Publications of Interest

Publications of Interest – Recent Open Access Articles on Trauma and Dissociation


The topic of ISSTD’s June 2022 publications of interests includes recent (2021 or later) and compelling open access articles that relate to the study of trauma and dissociation. Our aim this month is to provide articles that all our members can access and utilize to inform their practice and educate clients.

Oprel, D. A. C., Hoeboer, C. M., Schoorl, M., Kleine, R. A. de, Cloitre, M., Wigard, I. G., van Minnen, A., & van der Does, W. (2021). Effect of Prolonged Exposure, intensified Prolonged Exposure and STAIR+Prolonged Exposure in patients with PTSD related to childhood abuse: A randomized controlled trial. European Journal of Psychotraumatology12(1), 1851511.

Background The effectiveness of evidence-based treatments for CA-PTSD versus PTSD is unclear. This study aimed to investigate the effectiveness of three variants of prolonged exposure therapy.

Methods The authors recruited adults with CA-PTSD. Participants were randomly assigned to Prolonged Exposure (PE; 16 sessions in 16 weeks), intensified Prolonged Exposure (iPE; 12 sessions in 4 weeks followed by 2 booster sessions) or a phase-based treatment, in which 8 sessions of PE were preceded by 8 sessions of Skills Training in Affective and Interpersonal Regulation (STAIR+PE; 16 sessions in 16 weeks). Assessments took place in week 0 (baseline), week 4, week 8, week 16 (post-treatment) and at a 6-and 12-month follow-up. The primary outcome was clinician-rated PTSD symptom severity.

Results The authors randomly assigned 149 patients to PE (48), iPE (51) or STAIR+PE (50). All treatments resulted in large improvements in clinician assessed and self-reported PTSD symptoms from baseline to 1-year follow-up (Cohen’s d > 1.6), with no significant differences among treatments. iPE led to faster initial symptom reduction than PE for self-report PTSD symptoms (t135 = −2.85, p = .005, d = .49) but not clinician-assessed symptoms (t135 = −1.65, p = .10) and faster initial symptom reduction than STAIR+PE for self-reported (t135 = −4.11, p < .001, d = .71) and clinician-assessed symptoms (t135 = −2.77, p = .006, Cohen’s d = .48) STAIR+PE did not result in significantly more improvement from baseline to 1-year follow-up on the secondary outcome emotion regulation, interpersonal problems and self-esteem compared to PE and iPE. Dropout rates did not differ significantly between conditions.

Conclusions: Variants of exposure therapy are tolerated well and lead to large improvements in patients with CA-PTSD. Intensifying treatment may lead to faster improvement but not to overall better outcomes.

Dimitrova, L., Dean, S., Schlumpf, Y., Vissia, E., Nijenhuis, E., Chatzi, V., Reinders, A. (2021). A neurostructural biomarker of dissociative amnesia: A hippocampal study in dissociative identity disorder. Psychological Medicine, 1-9. doi: 10.1017/S0033291721002154

Background Little is known about the neural correlates of dissociative amnesia, a transdiagnostic symptom mostly present in the dissociative disorders and core characteristic of dissociative identity disorder (DID). Given the vital role of the hippocampus in memory, a prime candidate for investigation is whether total and/or subfield hippocampal volume can serve as biological markers of dissociative amnesia.

Methods A total of 75 women, 32 with DID and 43 matched healthy controls (HC), underwent structural magnetic resonance imaging (MRI). Using Freesurfer (version 6.0), volumes were extracted for bilateral global hippocampus, cornu ammonis (CA) 1–4, the granule cell molecular layer of the dentate gyrus (GC-ML-DG), fimbria, hippocampal−amygdaloid transition area (HATA), parasubiculum, presubiculum and subiculum. Analyses of covariance showed volumetric differences between DID and HC. Partial correlations exhibited relationships between the three factors of the dissociative experience scale scores (dissociative amnesia, absorption, depersonalization/derealization) and traumatization measures with hippocampal global and subfield volumes.

Results Hippocampal volumes were found to be smaller in DID as compared with HC in bilateral global hippocampus and bilateral CA1, right CA4, right GC-ML-DG, and left presubiculum. Dissociative amnesia was the only dissociative symptom that correlated uniquely and significantly with reduced bilateral hippocampal CA1 subfield volumes. Regarding traumatization, only emotional neglect correlated negatively with bilateral global hippocampus, bilateral CA1, CA4 and GC-ML-DG, and right CA3.

Conclusions Authors propose decreased CA1 volume as a biomarker for dissociative amnesia. Authors also propose that traumatization, specifically emotional neglect, is interlinked with dissociative amnesia in having a detrimental effect on hippocampal volume.

McQuillan, K., Hyland, P., & Vallières, F. (2022). Prevalence, correlates, and the mitigation of ICD-11 CPTSD among homeless adults: The role of self-compassion. Child Abuse & Neglect127, 105569.

