Culture, trauma and dissociation: A broadening perspective for our field.

In the field of trauma and dissociation, culture has a significant influence on the clinical presentation of patients. A growing body of literature addresses the relationship between culture and dissociation. Studies of this relationship though, evoke the important, but at the same time extremely sensitive issue of cross-cultural comparisons. In this editorial, I provide a limited overview of various ways in which cultural influences have been addressed in the field of trauma and dissociation. Most studies have examined the occurrence of dissociative disorders in clinical populations in different cultures and countries. Some have focused on normative dissociation as a response to traumatic events in non-clinical samples from different cultures. This editorial also explores the concepts of double consciousness and black consciousness, which have emerged from the fields of social psychology and black psychology; and how these concepts influence our thinking about non-clinical dissociation. Culture-related challenges in the field of trauma and dissociation create opportunities for training in cultural competence for therapists. Qualitative research methods might be best suited to future research on the relationship between culture, trauma and dissociation. The chances of reaching a thorough and deep understanding of the influence of culture on trauma and dissociation might be best if the entire spectrum of dissociation is studied - from normal to pathological dissociation, and in its different manifestations from universal to those unique to certain cultural groups.

Traditionality, Spirituality and Somatoform Dissociation Symptoms in Chinese Buddhists.

To evaluate the relationship between spiritual experience and hysterical experiences in Buddhist participants in ethnic groups in China, this cross-sectional study recruited 39 participants aged 16-57 years old, and self-administered surveys were administered in two villages, one city and one town by four research assistants in the Inner Mongolia and Qinhai areas. Binary logistic regression analyses were used to evaluate the factors associated with somatoform dissociation symptoms. Surveys were completed by 639 participants (mean age 31 years; 54.6% females) in 2017. Binary regression models showed that diverging from tradition and having a college education or above were associated with suffering from somatoform dissociation symptoms. By contrast, participants with higher experiences and older people were less likely to experience somatoform dissociation symptoms. Our current research highlights the contribution of spiritual experiences and traditional values to reducing somatization dissociation symptoms, and the findings could help to promote a new relationship between psychiatry and spiritual experiences that will benefit both mental health professionals and those who seek their assistance.

Group dynamics as a predictor of dissociation for Black victims of violence: An exploratory study of cultural betrayal trauma theory.

Violence victimization is prevalent in the US and is linked to costly mental health outcomes, including dissociation and posttraumatic stress disorder (PTSD). Black Americans are at increased risk for violence victimization, while additionally enduring racism that impacts mental health. Moreover, discrimination affects outcomes of violence. Cultural betrayal trauma theory (CBTT) is a new framework for examining the impact of within-group violence victimization (termed cultural betrayal trauma) and minority status on outcomes. Furthermore, CBTT examines posttraumatic group dynamics, such as (intra)cultural pressure. As pressure to protect the minority in-group by not disclosing cultural betrayal trauma, (intra)cultural pressure may impact outcomes. The purpose of the exploratory study was to examine the impact of cultural betrayal trauma and (intra)cultural pressure on dissociation and posttraumatic stress symptoms (PTSS). Participants (N = 43) were Black/African American university students who completed online measures assessing violence victimization and outcomes. Linear regression analyses revealed that cultural betrayal trauma predicted PTSS, whereas (intra)cultural pressure predicted dissociation. The current study has implications for examining the impact of group dynamics, such as (intra)cultural pressure, in clinical interventions for Black victims of cultural betrayal trauma. Such cultural competency in mental health care treatment may help reduce mental health disparities.

Physiologic correlates of culture-bound dissociation: A comparative study of Brazilian spiritist mediums and controls.

Mediumship and spirit possession are cultural phenomena found in many societies worldwide. In Brazil, Spiritism (a tradition in which mediumship is emphasized) is the third largest religious denomination. The present study aimed to investigate physiologic correlates of nonpathological dissociative experiences by comparing 20 female spiritist mediums with several years of socially sanctioned practice to 20 female nonmedium control subjects from the same religious context. We measured plasma levels of hormones and neuroactive substances, as well as vital signs and heart rate variability (HRV) parameters, before and immediately after spirit communication. Although no between-group differences were noted in basal physiological parameters, in response to the possession experiences the groups differed in heart rate and in plasma concentrations of noradrenaline, thyroid-stimulating hormone (TSH), prolactin, and creatine phosphokinase (CPK). The changes in parameters indicated an arousal response in mediums and a relaxation response in control participants, and the same pattern of changes was observed in HRV parameters from each group during the possession experiences. However, the changes in physiologic parameters for mediums were mild and of short duration: 1 hour after the possession experiences, no difference in cardiac autonomic regulation was noted. No significant group effect was noted for melatonin. Cognitive control processes may explain the arousal associated with the dissociative state. Findings from this study suggest that pathological and nonpathological dissociation may have different physiological correlates.

