Evidence for a Dissociative Subtype
of Post-Traumatic Stress Disorder
Childhood Sexual Abuse Survivors
Karni Ginzburg, PhD
Cheryl Koopman, PhD
Lisa D. Butler, PhD
Oxana Palesh, PhD
Helena C. Kraemer, PhD
Catherine C. Classen, PhD
David Spiegel, MD
ABSTRACT. This study examined evidence for a dissociative subtype
therapy for childhood sexual abuse (CSA). One hundred and twenty-two
Karni Ginzburg is affiliated with the Bob Shappel School of Social Work, Tel Aviv
University, Tel Aviv, Israel.
Cheryl Koopman, Lisa D. Butler, Oxana Palesh, Helena C. Kraemer, and David
Spiegel are affiliated with the Department of Psychiatry and Behavioral Sciences,
Stanford University School of Medicine, Stanford, CA.
Catherine C. Classen is affiliated with Women’s College of Ambulatory Care Cen-
tre, Toronto, Canada.
Address correspondence to: Karni Ginzburg, The Bob Shapell School of Social
Work, Tel Aviv University, Tel Aviv 69978, Israel (E-mail: firstname.lastname@example.org).
The authors express their gratitude to Charles R. Marmar, Lori Peterson, Helen
Marlo, Rashi Aggarwal, Courtenay Cavanaugh, Renee Schneider, Ruth Nevo, Nadia
This study was funded by a grant from the National Institute of Mental Health, MH
R01 # 1RO1MH60556 with David Spiegel, as Principal Investigator.
Journal of Trauma & Dissociation, Vol. 7(2) 2006
Available online at http://www.haworthpress.com/web/JTD
© 2006 by The Haworth Press, Inc. All rights reserved.
women seeking treatment for CSA completed a battery of questionnaires
assessing PTSD, dissociative symptoms, and child maltreatment. Using
signal detection analysis, we identified high and low dissociation PTSD
subgroups. A constellation of three PTSD symptoms–hypervigilance,
sense of foreshortened future, and sleep difficulties–discriminated be-
tween these two subgroups (OR = 8.15). Further evidence was provided
by the finding of a nonlinear relationship between severity of childhood
maltreatment and dissociation in the women with PTSD. These results
provide support for a dissociative subtype of PTSD that may stem from
more severe childhood experiences of neglect and abuse. [Article copies
available for a fee from The Haworth Document Delivery Service: 1-800-
HAWORTH. E-mail address: <docdelivery@haworthpress. com> Website:
KEYWORDS. Post-traumatic stress disorder, dissociation, subtype,
sexual abuse, child maltreatment
Although post-traumatic stress disorder (PTSD) is currently classi-
fied by the DSM-IV (APA, 1994) as an anxiety disorder, some re-
searchers have proposed that PTSD is, in its essence, a dissociative
disorder (e.g., Braun, 1988; Butler, Duran, Jasiukaitis, Koopman &
Spiegel, 1996; Spiegel, 1988; van der Hart, Nijenhuis, Steele & Brown,
2004; van der Kolk & Fisler, 1995; reviewed in Ginzburg, Butler,
as reflecting a structural separation of mental processes, resulting from
the trauma victim’s dissociation of consciousness from the immediate
painful traumatic event (Spiegel, 1988). This dissociation prevents the
tion that is manifested in the symptomatology of the disorder (Spiegel,
1988). According to this perspective, intrusive PTSD symptoms are
sensations, emotions and memory fragments of the traumatic experi-
avoidance of PTSD symptoms can be classified as dissociative: amne-
sia for an important aspect of the trauma, diminished interest in signifi-
cant activities, detachment from others, and a restricted range of affect
may all represent a dissociative compartmentalization of experience or
emotional response (Butler et al., 1996). Finally, hyperarousal PTSD
symptoms (i.e., hypervigilance, exaggerated startle, sleep disturbance,
8 JOURNAL OF TRAUMA & DISSOCIATION
the dissociated fixed memories. This perspective contributed to the in-
clusion of dissociative symptoms in the DSM-IV’s diagnosis of acute
stress disorder (Cardeña, Lewis-Fernández, Beahr, Pakianathan &
Nonetheless, other researchers continue to emphasize anxiety symp-
toms as essential to PTSD (e.g., Marshall, Spitzer & Liebowitz, 1999;
Tampke & Irwin, 1999; Zoellner, Jaycox, Watlington & Foa, 2003),
leaving the controversy regarding the centrality of the dissociative
symptoms in PTSD unresolved.
A third perspective has been offered by Bremner (1999) who, how-
ever, proposed that there may be two types of PTSD differentiated
by the prominence of dissociative symptoms. The possibility of a dis-
sociative subtype of PTSD deserves investigation because it raises
questions aboutpossible etiologicaldifferencesthatmayilluminatetra-
umatogenic processes and clarify treatment decisions about pharmaco-
logic and psychotherapeutic interventions. By utilizing an exploratory
approach that examines the presentation of PTSD symptoms, as well as
history of childhood maltreatment, in a sample of help-seeking child-
hood sexual abuse (CSA) survivors, the current study evaluates evi-
dence for a dissociative subtype of PTSD.