Background In 2018, Complex Post-Traumatic Stress Disorder (CPTSD) was accepted into the International Classification of Diseases, edition 11 (ICD-11) to capture symptoms associated with exposure to chronic, inescapable trauma. Thereafter, the disorder’s links with interpersonal trauma have been established.

Methods The data were analyzed using chi-squared and mediation analyses (via PROCESS).

Results CPTSD was highly prevalent (33.9%) among the sample, but PTSD was not (3.6%). Emotional neglect was the most prevalent interpersonal trauma and the most common index event. Only lifetime sexual abuse (from someone other than a parent or guardian) was associated with CPTSD diagnostic status (χ2 = 3.94, (1), p = .047). When adjusted for gender, relationship status, and living situation, self-compassion mediated the relationship between cumulative interpersonal trauma exposure and CPTSD severity (B = 1.30, SE = 0.50, 95% CI = [0.43–2.35]).

Conclusions Findings support the relevance of CPTSD to understanding psychopathology in homeless adults and the potential role of self-compassion in interventions. Further, they open debate on the nature of events that are considered traumatic – subjectively and in psychiatric canon.

Jowett, S., Karatzias, T., Shevlin, M., & Hyland, P. (2022). Psychological trauma at different developmental stages and ICD-11 CPTSD: The role of dissociation. Journal of Trauma & Dissociation23(1), 52–67.

Background Dissociation is commonly reported by individuals who meet criteria for posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD). However, the association between the age of trauma exposure, dissociation, and CPTSD is not well understood. This study aimed to test whether dissociation mediated the relationship between the developmental stage of trauma exposure and CPTSD symptoms.

Methods A nationally representative sample from Ireland (N = 1020) completed self-report measures on trauma exposure in childhood, adolescence, adulthood, current trauma symptomatology, and dissociation symptoms. A mediation analysis was conducted.

Results Childhood, adolescent, and adulthood trauma exposure were all related to dissociation and ICD-11 CPTSD symptom clusters. Dissociation mediated the effect of developmental stage of trauma exposure on PTSD and disturbances in self-organization (DSO). The direct and indirect effect models provided the best fit of the data. Childhood trauma exposure was the only developmental stage that was directly associated with both PTSD and DSO symptoms in our sample.

Conclusions Dissociation mediates the relationship between reported trauma exposure and the presence of ICD-11 CPTSD symptom clusters, and this relationship appears at its strongest when trauma occurs in childhood. CPTSD interventions should also promote dissociation management to aid recovery from this debilitating condition.

Mekawi, Y., Carter, S., Brown, B., Martinez de Andino, A., Fani, N., Michopoulos, V., & Powers, A. (2021). Interpersonal Trauma and Posttraumatic Stress Disorder among Black Women: Does Racial Discrimination Matter? Journal of Trauma & Dissociation22(2), 154–169.

Background There is evidence that the more frequent, severe, and chronic posttraumatic stress disorder (PTSD) symptomatology experienced by Black compared to White individuals in the United States cannot be explained by disparities in socioeconomic status or trauma exposure. One factor that may be important to consider is racial discrimination, which is associated with numerous negative mental health outcomes yet has not been studied in the context of interpersonal traumas for Black women. This study aims to fill this gap by examining the independent and interactive roles of racial discrimination and interpersonal trauma in predicting PTSD symptoms in a community sample of trauma-exposed, Black women (n = 292).

Methods Participants were drawn from an ongoing study of PTSD risk factors in a low-income, primarily Black, urban population. Only those participants who completed key measures (i.e., racial discrimination, PTSD assessment) were included in our analyses. Participants were Black women recruited from waiting rooms in a publicly funded hospital in the South. All participants were approached at random. Eligible participants were required to be at least 18 years old, not actively psychotic, and able to give informed consent. If eligible and willing to participate, individuals signed informed consent. An initial 30-to-75 minute interview was then administered by trained research assistants in private areas using questionnaires about trauma history, general demographic information, and other psychological factors. All participants were compensated 15 USD for their time. Participants were screened using the Experiences of Discrimination (EOD), Clinician-administered PTSD scale (CAPS-5), and Traumatic events inventory (TEI).

Results Consistent with the previous literature, we found that more frequent experiences of racial discrimination were associated with more severe PTSD symptoms overall (r = .34) and by symptom cluster. Furthermore, we found a significant interaction between experiences of racial discrimination and experiences of interpersonal trauma (b = .46, 95%CI[.04, .88], SE = .28; ΔR2 = .01, p = .03) such that the association between PTSD symptoms and interpersonal trauma was stronger at higher (+1 SD above the mean) levels of racial discrimination. This pattern was replicated for most PTSD symptom clusters. 

Conclusions These results suggest that racial discrimination experiences exacerbate the association between interpersonal traumatic experiences and PTSD symptoms among American Black women.