Reliability of the Dissociative Trance Disorder Interview Schedule: A preliminary report.

One hundred inpatients in a hospital-based Trauma Program in the USA were interviewed with the Dissociative Trance Disorder Interview Schedule (DTDIS). There were no significant differences for the DTDIS total score or any of the subscale scores on test-retest: all t-values comparing the two administrations of the DTDIS were below 0.7, and all p-values were above 0.5. Cronbach's alpha for the US sample was 0.966 and for the Israeli sample it was 0.971. The findings indicate that the DTDIS has good reliability and may be suitable for use in cross-cultural research; however, the results require replication by independent researchers in a variety of cultures and languages, and in both clinical and nonclinical samples.

Dissociation From a Cross-Cultural Perspective: Implications of Studies in Brazil.

A major issue in the study of dissociation concerns the cross-cultural validity of definitions and measurements used to identify and classify dissociative disorders. There is also extensive debate on the etiological factors underlying dissociative experiences. Cross-cultural research is essential to elucidate these issues, particularly regarding evidence obtained from countries in which the study of dissociation is still in its infancy. The aim of this article was to discuss Brazilian research on the topic of dissociation, highlighting its contributions for the understanding of dissociative experiences in nonclinical populations and for the validity and relevance of dissociative disorders in the contexts of psychiatry, psychology, and psychotherapy. We also consider the ways in which dissociative experiences are assimilated by Brazilian culture and religious expressions, and the implications of Brazilian studies for the sociocultural investigation of dissociation. We conclude by addressing the limitations of these studies and potential areas for future research.

International/Institutional Trauma in Developmental Pediatric Practice.

CASE: "Aabis" is a school-aged boy from a predominantly conservative Muslim nation who presented to a tertiary developmental-behavioral pediatric (DBP) clinic to seek "expert opinion" for significant social and learning difficulties in the context of a history of frequent falling and "clumsiness." He was seen by a psychiatrist in his home country, who ordered an electroencephalogram and "brain map" (both normal), and received occupational and physical therapies. Frequent tantrums and intense emotional reactions to minor events-revealed to be related to a history of repeated physical beatings from groups of his "friends"-prompted referral to the DBP clinic. When asked why he did not fight back, Aabis said that he did not want to lose his friends. He and his parents further explained that this kind of organized aggression is considered part of normative development in their country and that Aabis needed to "toughen up."Aabis was described by his parents as being very "sensitive" when others raised their voices, shivering when reprimanded and profusely apologizing for real and imagined mistakes. He bit his nails until they bled, washed his hands repetitively, and changed his clothes several times per day. On witnessing his parents arguing, Aabis threatened to harm himself with a decorative knife.The assessment presented with several procedural complications specifically the use of an interpreter and the cultural differences regarding many of the topics discussed. Aabis spoke very little English, and an interpreter was not available in person on the initial day of the assessment. Telephonic phone translation services were attempted, but there were concerns that Aabis would not feel comfortable with sharing his emotions over the phone with an unidentified individual. As feared, Aabis was resistant to discuss emotionally charged topics (e.g., feeling sad, being bullied, hearing or seeing things) and grew impatient and irritated with the phone interpreter. After some unsuccessful experimentation with a Google-based translation system (implemented at Aabi's request to help build comfort and rapport), a second telephonic interpreter was brought into the session, who Aabis later described to his parents as "mean." (Aabis clarified that the second interpreter had been brusque and insensitive to his tentative attempts to express his feelings, e.g., by telling him to "Speak up. Spit it out.")Toward the end of the interview, Aabis seemed to dissociate and insisted anxiously that he did not want to relay certain information without his parents present in the room. What would you do next in this situation?Details about this case, including name and age, have been altered to protect the child's identity.

Dissociative trance and spirit possession: Challenges for cultures in transition.

The cross-cultural validity of dissociative possession and trance disorders is a matter of some debate, limiting research and meaningful interpretation of prevalence data. Intimate to these concerns is the status of spirit possession categories studied in the social sciences, particularly anthropology. These two categories are phenomenologically related and display similar epidemiological associations. In India, dissociative and conversion disorders are fairly common in clinical settings. There is no doubt that there are true cultural variations in possession and trance disorders. A new framework may enable clinicians to better understand possession states and spirit possession.

Dissociative features in posttraumatic stress disorder: A latent profile analysis.