EVIDENCE FOR THE DISSOCIATIVE SUBTYPE OF PTSD
Empirical support for a dissociative subtype of PTSD is suggested
by the findings of a number of researchers. Yehuda and her colleagues
of the subjects with PTSD had high levels of dissociation. The level of
dissociation among the other subjects with PTSD was similar to that of
Holocaust survivors without PTSD. Similar findings have been re-
portedamongVietnamveteranswithPTSD (Bremneretal.,1992). Ad-
ditionally, Putnam et al. (1996), examining a large clinical population,
found that those with PTSD were divisible into two equal subgroups–
the first characterizedby high dissociation, and the second by moderate
level dissociative symptoms.
Physiologicalstudies of PTSD also provide evidenceconsistent with
the possibility of PTSD subtyping based on dissociative symptoms.
A small but growing literature suggests that among those with PTSD,
those who experience greater dissociative symptoms may have some-
what different autonomic responses from those who experience fewer
Ginzburg et al.9
dissociative symptoms. For example, in one recent laboratory study
conducted with rape survivors within two weeks of the rape, among the
women with PTSD, those who reported high levels of peritraumatic
dissociation during their rape experience were characterized by sup-
pression of autonomic response during exposure to trauma-related
increased arousal, reflected by increase in skin conductance and heart
rate (Griffin, Resick & Mechanic, 1997). In another study, which fo-
cused on changes in salivary cortisol following a similar stressful inter-
view among adult women CSA survivors with PTSD, the evidence
suggested a delayed increase in arousal among women who experi-
enced high levels of dissociation. Specifically, that study found that the
women, who reported high levels compared with those reporting low
levels of acute dissociative symptoms following stressful life events in
the previous month, had significantly greater increases in salivary
cortisol 24 hours after the stressful interview (Koopman et al., 2003).
There is also evidence of psychophysiological differences being as-
sociated with levels of dissociative symptoms among delinquent ado-
youths with higher levels of dissociative symptoms, compared with
those with lower levels, experienced significantly lower mean heart
rates in response to a stressful interview. Similarly, Lanius et al. (2001,
2002) demonstrated that among persons with PTSD for sexual abuse or
ciation to script-driven imagery showed no increase in heart rate in
response to recalling a traumatic memory, whereas those with lower
levels of dissociation responded with increased heart rates during this
It is noteworthy that these findings of a blunted autonomic response
in PTSD participants with dissociation, including those in the study of
rape survivors (Griffin et al., 1997), conflict with the general findings
stress, such as increases in heart rate in response to sudden, loud tones
(Orr et al., 2003) or reliving of a self-chosen anger memory (Beckham
et al., 2002). Furthermore, the delayed increase in cortisol found in the
Koopman et al. (2003) study among the women with PTSD who re-
ported high acute dissociative symptoms suggests that the patterns
of arousal that distinguish high from low levels of dissociative symp-
toms may change course over time following a stressor. In summary,
although preliminary, the evidence of several studies on physiological
10 JOURNAL OF TRAUMA & DISSOCIATION
differences related to dissociative symptoms is consistent with a
possible dissociative subtype of PTSD.
While the determinants of different possible PTSD subtypes have
abuse might be a risk factor for a dissociative subtype of PTSD. This
suggestion accords with evidence for complex PTSD, a condition that
and in which dissociative phenomena are central (Herman, 1992). A
closely linked but somewhat distinctive etiological interpretation is
suggested by the research of Nash and colleagues (Nash, Hulsey, Sex-
ton, Harralson & Lambert, 1993), who concluded that dissociation
pathology than by the sexual abuse per se. Regardless of whether a
dissociative subtype is linked either to childhood abuse or to the more
inclusive stressful conditions associated with family pathology, it sug-
biological, or both–to early and highly stressful life experiences.
THE PRESENT STUDY
The first goal of this study was to determine whether there was evi-
dence for a dissociative subtype of PTSD by utilizing an exploratory
approach. We drew upon a model for establishing the validity of dia-
gnostic subtypes developed by Robins and Guze (1989). They stipulate
scribe the subtype with symptoms, epidemiological data, and risk fac-
tors. Therefore, to support the existence of a dissociative subtype of
PTSD, specific differentiating factors would need to be identified, with
the first step being exploration of symptomatic expression in PTSD.
Therefore, in the present study, after distinguishing between two sub-
groups of PTSD according to their level of dissociation, we examined
whether there were PTSD symptoms that discriminated between these
dissociative and non-dissociative subtypes of PTSD.
severity of childhood maltreatment and the dissociative subtype of
PTSD. More specifically, we examined whether childhood maltreat-
ment is a risk factor for the dissociative PTSD subtype in CSA survi-
clinically describe the disorder considered as a potential subtype by ex-
amining for possible precipitating factors.
Ginzburg et al. 11
Participants and Procedure
This study used baseline (pre-randomization) data collected from
women recruited to participate in a clinical trial evaluating the effec-
factors (i.e., sexual revictimization, high-risk sexual behavior, or drug/
alcohol abuse or dependence).
Participants were recruited through newspaper and radio adver-
tisements, flyers posted in the community and local community orga-
nizations. Initial contact was made with 1,431 women. Following
screening, 171 women met all of the following study inclusion crite-
ria: 18 years of age or older, English-speaking, at least one explicit
memory of sexual abuse that involved genital or anal contact, at least
one sexual abuse event that occurred when the survivor was between
4 and 17 years and the perpetrator at least 5 years older than the
survivor. The CSA survivor agreed that she was capable of talking
about the abuse in a group therapy situation, and she signed an
informed consent statement. Additionally, at least one of the follow-
ing HIV risk factors was present within the previous year: sexual
revictimization, high-risk sexual behavior, or meeting DSM-IV crite-
ria for substance abuse or dependence. Because the study was part of a
clinical trial evaluating the effectiveness of group therapy, exclusion
propriate for group therapy for CSA survivors. More specifically, the
exclusion criteria included any of the following characteristics: diag-
nosis of schizophrenia or other psychotic disorders, dementia, delir-
ium, amnestic or other cognitive disorders, the CSA described as a
ritual, currently engaged in psychotherapy, suicidal activity within
one month prior to the screening, or being judged as currently unable
to benefit from, or inappropriate for, group therapy. Of the 171 study
participants, 122 provided complete data on the set of questionnaires
that are included in the present analyses. Each participant received
$75 for completing the baseline assessment.
