Intrusive images and intrusive thoughts as different phenomena: two experimental studies.

According to the dual representation theory of PTSD, intrusive trauma images and intrusive verbal thoughts are produced by separate memory systems. In a previous article it was shown that after watching an aversive film, participants in non-movement conditions reported more intrusive images than participants in a free-to-move control condition (Hagenaars, Van Minnen, Holmes, Brewin, & Hoogduin, 2008). The present study investigates whether the experimental conditions of the Hagenaars et al. study had a different effect on intrusive thoughts than on intrusive images. Experiment 2 further investigated the image-thoughts distinction by manipulating stimulus valence (trauma film versus neutral film) and assessing the subsequent development of intrusive images and thoughts. In addition, both experiments studied the impact of peri-traumatic emotions on subsequent intrusive images and thoughts frequency across conditions. Results showed that experimental manipulations (non-movement and trauma film) caused higher levels of intrusive images relative to control conditions (free movement and neutral film) but they did not affect intrusive thoughts. Peri-traumatic anxiety and horror were associated with subsequent higher levels of intrusive images, but not intrusive thoughts. Correlations were inconclusive for anger and sadness. The results suggest intrusive images and thoughts can be manipulated independently and as such can be considered different phenomena.

The impact of dissociation and depression on the efficacy of prolonged exposure treatment for PTSD.

This study investigates the impact of dissociative phenomena and depression on the efficacy of prolonged exposure treatment in 71 patients with posttraumatic stress disorder (PTSD). Diagnoses, comorbidity, pretreatment depressive symptoms, PTSD symptom severity, and dissociative phenomena (trait dissociation, numbing, and depersonalization) were assessed at pretreatment using semi-structured interviews and questionnaires. In a pretreatment behavioral exposure test, patients were imaginally exposed to (part of) their trauma memory for 9 min, during which subjective fear was assessed. At posttreatment and 6 months follow-up PTSD, depressive and dissociative symptoms were again assessed in the completers (n = 60). Pretreatment levels of dissociative and depressive symptoms were similar in dropouts and completers and none of the dissociative phenomena nor depression predicted improvement. Against expectations, dissociative phenomena and depression were associated with enhanced rather than impeded fear activation during the behavioral exposure test. However, these effects disappeared after controlling for initial PTSD severity. Hence, rather than supporting contraindication, the current results imply that patients presenting with even severe dissociative or depressive symptoms may profit similarly from exposure treatment as do patients with minimal dissociative or depressive symptoms.

Reliving and disorganization in posttraumatic stress disorder and panic disorder memories.

Intense, disorganized recollections are one of the core symptoms of posttraumatic stress disorder (PTSD), and considered to be the result of inadequate processing of trauma information. A first panic attack resembles trauma in being an unexpected frightening and subjectively life-threatening event, and like PTSD, panic disorder with agoraphobia also involves fear conditioning after the first event. Therefore, a panic attack may be processed similarly to a trauma, and as a result, memories of a panic attack may share characteristics like reliving and disorganization with PTSD trauma memories. To test this hypothesis, scripts of PTSD trauma memories (n = 21) were compared with scripts of panic disorder with agoraphobia panic memories (n = 25) using a narrative rating scale. No differences were found between reliving intensity and disorganization levels in the scripts of both patient groups. The results suggest a panic attack may affect information processing similarly to a traumatic event.

Peritraumatic psychological and somatoform dissociation in predicting PTSD symptoms: a prospective study.

The present prospective study evaluates the predictive value of 2 different types of dissociation (psychological and somatoform peritraumatic dissociation), and dysfunctional cognitions on symptoms of posttraumatic stress disorder (PTSD) at 6 months. Assessment of dissociation, PTSD symptoms, and dysfunctional cognitions took place in 49 participants approximately 3 weeks after a traumatic event. Six months later PTSD symptoms were assessed again. The effect of both psychological and somatoform peritraumatic dissociation disappeared after controlling for initial PTSD numbing symptoms. Dysfunctional cognitions predicted PTSD at 6 months after controlling for initial numbing symptoms. The present study indicates that peritraumatic dissociation may not be a predictor of PTSD. In contrast, maladaptive posttraumatic coping behavior like persistent dissociation and dysfunctional cognitions may be predictors.

