the least common DESNOS features
(i.e., affect dysregulation, somatization). Thus, even among relatively resilient,
advantaged, and otherwise low-risk individuals, ongoing childhood interper-
sonal violence or violation appears to be associated with severe and persistent
forms of self-regulatory impairment (Cole-Detke & Kobak, 1998; DeBellis,
2001; Perry & Pollard, 1998; Scheeringa & Zeanah, 2001; Schore, 2001).
Although dissociation and PTSD were most common for women who
had experienced cumulative abuse, single-incident noninterpersonal or
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interpersonal traumas also were associated with an increased risk of both dis-
sociation and PTSD compared to no history of trauma. Thus, even a single
incident of accidental, illness-related, bereavement, or assault trauma may be
associated with PTSD and impairment in the regulation of consciousness.
However, single-incident trauma was associated with higher overall
DESNOS levels only if the trauma was interpersonal. Single-incident inter-
personal trauma was associated with higher likelihood of reporting several
specific DESNOS features (i.e., affect dysregulation, altered self-perceptions
and relationships), compared with noninterpersonal trauma or no trauma.
Interpersonal assault is prevalent in childhood and adolescence and is asso-
ciated with PTSD, depression, and substance abuse (Duncan et al., 1996).
Our findings add the possibility that interpersonal assault, even when it occurs
as a single incident, may be associated with lasting stress-related dysregula-
tion. This finding underscores the importance of developing and broadly
implementing effective violence prevention and social competence programs
for children and adolescents.
Generally, the DESNOS symptoms were not reported by respondents
with no trauma history, except for 1 in 4 who reported alterations in sus-
taining beliefs and about 1 in 10 who endorsed dissociation and altered
relationships. The substantial jump in the likelihood of reporting all of the
DESNOS features, especially dissociation, when even a single incident of
trauma had occurred and the still greater increase in prevalence when abuse
or multiple interpersonal trauma had occurred suggest that trauma (and not
just more routine stressors or developmental challenges) may cause other-
wise healthy and productive young women to suffer potentially problematic
self-regulatory difficulties. This finding replicates and extends prior results
from this data set that single-incident noninterpersonal trauma is associated
with functional impairment (Green et al., 2001).
Several limitations suggest caution in interpreting the findings. Trauma
history was assessed retrospectively and without external confirmation.
However, the presence and specific type of trauma was independently
determined by an intensive interview after first being identified with a com-
prehensive screening questionnaire (the SLESQ) that has shown good evi-
dence of reliability and validity with this (Green et al., 2000) and similar
(Goodman et al., 1998) populations. We did not examine the exact timing
of trauma in childhood or adolescence. Given evidence that the timing of
trauma in infancy (Scheeringa & Zeanah, 2001) and throughout childhood
and adolescence (Thornberry, Ireland, & Smith, 2001) may affect critical
outcomes, future studies should examine the effects of trauma’s timing and
the interpersonal and cumulative effects tested in this study.
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The self-report interview measure used to assess DESNOS, the SIDES, has
shown evidence of reliability, but the criterion and construct validity of the
SIDES subscales are uncertain. Our finding that the SIDES subscales were
interrelated but largely distinct provides additional support for their validity
and for the syndromal coherence of DESNOS (Ford, 1999; Roth et al., 1997).
Findings from this socioeconomically advantaged sample of young
women cannot of course be generalized to men or to older or more disad-
vantaged populations. However, the study shows that DESNOS may be pre-
sent and be of concern even in a relatively healthy population and in the
populations in which trauma and psychopathology are more typically inves-
tigated (e.g., Follette et al., 1996; Ford, 1999; McGloin & Widom, 2001;
Stein et al., 1996; van der Kolk et al., 1996; Zlotnick et al., 2001).
Replication of the findings concerning DESNOS and trauma exposure is
warranted with other apparently psychologically healthy individuals for whom
stress reactivity may lead to impaired functioning (e.g., medically compro-
mised individuals; Schnurr & Green, 2004).
In conclusion, it appears that interpersonal trauma—and particularly
childhood and adolescent abuse—place even relatively advantaged and well-
functioning young women at risk for not only PTSD but also for stress-related
impairment in biopsychosocial self-regulation. The hierarchical dose-
response pattern of the relationship among no trauma, single-incident trau-
mas, and abuse with DESNOS severity was independent of other sequelae
of trauma, including PTSD (Cloitre, Scarvalone, & Difede, 1997) or affec-
tive or other anxiety disorders (Stein et al., 1996; Zlotnick et al., 2001).
Therefore, careful health care screening and interventions designed specif-
ically to address the adverse impact of interpersonal trauma in any form and
abuse in particular, and posttraumatic self-dysregulation (e.g., Cloitre, Koenen,
Cohen, & Han, 2002), are important not only with clinical populations but
also as approaches to secondary prevention with relatively low-risk groups
of apparently healthy and high-achieving youths or young adults.
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Julian D. Ford, PhD, is an associate professor in the Department of Psychiatry at the University
of Connecticut School of Medicine. His research interests include the etiology and effects on
physical and mental health and treatment outcome of complex posttraumatic stress disorder.
Patricia Stockton, PhD, is a health services researcher who has conducted studies of the
prevalence and treatment of mental disorders in community-based populations in both the
United Kingdom and the United States. As research assistant professor in the Division of
Psychosocial Research, Department of Psychiatry, Georgetown University Medical Center,
her recent work has focused on studies of traumatic stress in nonclinical populations and the
management of depression by community-based psychiatrists.
Stacey Kaltman is an assistant professor in the Department of Psychiatry, Georgetown
University School of Medicine. She is a licensed clinical psychologist and trauma researcher.
Currently, she is the co-PI of an National Institute of Mental Health-funded grant addressing
the development and evaluation of a novel posttraumatic stress disorder intervention for low-
income battered women.
Bonnie L. Green, PhD, is professor of psychiatry and director of research in the Department
of Psychiatry at Georgetown University Medical School in Washington, DC. Her recent focus
is the mental health needs of poor women with trauma histories who obtain health care in
primary care settings serving low-income patients.
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