Examination of the background characteristics of the present study
sample compared with the larger original sample indicated that the two
groups did not differ in age, ethnic background, education, income,
employment, relationship status, sexual orientation, addiction, sexual
revictimization, or practice of unsafe sex. The two groups also did not
differ in the age of onset of the abuse or in their relationship with the
12 JOURNAL OF TRAUMA & DISSOCIATION
abusers. Finally, there were no group differences in severity of PTSD.
characteristics of the present study sample.
The Post-Traumatic Stress Disorder Checklist–Specific (PCL-S;
Weathers & Ford, 1996) is a self-report measure consisting of 17 items
directly adapted from DSM-IV PTSD criteria B-D (APA, 1994). Sub-
jects are asked to indicate on a 5-point Likert type scale the extent to
which they experienced each symptom in the past month. Based on
DSM-IV criteria (APA, 1994), subjects were designated as having
at least one intrusive symptom, at least three avoidant symptoms, and
at least two hyperarousal symptoms (Smith, Egert, Winkel& Jacobson,
2002). The PCL has good validity and reliability (Weathers, Litz,
Herman, Huska & Keane, 1993; Weathers & Ford, 1996). Internal con-
sistency for the current sample was satisfactory (Cronbach’s alpha =
A global tendency to experience dissociation was assessed by three
self-report measures that tapped various aspects of dissociation. The
Peritraumatic Dissociative Experiences Questionnaire (PDEQ)–Self
experiences that occurred during or in the immediate aftermath of their
CSA experience. This measure consisted of 10 items. Participants were
asked to rate each itemon a 5-point scale to indicatethe extent to which
all” to “extremely true.” This measure was found to have good validity
and reliability (Marmar et al., 1997). The Cronbach’s alpha for the cur-
rent sample was high (0.89), indicating satisfactory internal consis-
The Stanford Acute Stress Reaction Questionnaire (SASRQ)–Dis-
sociation Subscale (Cardeña, Koopman, Classen, Waelde & Spiegel,
2000) assessed acute dissociation symptoms in response to a stressful
event experienced in the previous month. The SASRQ dissociative
symptom scale included items that measure a subjective sense of
Ginzburg et al.13
14 JOURNAL OF TRAUMA & DISSOCIATION
TABLE 1. Characteristics of the Sample (N = 122)1
Age Relational status
Unsafe sex1, 2
Number of abuse episodes
Age of first episode
Relation to abuser/s3
Refuse to answer
1There is some missing data on the sociodemographic variables.
2During the previous 12 months.
3Some of the respondents had more that one abuser.
detachment, reduction in awareness, derealization, depersonalization,
and dissociative amnesia. Participants were asked to use 0-5 point
scale to characterize their experience. A total dissociation score was
calculated by summing the scores on the 10 dissociative items. The
SASRQ has demonstrated acceptable reliability and validity in many
studies and diverse samples (Cardeña et al., 2000). Cronbach’s alpha
for the current sample was 0.84, indicating satisfactory internal con-
The Multiscale Dissociation Inventory (MDI; Briere, 2002). The
MDI, developed by Briere (2002) as a relatively new, 30-item mea-
sure, assessed six different types of dissociative experiences: disen-
gagement, depersonalization, derealization, emotional constriction,
memory disturbance, and identity dissociation. The measure used a
5-point Likert type scale to assess the frequency of dissociative expe-
riences in the past month, with 1 = “Never,” 2 = “Once or twice,” 3 =
“Sometimes,” 4 = “Often,” and 5 = “Very often.” The subscales are
calculated by summing the scores on the subscales’ respective items.
lations and has been shown to have good sensitivity and specificity in
correctly identifying participants with a dissociative identity diagno-
sis (Briere, 2002). Cronbach’s alphas in the current sample were
bance to 0.93 for emotional constriction.
To create a global dissociation score, we performed a principal
components analysis on all dissociation measure scores. This analysis
on this factor, suggesting that it represents a reliable index of a general
dissociation tendency (factor loadings: peritraumatic dissociation =
0.53, acute dissociation = 0.62, disengagement = 0.71, depersonaliza-
disturbance = 0.83, and identity dissociation = 0.75). Based on this fac-
tor, each subject received a global dissociation score. These scores
ranged from ?1.49 to 3.76 (M = 0.00, SD = 1.00).
Childhood maltreatment was assessed by The Child Trauma Ques-
tionnaire (CTQ; Scher, Stein, Asmundson, McCreary & Forde, 2001).
This is a 28-item self-report measure designed to assess childhood
maltreatment history. The responses on the CTQ items had a 5-point
Ginzburg et al. 15
CTQ was comprised of five scales: Emotional Abuse, Physical Abuse,
Sexual Abuse, Emotional Neglect and Physical Neglect. Because all
participants in the present study had been sexually abused, the Sexual
Abuse Scale was not used in this analysis. The CTQ has been demon-
strated to have strong psychometric properties in both clinical and
community samples (Scher et al., 2001).