The impact of early trauma and recent life-events on symptom severity in patients with conversion disorder.

Although the presence of psychological stress factors in the evolution of conversion symptoms forms an important criterion for the DSM-IV diagnosis of conversion disorder, little is known about the nature and timing of these stress factors. Fifty-four patients with conversion disorder and 50 control patients with an affective disorder were screened for life events experienced in the year before the symptom onset. Conversion patients did not differ from control patients in the number or severity of life events, but showed a significant relation between the recent life events and the severity of conversion symptoms. Especially life events with respect to work and relationships contributed to this effect. These results remained when controlling for the previously found effects of childhood traumatization on the severity of conversion symptoms. The findings imply that conversion symptoms may be elicited by a complex of early and later negative life events and that traditional unifactorial trauma-theories of conversion disorder should be replaced by multifactorial stress models.

A Rasch analysis of the Stanford Hypnotic Susceptibility Scale, Form C.

The psychometric structure of the Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C) was tested in a Rasch analysis using data from 279 subjects. The Rasch model is the model of choice because it justifies the use of the sum of the item scores as a measure for the underlying construct. Rasch analysis revealed that use of a single sum score (number of suggestions passed) to express hypnotic ability is not sufficiently justified. However, the omission of the mosquito-hallucination and anosmia items (Items 3 and 9) rendered this short 10-item form of the SHSS:C sufficiently compatible with requirements of one-dimensionality, local stochastic independence,and equi-discriminability. Hence, the 10-item form justifies use of a sum score.

A randomized controlled clinical trial of a hypnosis-based treatment for patients with conversion disorder, motor type.

This study tested whether a hypnosis-based intervention showed promise as a treatment for patients with conversion disorder, motor type. Forty-four outpatients with conversion disorder, motor type, or somatization disorder with motor conversion symptoms, were randomly assigned to a hypnosis or a waiting-list condition. The hypnosis-condition patients were more improved relative to baseline and the waiting-list controls. Improvement was evident on an observational index of behavioral symptoms associated with the motor conversion and on an interview measure of extent of motor disability. No effect was obtained on a nonspecific measure of broad psychopathology immediately posttreatment. At 6-month follow-up, improvement was maintained across the behavioral and interview measures. The effect size of hypnotizability as a predictor of treatment outcome was comparable to that found for other individual patient differences associated with psychotherapy outcome although non-significant. Hypnotizability scored above patient expectations as a predictor of treatment outcome.

Treatment of trichotillomania with behavioral therapy or fluoxetine: a randomized, waiting-list controlled study.

BACKGROUND: Both behavioral therapy (BT) and serotonin reuptake inhibitors have been reported effective in the treatment of trichotillomania. This study examines the efficacy of BT and fluoxetine hydrochloride compared with a waiting-list (WL) control group. METHODS: Forty-three patients with trichotillomania entered a 12-week randomized, WL-controlled study of BT and fluoxetine (60 mg/d). Forty patients (14 in the BT group, 11 in the fluoxetine group, and 15 in the WL group) completed the trial. Treatment effects were evaluated using the Massachusetts General Hospital Hairpulling Scale, and severity of hair loss was rated by independent assessors. In addition, we measured general symptoms of psychopathologic abnormalities and depression. RESULTS: For reducing the symptoms of trichotillomania, BT was superior. Patients in the BT group showed a significantly greater reduction in trichotillomania symptoms, higher effect sizes (Massachusetts General Hospital Hairpulling Scale: BT, 3.80; fluoxetine, 0.42; and WL, 1.09), and more clinically significant changes (BT, 64%; fluoxetine, 9%; and WL, 20%) than patients in the fluoxetine and WL groups. For severity of hair loss, a similar trend was also found in favor of the BT group. No significant differences between groups were established for general psychopathologic and depressive symptoms. CONCLUSIONS: Behavioral therapy is highly effective for reducing symptoms of trichotillomania in the short term, whereas fluoxetine is not.

Childhood abuse in patients with conversion disorder.