OBJECTIVE: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) characterizes the dissociative subtype of posttraumatic stress disorder (PTSD) in terms of the individual meeting the criteria for PTSD and additionally reporting symptoms of depersonalization and/or derealization. The current study aimed to examine whether a dissociative PTSD profile may include alternative features of dissociation and whether it could be differentiated from a nondissociative PTSD profile on certain psychopathologies and demographics. METHOD: Data from 309 trauma-exposed participants, collected through Amazon Mechanical Turk, were subjected to latent profile analysis. Regression analyses were used to examine the predictors of latent classes. RESULTS: Three discrete profiles named Baseline, PTSD, and Dissociative profile were uncovered. All examined features of dissociation were significantly elevated in the Dissociative profile. Anxiety, male sex, being employed, and having a minority racial background significantly predicted the Dissociative profile relative to the PTSD profile. CONCLUSIONS: The study points to the importance of alternative symptoms of dissociation in the dissociative PTSD subtype beyond the symptoms of depersonalization and derealization. (PsycINFO Database Record

Racial discrimination as race-based trauma, coping strategies, and dissociative symptoms among emerging adults.

OBJECTIVE: The race-based traumatic stress theory (Carter, 2007) suggests that some racial- and ethnic-minority individuals experience racial discrimination as psychological trauma, as it may elicit a response comparable to posttraumatic stress. In the present study, we examined this further by determining the relation between racial discrimination and dissociation, a common response to trauma exposure. Further, we examined whether active coping strategies specifically employed to cope with racial discrimination related to less dissociative symptomatology. METHOD: The predominant racial- and ethnic-minority sample (N = 743) of emerging adults, ages 18-29, recruited from a public university in northeastern United States completed a battery of self-report measures on racial discrimination, responses to racial discrimination, traumatic life events, and dissociative symptoms. RESULTS: Frequency of racial discrimination was positively associated with dissociative symptoms in regression analyses adjusted for demographics and other traumatic life events. In addition, more active coping strategies in response to racial discrimination were negatively associated with dissociative symptoms. CONCLUSION: Racial- and ethnic-minority emerging adults who experience racial discrimination, possibly as traumatic, may be more vulnerable to dissociative symptoms. However, different strategies of coping with racial discrimination may differentially impact risk for dissociation. (PsycINFO Database Record

Predicting three types of dissociation in female survivors of intimate partner violence.

Previous research suggests that studying the effect of dissociation is particularly important in survivors of intimate partner violence because of the risk of revictimization. The current study investigated demographic variables, child and current abuse characteristics, coping style, and cognitive distortions as predictors of peritraumatic, trait, and posttraumatic stress disorder (PTSD)-related dissociation in a sample of female intimate partner violence survivors. The sample consisted of 372 women, the majority African American, with an average age of 34.41 years (SD = 8.09). Peritraumatic dissociation was significantly predicted by child physical abuse, current abuse injury, cognitive distortions about safety, and problem disengagement coping. Trait dissociation was significantly predicted by minority race, personal income, and cognitive distortions about safety and self-worth. PTSD-related dissociation was significantly predicted by cognitive distortions about self-worth, problem and emotion disengagement coping, and peritraumatic dissociation. In the models predicting both trait and PTSD-related dissociation, abuse characteristics significantly predicted dissociation until the entry of cognitive variables into the model. The analysis indicated a significant indirect effect of cognitive distortions on the relationship between current sexual aggression and trait dissociation. Results also suggested that there were indirect effects of both cognitive distortions and peritraumatic dissociation on the relationships between current psychological abuse/injury and PTSD-related dissociation. Findings point to the importance of cognitions in the development and maintenance of dissociation and suggest that treatments designed to help clients accept and process traumatic events may help reduce dissociation and in turn prevent future revictimization.

Assessment of dissociation in Bosnian treatment-seeking refugees in Denmark.

BACKGROUND: Dissociative experiences are common in traumatized individuals, and can sometimes be mistaken for psychosis. It is difficult to identify pathological dissociation in the treatment of traumatized refugees, because there is a lack of systematic clinical descriptions of dissociative phenomena in refugees. Furthermore, we are currently unaware of how dissociation measures perform in this clinical group. AIMS: To describe the phenomenology of dissociative symptoms in Bosnian treatment-seeking refugees in Denmark. METHOD: As a part of a larger study, dissociation was assessed systematically in 86 Bosnian treatment-seeking refugees using a semi-structured clinical interview (Structured Interview for Disorders of Extreme Stress-dissociation subscale; SIDES-D) and a self-report scale (Dissociative Experiences Scale; DES). RESULTS: The SIDES-D indicated twice as high prevalence of pathological dissociation as the DES. According to the DES, 30% of the refugees had pathological dissociation 15 years after their resettlement. On the SIDES-D, depersonalization and derealization experiences were the most common. Also, questions about depersonalization and derealization at times elicited reporting of visual and perceptual hallucinations, which were unrelated to traumatic re-experiencing. Questions about personality alteration elicited spontaneous reports of a phenomenon of "split" pre- and post-war identity in the refugee group. Whether this in fact is a dissociative phenomenon, characteristic of severe traumatization in adulthood, needs further examination. CONCLUSIONS: Knowledge of dissociative symptoms in traumatized refugees is important in clinical settings to prevent misclassification and to better target psychotherapeutic interventions. Much development in the measurement of dissociation in refugees is needed.

