As society has become increasingly aware of the prevalence of child abuse and its serious consequences, there has been an explosion of information on posttraumatic and dissociative disorders resulting from abuse in childhood. Since most clinicians learned little about childhood trauma and its aftereffects in their training, many are struggling to build their knowledge base and clinical skills to effectively treat survivors and their families.
Understanding dissociation and its relationship to trauma is basic to understanding the posttraumatic and dissociative disorders. Dissociation is the disconnection from full awareness of self, time, and/or external circumstances. It is a complex neuropsychological process. Dissociation exists along a continuum from normal everyday experiences to disorders that interfere with everyday functioning. Common examples of normal dissociation are highway hypnosis (a trance-like feeling that develops as the miles go by), "getting lost" in a book or a movie so that one loses a sense of passing time and surroundings, and daydreaming.
Researchers and clinicians believe that dissociation is a common, naturally occurring defense against childhood trauma. Children tend to dissociate more readily than adults. Faced with overwhelming abuse, it is not surprising that children would psychologically flee (dissociate) from full awareness of their experience. Dissociation may become a defensive pattern that persists into adulthood and can result in a full-fledged dissociative disorder.
The essential feature of dissociative disorders is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. If the disturbance occurs primarily in memory, Dissociative Amnesia or Fugue (APA, 1994) results; important personal events cannot be recalled. Dissociative Amnesia with acute loss of memory may result from wartime trauma, a severe accident, or rape. Dissociative Fugue is indicated by not only loss of memory, but also travel to a new location and the assumption of a new identity. Posttraumatic Stress Disorder (PTSD), although not officially a dissociative disorder (it is classified as an anxiety disorder), can be thought of as part of the dissociative spectrum. In PTSD, recall/re-experiencing of the trauma (flashbacks) alternates with numbing (detachment or dissociation), and avoidance. Atypical dissociative disorders are classified as Dissociative Disorders Not Otherwise Specified (DDNOS). If the disturbance occurs primarily in identity with parts of the self assuming separate identities, the resulting disorder is Dissociative Identity Disorder (DID), formerly called Multiple Personality Disorder.
The dissociative spectrum (Braun, 1988) extends from normal dissociation to poly-fragmented DID. All of the disorders are trauma-based, and symptoms result from the habitual dissociation of traumatic memories. For example, a rape victim with Dissociative Amnesia may have no conscious memory of the attack, yet experience depression, numbness, and distress resulting from environmental stimuli such as colors, odors, sounds, and images that recall the traumatic experience. The dissociated memory is alive and active--not forgotten, merely submerged (Tasman Goldfinger, 1991). Major studies have confirmed the traumatic origin of DID (Putnam, 1989, and Ross, 1989), which arises before the age of 12 (and often before age 5) as a result of severe physical, sexual, and/or emotional abuse. Poly-fragmented DID (involving over 100 personality states) may be the result of sadistic abuse by multiple perpetrators over an extended period of time.
Although DID is a common disorder (perhaps as common as one in 100) (Ross, 1989), the combination of PTSD-DDNOS is the most frequent diagnosis in survivors of childhood abuse. These survivors experience the flashbacks and intrusion of trauma memories, sometimes not until years after the childhood abuse, with dissociative experiences of distancing, "trancing out", feeling unreal, the ability to ignore pain, and feeling as if they were looking at the world through a fog.
The symptom profile of adults who were abuse as children includes posttraumatic and dissociative disorders combined with depression, anxiety syndromes, and addictions. These symptoms include (1) recurrent depression; (2) anxiety, panic, and phobias; (3) anger and rage; (4) low self-esteem, and feeling damaged and/or worthless; (5) shame; (6) somatic pain syndromes (7) self-destructive thoughts and/or behavior; (8) substance abuse; (9) eating disorders: bulimia, anorexia, and compulsive overeating; (10) relationship and intimacy difficulties; (11) sexual dysfunction, including addictions and avoidance; (12) time loss, memory gaps, and a sense of unreality; (13) flashbacks, intrusive thoughts and images of trauma; (14) hypervigilance; (15) sleep disturbances: nightmares, insomnia, and sleepwalking; and (16) alternative states of consciousness or personalities.
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