To create a global childhood maltreatment score, a principal compo-
nents analysis was performed on the four CTQ subscales. This analysis
yielded one factor, accounting for 67% of the total variance. All of the
maltreatment measure scores loaded highly on the factor, suggesting
that this is a reliable index for childhood maltreatment (factor loadings
ranged between 0.79 and 0.88). Based on this factor, each participant
who metcriteriafor PTSD receiveda globalmaltreatmentscore thatre-
flectedthe severity of her childhood maltreatment.These scores ranged
from ?1.92 to 1.99 (M = 0.00, SD = 1.00).
The first section of the results is based on a series of signal detection
analyses, using the receiver operator characteristics (ROC) technique
(Kraemer, 1992). This analytic approach is exploratory, i.e., it relies on
hypothesis-generating techniques, rather than being a method of hy-
pothesis testing. This analysis examines whether a sample can be di-
vided into two groups, according to a criterion, or “gold standard,” by
using a predicting variable or set of variables. More specifically, the
ROC analysis searches all the predictor variables, yields those predic-
cutpoint at which each predictor makes this distinction. This cutpoint is
tor its sensitivity and specificity against the outcome. Then, based on
a predetermined balance between false positives and false negatives
(in this study, equal weight was given to false positives and negatives)
see Agras et al., 2000; Kiernan, Kraemer, Winkleby, King & Taylor,
2001; Kraemer, 1992.)
into two subgroups according to the level of dissociation. This analysis
identified a particular cutpoint for the global dissociation variable, in
which its sensitivity and specificity in predicting the presence or ab-
16 JOURNAL OF TRAUMA & DISSOCIATION
sence of PTSD were at their optimal levels. Based on this cutpoint, the
PTSD group was divided into high and low dissociation subgroups.
A second signal detection analysis was then conducted to examine
whether high and low dissociation PTSD subjects could be distin-
guished according to the level of each of the PTSD symptoms.
To examine whether childhood maltreatment could be considered a
tionship was investigated by dividing the PTSD group into two sub-
groups using the median score of childhood maltreatment, and then
computing the Spearman correlations between childhood maltreatment
and dissociation within each subgroup.
Distinguishing PTSD vs. Non-PTSD Using Dissociation Scores
To examine the relationship between PTSD and global dissociation,
we divided the sample according to whether or not participants met the
criteria for PTSD. Sixty-six (54%) participants screened positively for
PTSD, while 56 (46%) did not.
A signal detection analysis was conducted within the entire sample
with PTSD as the “gold standard,” i.e., the outcome criterion, and
global dissociation as the predictor. The signal detection procedure
identified a cutpoint global dissociation score of higher than or equal to
0.20, at which the specificity and sensitivity of the global dissociation
score in predicting PTSD were optimal. At this cutpoint, the PTSD
group included 77% of the high dissociation subgroup and 30% of the
low dissociation subgroup, and the non-PTSD group included 23% of
the high dissociation subgroup and 70% of the low dissociation sub-
group (?2= 27.61, p < 0.001).
Distinguishing a Dissociative vs. Non-Dissociative PTSD Subtype
sociation subjects could be distinguished according to the level of spe-
cific PTSD symptoms, using a second signal detection analysis. This
of hypervigilance, as 83% of women with a hypervigilance score of
greater than or equal to 4 belonged to the high dissociation subgroup,
compared to only 50% of the women with hypervigilance level lower
Ginzburg et al. 17
than 4 (odds ratio = 4.88, Kappa = 0.35, ?2= 8.28, p < 0.01). Further
analyses did not produce any other significant predictor.
However, further examination of the results of the signal detection
indicated that two other PTSD symptoms, namely a sense of foreshort-
ened future and difficulties in falling or staying asleep, had high Kappa
values (0.33, 0.32), althoughthey were not identifiedas significantpre-
dictors. Spearman correlations supported our speculation that the lack
lations between these symptoms and hypervigilance (for sense of fore-
r = 0.34).
Consequently, another signal detection analysis was conducted in
which an 18th (composite symptom) score–composed of the mean of
the three symptoms (hypervigilance, sense of foreshortened future, and
difficulties in falling or staying asleep)–was added to the 17 PTSD
symptoms in the previous analysis. This new analysis found that the
best predictor of high dissociation was the mean score of these three
symptoms, with 87.5% of women with a score greater than or equal to
3.33 belonging to the high dissociation subgroup, compared to only
46.2% of the women with a score lower than 3.33 (odds ratio = 8.15,
Kappa = 0.43, ?2= 13.14, p < 0.001). Further analysis did not produce
any other significant predictor. Of note that the combined score
replaced the hypervigilance score.
Figure 1 presents the cutpoints of the PTSD symptoms, i.e., those
with the optimal specificity and sensitivity, in distinguishing between
high and low dissociative PTSD. Nine symptoms (e.g., loss of interest
in various activities, concentration difficulties, feeling upset when re-
minded of the trauma) have cutpoints with negative values, indicating
that lower levels of these symptoms characterize the high dissociation
symptoms are relativelylow, so none of thesesymptoms can be consid-
ered to contributesignificantlyto the predictionof the high dissociative
Dissociation and Childhood Maltreatment in CSA Survivors
sociationand childhoodmaltreatmentamong PTSD subjects. To exam-
ine whether a nonlinear association exists between the two variables,
the sample was divided into high and low childhood maltreatment, ac-
18 JOURNAL OF TRAUMA & DISSOCIATION
Ginzburg et al.19
FIGURE 1. Optimal Sensitivity and Specificity of PTSD Symptoms as Predic-
tors of Dissociative Subtype of PTSD
The line represents the random prediction.