Dissociative disorders and possession experiences in Israel: a comparison of opiate use disorder patients, Arab women subjected to domestic violence, and a nonclinical group.

This study examined the association between exposure to domestic violence and dissociative symptoms. A sample of 68 Israeli opiate use disorder patients in recovery, 80 battered Arab Israeli women, and 103 respondents from a community sample participated in structured interviews that included the Dissociative Disorders Interview Schedule (DDIS), the Dissociative Trance Disorder Interview Schedule (DTDIS), and the Dissociative Experiences Scale (DES). As predicted, community participants reported significantly less exposure to traumatizing events and lower levels of dissociative psychopathology than individuals sampled from specialized treatment centers. In all, 91% of battered female participants were taxon-positive for dissociative disorder with 1 of every 2 respondents reporting symptoms corresponding to dissociative amnesia and depersonalization disorder, suggesting that this group may be particularly vulnerable to dissociative psychopathology. Extrasensory and paranormal experiences (ESP) and dissociative trance disorder experiences were strongly related to dissociative experiences and features of dissociative identity disorder (DID). These statistical associations suggest that dissociative disorders and ESP/trance experiences may share an underlying construct. Further research is needed on trauma and dissociation among female victims of domestic abuse in patriarchal, collectivist societies, particularly in the Arab world.

Ethnic variation in whether dissociation mediates the relation between traumatic life events and attenuated positive psychotic symptoms.

The present study sought to determine whether dissociative experiences mediated the relationship between traumatic life events and attenuated positive psychotic symptoms in a non-treatment-seeking sample of racial and ethnic minority young adults. Participants (n = 549) completed a self-report inventory for psychosis risk (i.e., the Prodromal Questionnaire; R. L. Loewy, C. E. Bearden, J. K. Johnson, A. Raine, & T. D. Cannon, 2005), from which a total number of attenuated positive psychotic symptoms was assessed. Participants also completed a checklist of potentially traumatic life events and a traumatic dissociation scale. Hierarchical linear regression models and bootstrapping results indicated that dissociation mediated the relationship between traumatic life events and attenuated positive psychotic symptoms. Stratified analyses of Black, Asian, and Hispanic subgroups revealed that full mediation was only evident in the Black subgroup of young adults. Partial mediation was found among the Hispanic group, and no mediation occurred in the Asian subgroup. For the latter, traumatic life events were not significantly associated with dissociative experiences. A dissociative response style may be particularly relevant to trauma-exposed Black young adults exhibiting subclinical psychotic experiences and less so for Asian young adults. Trauma-induced dissociative experiences should be assessed further in clinical high-risk studies, especially among Black traumatized youth.

Dissociative experiences in epilepsy--a neuropathological and sociodemographic study in a Chinese population.

BACKGROUND: It is well known that dissociative experiences coexist with various epilepsy syndromes. However, the prevalence of dissociative experiences in different subtypes of epilepsy remains unknown. This is especially important because of the current prevalent view that the etiology of dissociation in seizures is neurobiological rather than psychosocial. The amygdala especially has been implicated in such dissociative features of epilepsy. This would indirectly imply that the patients with CPS have higher prevalence of dissociative symptoms compared with those with GTCS. METHODOLOGY: We studied and compared the dissociative experiences as well as the depression and anxiety levels between 24 patients suffering from temporal lobe epilepsy and 26 patients suffering from generalized tonic-clonic seizures. We used the Dissociative Experiences Scale to evaluate the dissociative experiences. A third group of healthy individuals was included as the control group. The statistical significance was fixed at 0.05. RESULTS: There were significant differences between the scores of DES-II of the healthy individuals and those of patients with epilepsy. However, there were no significant differences between the DES scores of different patients with epilepsy categorized according to neuropathology. There were also no significant differences between HAM-A and HAM-D scores between groups with epilepsy, but the scores were higher than those of the healthy individuals. There were significant differences between the DES scores in different sociodemographic groups such that higher scores were observed in groups with lower education (p<0.05). In addition, the scores on DES were higher in individuals with low socioeconomic status than in those with high socioeconomic status. CONCLUSION: The patients with temporal lobe epilepsy and those with generalized tonic-clonic seizures have similar dissociative experiences which are both more than those found in individuals without epilepsy. However, these dissociative experiences may not be related to the neuropathological parameters as much as they are to the sociodemographic parameters like education, age, socioeconomic status, and sex. This shows that the psychopathology of dissociation in epilepsy is similar to that of the general population.