OBJECTIVE: Despite the fact that the assumption of a relationship between conversion disorder and childhood traumatization has a long history, there is little empirical evidence to support this premise. The present study examined this relation and investigated whether hypnotic susceptibility mediates the relation between trauma and conversion symptoms, as suggested by Janet's autohypnosis theory of conversion disorder. METHOD: A total of 54 patients with conversion disorder and 50 matched comparison patients with an affective disorder were administered the Structured Trauma Interview as well as measures of cognitive (Dissociative Experiences Scale) and somatoform (20-item Somatoform Dissociation Questionnaire) dissociative experiences. RESULTS: Patients with conversion disorder reported a higher incidence of physical/sexual abuse, a larger number of different types of physical abuse, sexual abuse of longer duration, and incestuous experiences more often than comparison patients. In addition, within the group of patients with conversion disorder, parental dysfunction by the mother-not the father-was associated with higher scores on the Dissociative Experiences Scale and the Somatoform Dissociation Questionnaire. Physical abuse was associated with a larger number of conversion symptoms (Structured Clinical Interview for DSM-IV Axis I Disorders). Hypnotic susceptibility proved to partially mediate the relation between physical abuse and conversion symptoms. CONCLUSIONS: The present results provide evidence of a relationship between childhood traumatization and conversion disorder.

Hypnotic susceptibility in patients with conversion disorder.

Conversion disorder has been associated with hypnotic susceptibility for over a century and is currently still believed to be a form of autohypnosis. There is, however, little empirical evidence for the relation between hypnotic susceptibility and conversion symptoms. The authors compared 50 patients with conversion disorder with 50 matched control patients with an affective disorder on measures of hypnotic susceptibility, cognitive dissociation, and somatoform dissociation. Conversion patients were significantly more responsive to hypnotic suggestions than control patients. In addition, conversion patients showed a significant correlation between hypnotic susceptibility and the number of conversion complaints. These results provide the first evidence of a relationship between hypnotic susceptibility and the presence and number of conversion symptoms.

A randomised controlled clinical trial on the additional effect of hypnosis in a comprehensive treatment programme for in-patients with conversion disorder of the motor type.

BACKGROUND: The primary aim of this study was threefold: (1) to examine the additional effects of hypnosis aimed at symptom reduction, using symptom-oriented and expression- and insight-oriented techniques in a comprehensive clinical treatment programme for in-patients with a persistent conversion disorder of the motor type; (2) to assess whether the level of hypnotisability was predictive of treatment outcome, and (3) to explore the efficacy of the total clinical treatment programme. METHODS: The study population consisted of 45 in-patients between 18 and 65 years of age meeting the DSM-III-R criteria for conversion disorder of the motor type or somatisation disorder with motor conversion symptoms. A randomised controlled clinical trial was undertaken. The primary outcome measures were the Video Rating Scale for Motor Conversion Symptoms, the D(isabilities) code items from the International Classification of Impairments, Disabilities and Handicaps and the Symptom Checklist-90. Measures of the credibility of treatment and patient expectations of treatment outcome were used as manipulation checks. Hypnotisability was measured using the Stanford Hypnotic Clinical Scale. RESULTS: Significant treatment results for all outcome measures were found for the total sample. These effects proved to be clinically significant. The use of hypnosis had no additional effect on treatment outcome. Hypnotisability was not predictive of treatment outcome. CONCLUSION: A comprehensive treatment programme, either with or without hypnosis, can be worthwhile for patients with long-standing conversion symptoms.

Motor imagery during hypnotic arm paralysis in high and low hypnotizable subjects.

Previous research suggests that conversion disordered patients with hand/arm paralysis exhibit slowed reaction times for mental hand-rotation tasks that correspond to their affected arm when the tasks are explicitly instructed and not when they are implicitly cued. Because of the many similarities between hypnotic phenomena and conversion symptoms, the authors tested whether similar motor imagery impairment would occur among normal high hypnotizable subjects when paralysis is suggested. Nine high and 8 low hypnotizable subjects were administered an implicit and an explicit mental hand-rotation task during hypnotically suggested paralysis of the right arm. On the implicit task, there were no significant reaction time (RT) differences between highs and lows. On the explicit task, only highs showed a significantly larger RT increase per degree of rotation with the paralyzed arm, compared to the normal arm. These preliminary findings suggest that the motor imagery impairment observed in conversion paralysis can be induced in highs using hypnosis.