The triangles represent cutpoints with positive values.
The circles represent cutpoints with negative values.
1. Repeateddisturbingmemories,thoughts or imagesof the stressfulexperience(kappa=0.11; X2=1.00);
2. Repeated disturbing dreams of the stressful experience (kappa = 0.17; X2= 2.54); 3. Acting or feeling as
if the experiences were happening again (kappa = 0.18; X2= 2.38); 4. Feeling very upset when something
reminds the experiences (kappa = 0.13; X2= 1.19); 5. Having physical reactions when something reminds
the experiences (kappa = 0.12; X2= 0.92); 6. Avoiding thinking or talking about the stressful experience
(kappa=0.26; X2=4.47); 7. Avoidingactivitiesor situationsbecausetheyremindthe experiences(kappa=
0.23; X2= 4.57); 8. Trouble remembering important parts of the experience (kappa = 0.09; X2= 0.86); 9.
Loss of interest in various activities (kappa = 0.02; X2= 0.04); 10. Feeling distant or cut off from others
(kappa = 0.15; X2= 1.52); 11. Feeling emotionally numb (kappa = 0.17; X2= 2.30); 12. Sense of a fore-
shortened future (kappa = 0.34; X2= 7.40); 13. Trouble falling or staying asleep (kappa = 0.32; X2= 7.38);
14. Irritability or angry outburst (kappa = 0.16; X2= 4.63); 15. Concentration difficulties (kappa = 0.07; X2=
1.05); 16. Hypervigilance (kappa = 0.35; X2= 8.28); 17. Exaggerated startle response (kappa = 0.11; X2=
1.10); 18. Mean score of hypervigilance, sense of a foreshortened future, and trouble falling or staying
asleep (kappa = 0.43; X2= 13.14).
cording the median score. Spearman correlations supported this pattern
to dissociation (r = 0.01, p = 0.98), though there was a significant posi-
tive association between extent of maltreatmentand degree of dissocia-
tion for higher levels of maltreatment (r = 0.47, p = 0.01).
This study provides empiricalsupportfor the hypothesis thatthere is a
of PTSD in which dissociative symptoms are not prominent. The results
show that a constellation of several specific symptoms, including high
hypervigilance, a sense of a foreshortened future, and sleep difficulties,
differentiates highandlow dissociationPTSD subgroups.Suchevidence
in itself does not prove the existence of a dissociative subtype, but pro-
gest that among CSA survivors with PTSD, there is a threshold level of
childhood maltreatment that is associated with experiencing high levels
of dissociation, suggesting that higher levels of childhood maltreatment
may be a risk factor for a dissociative subtype of PTSD among adult sur-
20 JOURNAL OF TRAUMA & DISSOCIATION
–2.0–1.5 –1.0–0.5 0.00.0 0.5 1.01.5 2.0
FIGURE 2. Raw Dissociation Scores According to Childhood Maltreatment
The black vertical line represents the median score of childhood maltreatment.
The gray lines are the regression curves, under and below the median.
Of note, two of the discriminatingPTSD symptoms are hyperarousal
symptoms. At first glance, it may seem that this finding conflicts with
reports of suppression of autonomic response in the highly dissociative
subgroup (Griffin et al., 1997; Koopman et al., 2004; Lanius et al.,
2001). However, Griffin et al. (1997) found that high dissociating
women who reacted to trauma-related memories without increasing
jective experiences of hyperarousal. Similarly, among journalists who
witnessed an execution (Freinkel, Koopman & Spiegel, 1994), disso-
ciative symptoms were highly correlated with anxiety/hyperarousal
One possible interpretation of this association is that dissociative ex-
periences may arise in the face of hyperarousal responses to disturbing
stimuli, but because they lack the capability to fully block the experi-
ence of hyperarousal, they co-occur. Alternatively, as suggested by
Noyes andKletti(1977), dissociativeexperiencescanhaveacontradic-
tory relationship in that they are clearly associated with intense anxiety
ety, and therefore of its sources. Thus, this reduced awareness may add
to the physiological effect of trauma-relatedreminders by making them
seem more unbidden and uncontrolled and, therefore, “retraumatizing”
(Butler et al., 1996). This explanation is supported by evidence
(Koopman et al., 2003) that women with PTSD who had high levels of
acute dissociative symptoms also had higher levels of salivary cortisol
24 hours following a stressful interview. These findings may reflectde-
layed hyper-reactivity, a rebound effect of the dissociation during the
symptoms, possibly through biological mechanisms such as alterations
in thalamic activation that are associated with hyperarousal, which
Krystal and colleagues (Krystal, Bennett, Bremner, Southwick &
Charney, 1995) have suggested may underlie dissociative symptoms.
A second piece of evidencefrom the present study that provides sup-
a monotonic but nonlinear relationship in which greater dissociative
symptoms are associated with greater levels of severity of childhood
maltreatment. Similar to findings reported by Litwin and Cardeña
(2000), this nonlinear relation may explain the inconsistent reports re-
garding the relationship between childhood trauma and dissociation,
with some studies having found a positive association (e.g., Saxe et al.,
Ginzburg et al. 21
1993), while others have not (e.g., Langeland, Draijer & van der Brink,
Traumatic experiences during childhood, when the tendency to dis-
sociate is normally at its peak (Steiner, Carrion, Plattner & Koopman,
2003), may prompt the persistent use of the defense of dissociation to
ward off conscious awareness of the experience or other aversive
trauma sequelae. Growing up in a chaotic, violent, or neglectful envi-
ronment may result in the development of an overlearned, relatively
automatic, dissociative response to difficult and stressful situations.
tom development proposes that traumatic experience is particularly
likely to lead to dissociative symptoms among those who are more
risk factor for the dissociative subtype of PTSD. This proposal was
recently supported by findings indicating an association between hyp-
notizability and the development of acute stress disorder (Bryant et al.,
2001), along with earlier findings linking higher hypnotizability with
PTSD (Spiegel, Hunt & Dondershine, 1988; Stutman & Bliss, 1985).
among adult survivors with PTSD who appear to have a dissociative
subtype of PTSD.
Hyer and colleagues (Hyer, Albrecht, Boudewyns, Woods &
Brandsma, 1993) have suggested that the level of dissociation in PTSD
reflects the severity of the PTSD, which also implies that high disso-
ciative PTSD in the present sample represents more severe PTSD,
rather than a specific subtype of PTSD. However, this view was not
supported by our finding that 23% of the high dissociation subgroup
was classified as non-PTSD.
Findings from the present study may be viewed as complementing
and extending the previous body of work on the specific pattern of
bid conditions and associated features of PTSD, including dissociation
as well as depression, somatization, affect modulation, impaired
schemas, isolation and impaired attachments, substance abuse, suici-
dality, and revictimization (Allen, Coyne & Huntoon, 1998; Herman,
1992; van der Kolk et al., 1996). Van der Hart, Nijenhuis and Steele
PTSD has not received sufficient recognition. Although the other fea-
tures of complex PTSD were not examined in this study, the disso-
ciative subtype of PTSD may be equivalent to complex PTSD.
22 JOURNAL OF TRAUMA & DISSOCIATION
Conceptualizing a single diagnostic entity to describe post-traumatic
reactions across trauma survivors, regardless of the nature of their de-
velopmental experiences or the precipitating trauma, is understandable
as a theoreticalstartingpoint, but perhaps too simplisticto fully charac-
terize the possible sequelae of traumatic experience. It is worth consid-
ering, instead, that PTSD may be similar to other major psychiatric
disorders, such as schizophrenia,bipolardisorder, or depression, where
of physiological substrates and/or correlates (e.g., McGinn, Asnis &
Rubinson, 1996). If thereare distinctsubtypes of PTSD, thentheremay
be important differences in treatment type and dosage indicated for
for trauma survivors. For example, our finding that hyperarousal was
associated with the dissociative subtype of PTSD suggests that some
traditional psychotherapeutic treatments for PTSD, such as flooding
and desensitization, may be less effective for this subtype, potentially
the stimulus and the response (Spiegel, Koopman & Classen, 1994;
Spiegel,Koopman, Cardeña& Classen, 1996). Psychotherapiesaiming
at establishing connections between dissociated elements of the trauma
experience and its aftermath and the physiological arousal symptoms
might be more helpful. The burgeoning literature on the treatment of
complex PTSD may provide the best models of treatment for this
subtype (e.g., Courtois, 2004).
Several methodological limitations may restrict this study’s
generalizability. A sample composed of women seeking treatment for
CSA may not be representative of non-treatment seeking women who
composed of women who volunteer to participate in a clinical trial may
not represent the help-seeking population. Limits to generalizability
maybe also be evidentin thefactthatthesamplewas comprisedof pre-
dominantly educated women with middle to high household incomes.
Additionally, it would have been preferable to assess both PTSD and
dissociation using a structured clinical interview, so as to yield a more
definitiveindicationof PTSD diagnosis in this study. Similarly,several
measures, particularly those assessing childhood maltreatment and
peritraumatic dissociation in childhood, may be subject to the well-
known limitations of retrospective measures, even though they may
reliably reflect the respondents’ current experience.
The findings of this study should be regarded as preliminary and ex-
ploratory; replication with other samples and measures is needed.
Ginzburg et al.23
Further research will be necessary to evaluate evidence addressing the
ity of this proposed dissociative PTSD subtype. These additional
fication and specification of exclusion criteria, longitudinal studies ex-
ploring the course of the condition, research on treatment responses by
subtype, and family studies (1989). Together with the two recent labo-
ratory studies (Griffin et al., 1997; Koopman et al., 2003), the current
findings may be considered a preliminary step toward examining the
validity of a dissociative subtype of PTSD.
Agras, W.S., Crow, S.J., Halmi, K.A., Mitchell, J.E., Wilson, G.T., & Kraemer, H.C.
(2000). Outcome predictors for the cognitive behavior treatment of bulimia
nervosa: Data from a multisite study. American Journal of Psychiatry, 157,
Allen, J.G., Coyne, L., & Huntoon, J. (1998). Complex post-traumatic stress disorder
in women from a psychometricperspective.Journalof PersonalityAssessment,70,
disorders (4th ed). Washington DC: Author.
Beckham, J.C., Vrana, S.R., Barefoot, J.C., Feldman, M.E., Fairbank, J., & Moore,
S.D. (2002). Magnitude and duration of cardiovascular responses to anger in Viet-
nam veterans with and without post-traumatic stress disorder. Journal of Consult-
ing Clinical Psychology, 70, 228-234.
Braun, B.G. (1988). The BASK model of dissociation. Dissociation, 1, 4-23.
we go from here? American Journal of Psychiatry, 156, 349-351.
Bremner, J.D., Southwick, S.M., Brett, E., Fontana, A., Rosenheck, R., & Charney,
D.S. (1992). Dissociation and post-traumatic stress disorder in Vietnam veterans.
American Journal of Psychiatry, 149, 328-332.
Briere, J. (2002). MDI: Multiscale Dissociation Inventory. Professional Manual.
Odessa, FL: Psychological Assessment Resources.
Bryant, R.A., Guthrie, R.M., & Moulds, M.L. (2001). Hypnotizability in acute stress
disorder. American Journal of Psychiatry, 158, 600-604.
Butler, L.D., Duran, R.E.F., Jasiukaitis, P., Koopman, C., & Spiegel, D. (1996).
Hypnotizability and traumatic experience: A diathesis-stress model of dissociative
symptomatology. American Journal of Psychiatry, 153, 42-63.
Butler, L.D., Kaufman, A., Hastings, T.A., Symons, B.K., Chen, X.H., & Spiegel, D.
under conditions of traumatic stress: Theory and supporting evidence. Paper pre-
sented at the annual meeting of the International Society for the Study of Dissocia-
tion, Chicago, IL.
24 JOURNAL OF TRAUMA & DISSOCIATION
Cardeña, E., Koopman, C., Classen, C., Waelde, L.C., & Spiegel, D. (2000).
Psychometric properties of the Stanford Acute Stress Reaction Questionnaire
Cardeña, E., Lewis-Fernández, R., Beahr, D., Pakianathan, I., & Spiegel, D. (1996).
Dissociative disorders. In T.A. Widiger, A.J. Frances, H.J. Pincus, R. Ross, M.B.
First, & W.W. Davis (Eds.) Sourcebook for the DSM-IV. Vol. II (pp. 973-1005),
Washington, DC: American Psychiatric Press.
Courtois, C.A. (2004). Complex trauma, complex reactions: Assessment and treat-
ment. Psychotherapy: Theory, Research, Practice, Training, 41(4), 412-425.
Freinkel, A., Koopman, C., & Spiegel, D. (1994). Dissociative symptoms in media
eyewitnesses of an execution. American Journal of Psychiatry, 151, 1335-1339.
Dissociation and the Dissociative Disorders–DSM-V and Beyond. Chicago: Inter-
national Society for the Study of Dissociation.
Griffin, M.G., Resick, P.A., & Mechanic, M.B. (1997). Objective assessment of
peritraumatic dissociation: Psychophysiological indicators. American Journal of
Psychiatry, 154, 1081-1088.
Herman, J.L. (1992). Trauma and Recovery, New York: Basic Books.
Hyer, L.A., Albrecht, W., Boudewyns, P.A., Woods, M.G., & Brandsma, J. (1993).
Dissociative experiences of Vietnam veterans with chronic post-traumatic stress
disorder. Psychological Reports, 73, 519-530.
Kiernan, M., Kraemer, H.C., Winkleby, M.A., King, A.C., & Taylor, C.B. (2001). Do
logistic regression and signal detection identify different subgroups at risk? Impli-
cations for the design of tailored interventions. Psychological Methods, 6, 35-48.
Relationships of dissociation and childhood abuse and neglect with heart rate in
delinquent adolescents. Journal of Traumatic Stress, 17, 47-54.
Koopman, C.,Sephton, S., Abercrombie, H.C.,Classen,C.,Butler, L.D.,Gore-Felton,
C., Borggrefe, A., & Spiegel, D. (2003). Dissociative symptoms and cortisol re-
sponses to recounting traumatic experiences among childhood sexual abuse survi-
vors with PTSD. Journal of Trauma and Dissociation, 4(4), 29-46.
Kraemer, H.C. (1992). Evaluating medical tests: Objective and quantitative guide-
lines. Newbury Park: Sage.
Krystal,J.H.,Bennett,A.L.,Bremner, J.D.,Southwick, S.M.,& Charney,D.S.(1995).
Towards a cognitive neuroscience of dissociation and altered memory functions in
post-traumatic stress disorder, in M. J. Friedman, D.S. Charney, A.Y. Deutsch
tions to PTSD (pp. 239-268), New York: Raven Press.
Langeland, W., Draijer, N., & van der Brink, W. (2002). Trauma and dissociation in
treatment-seeking alcoholics: Towards a resolution of inconsistent findings. Com-
prehensive Psychiatry, 43, 195-203.
Lanius, R.A., Williamson, P.C., Boksman, K., Densmore, M., Gupta, M., Neufeld,
R.W.J., Gati, J.S., & Menon, R.S. (2002). Brain activation during script-driven im-
Ginzburg et al.25
agery induced dissociative responses in PTSD: A functional magnetic resonance
imaging investigation. Biological Psychiatry, 52, 305-311.
Lanius, R.A., Williamson, P.C., Densmore, M., Boksman, K., Gupta, M.A., Neufeld,
R.W.,Gati,J.S.,& Menon,R.S.(2001). Neural correlates of traumatic memories in
post-traumatic stress disorder: A functional MRI investigation. American Journal
of Psychiatry, 158, 1920-1922.
Litwin, R., & Cardeña, E. (2000). Demographic and seizure variables, but not
hypnotizability or dissociation, differentiated psychogenic from organic seizures.
Journal of Trauma and Dissociation, 1 (4), 99-122.
Marmar, C.R., Weiss, D.S., & Metzler, T.J. (1997). The peritraumatic dissociative ex-
cal Trauma and PTSD (pp. 412-428). New York: Guilford Press.
Marshall,R.D.,Spitzer, R.,& Liebowitz, M.R.(1999). Reviewand critique of the new
DSM-IV diagnosis of acute stress disorder. American Journal of Psychiatry, 156,
McGinn, L.K., Asnis, G.M., & Rubinson, E. (1996). Biological and clinical validation
of atypical depression. Psychiatric Research, 60, 191-198.
Nash, M.R., Hulsey, T.L., Sexton, M.C., Harralson, T.L., & Lambert, W. (1993).
Long-term sequelae of childhood sexual abuse: Perceived family environment,
psychopathology, and dissociation. Journal of Consulting Clinical Psychology, 61,
Noyes, R., & Kletti, R. (1977). Depersonilization in response to life-threatening dan-
ger. Comprehensive Psychiatry, 18, 375-384.
Orr, S.P., Metzger, L.J., Lasko, N.B., Macklin, M.L., Hu, F.B., Shalev, A.Y., &
Pitman, R.K. (2003). Physiologic responses to sudden, loud tones in monozygotic
twins discordant for combat exposure: association with post-traumatic stress disor-
der. Archives of General Psychiatry, 60, 283-288.
Putnam, F.W., Carlson, E.B., Ross, C.A., Anderson, G., Clark, P., Torem, M., Bow-
Patterns of dissociationin clinical and nonclinical samples.Journalof Nervousand
Mental Diseases, 184, 673-679.
ity of Psychiatric Diagnosis (pp. 1-7), New York: Raven Press.
Saxe, G.N., van der Kolk, B.A., Berkowitz, R., Chinman, G., Hall, K., Lieberg, G., &
Schwartz, J. (1993). Dissociative disorders in psychiatric patients. American Jour-
nal of Psychiatry,150, 1037-1042.
Scher, C., Stein, M., Asmundson, G., McCreary, D., & Forde, D. (2001). The child-
hood trauma questionnaire in a community sample: Psychometric properties and
normative data. Journal of Traumatic Stress, 14, 843-857.
experience in persons with HIV/AIDS. Pain, 98, 9-17.
Spiegel, D. (1988). Dissociation and hypnosis in post-traumatic stress disorder. Jour-
nal of Traumatic Stress, 1, 17-34.
post-traumatic stress disorder. American Journal of Psychiatry, 145, 301-305.
26 JOURNAL OF TRAUMA & DISSOCIATION
Spiegel, D., Koopman, C., & Classen, C.C. (1994). Acute stress disorder and dissocia- Download full-text
tion. Australian Journal of Clinical and Experimental Hypnosis, 22, 11-23.
Spiegel, D., Koopman, C., Cardeña, E., & Classen, C.C. (1996). Dissociative Symp-
toms in the diagnosisof acute stressdisorder. In L.K.,Michelson& W.J.Ray (eds.)
Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives (pp.
367-380). New York, Plenum Press.
Steiner,H.,Carrion,V.,Plattner,B.& Koopman,C.(2003). Dissociativesymptomsin
post-traumatic stress disorder; Diagnosis and treatment. Child and Adolescent Psy-
chiatric Clinics in North America, 12, 231-249.
imagery. American Journal of Psychiatry, 142, 741-743.
Tampke, A.K., & Irwin, H.J. (1999). Dissociative processes and symptoms of post-
traumatic stress in Vietnam veterans. Journal of Traumatic Stress, 12, 725-738.
van der Hart, O., Nijenhuis, E., & Steele, K. (2005). Dissociation: An insufficiently
recognized feature of complex post-traumatic stressdisorder. Journal of Traumatic
Stress, 18, 413-423.
van der Hart, O., Nijenhuis, E., Steele, K., & Brown, D. (2004). Trauma-related disso-
ciation: Conceptual clarity lost and found. Australian and New Zealand Journal of
Psychiatry, 38, 906-914.
van der Kolk, B.A., Brown, P. & van der Hart, O. (1989). Pierre Janet on post-
traumatic stress. Journal of Traumatic Stress, 2, 365-378.
van der Kolk, B.A., & Fisler, R. (1995). Dissociation and the fragmentary nature of
traumatic memories: overview and exploratory study. Journal of Traumatic Stress,
van der Kolk, B.A., Pelcovitz, D., Roth, S., Mandel, F.S., McFarlane, A., & Herman,
J.L.(1996). Dissociation,somatization,and affect dysregulation: the complexity of
adaptation to trauma. American Journal of Psychiatry, 153, 83-93.
tion in psychological trauma. American Journal of Psychiatry, 146, 1530-1540.
Weathers, F., & Ford, J. (1996). Psychometric review of PTSD Checklist (PCL-C,
PCL-S, PCL-M, PCL-RP). In B. Stamm (e). Measurement of Stress, Trauma, and
Adaptation. Lutherville, MD: Sidran Press.
(PCL): Reliability, validity and diagnostic utility. Paper presented at: International
Society for Traumatic Stress Studies, San Antonio, Texas.
Yehuda, R., Elkin, A., Binder-Brynes, K., Kahana, B., Southwick, S.M., Schmeidler,
J., & Giller, E.L. (1996). Dissociation in aging Holocaust survivors. American
Journal of Psychiatry, 153, 935-940.
Zoellner, L.A., Jaycox, L.A., Watlington, C.G., & Foa, E.B. (2003). Are the
dissociative criteria in ASD useful? Journal of Traumatic Stress, 16, 341-350.
Ginzburg et al.27