Collective trauma processing: dissociation as a way of processing postwar traumatic stress in Guinea Bissau.

Guidelines on psychosocial interventions in postconflict areas commonly mention that interventions should be based on local needs and be built on culture-specific expertise. This paper is based on a dissociative cult, the Kiyang-yang (KYY), in Guinea Bissau. In a previous article, we used a refined definition of the concept of idiom of distress to analyze the dissociative behavior displayed in KYY as a symbolic language addressing politically dangerous truths. This paper uses the concept of "collective trauma processing" to analyze how the idiom offered the local population a pathway to mitigate the consequences of protracted and widespread political violence. The paper first argues that the field of psychotraumatology lacks a comprehensive ecological theory on trauma. Moreover, within clinical psychology and psychiatry, little attention is paid to local cultural healing mechanisms addressing traumatic stress. This paper is an effort to study such mechanisms in their own right. To compare trauma processing mechanisms across the globe, we propose to analyze trauma processing mechanisms with the help of a comprehensive model discerning five ontological dimensions that are considered to be involved in suffering and are addressed in healing approaches. Our paper describes similarities and differences between psychological healing traditions and collective trauma processing within the West African context of Guinea Bissau. We will illustrate how the KYY movement uses the idiom of dissociation as both a collective expression of distress and as a vehicle to process social suffering and traumatic stress as a circular phenomenon.

Ethnic syndromes as disguise for protest against colonialism: three ethnographic examples.

Historical connections are suggested between the domination of 1 culture by another and dissociative spiritual and religious responses to that oppression. Connections are drawn between colonial oppression, trauma, and 3 examples of dissociation and spirit possession: the Zar cult of Southern Sudan, "Puerto Rican syndrome" or ataque, and the Balinese trance dance. Discussed by means of these examples are the role and functions of spirit possession as a means of escape from unbearable reality, where it becomes a form of the expression of needs and desires forbidden by authorities, a way of entering an identity not subject to traditional authorities, and reenactment of traumatic experience.

Dissociation and symptoms of culture-bound syndromes in North America: a preliminary study.

The aim of this study was to determine whether classical culture-bound syndromes occur among psychiatric inpatients with dissociative disorders in North America. The Dissociative Trance Disorder Interview Schedule, the Dissociative Experiences Scale, and the Dissociative Disorders Interview Schedule were administered to 100 predominantly Caucasian, American, English-speaking trauma program inpatients at a hospital in the United States. The participants reported high rates of childhood physical and/or sexual abuse (87%), dissociative disorders (73%), and membership in the dissociative taxon (78%). They also reported a wide range of possession experiences and exorcism rituals, as well as the classical culture-bound syndromes of latah, bebainan, amok, and pibloktoq. Our data are consistent with the view that possession and classical culture-bound syndromes are predominantly dissociative in nature and not really culture-bound from the perspective of Caucasian, English-speaking America.

The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5.

BACKGROUND: There is considerable debate about the cross-cultural applicability of the posttraumatic stress disorder (PTSD) category as currently specified. Concerns include the possible status of PTSD as a Western culture-bound disorder and the validity of individual items and criteria thresholds. This review examines various types of cross-cultural validity of the PTSD criteria as defined in DSM-IV-TR, and presents options and preliminary recommendations to be considered for DSM-5. METHODS: Searches were conducted of the mental health literature, particularly since 1994, regarding cultural-, race-, or ethnicity-related factors that might limit the universal applicability of the diagnostic criteria of PTSD in DSM-IV-TR and the possible criteria for DSM-5. RESULTS: Substantial evidence of the cross-cultural validity of PTSD was found. However, evidence of cross-cultural variability in certain areas suggests the need for further research: the relative salience of avoidance/numbing symptoms, the role of the interpretation of trauma-caused symptoms in shaping symptomatology, and the prevalence of somatic symptoms. This review also indicates the need to modify certain criteria, such as the items on distressing dreams and on foreshortened future, to increase their cross-cultural applicability. Text additions are suggested to increase the applicability of the manual across cultural contexts: specifying that cultural syndromes-such as those indicated in the DSM-IV-TR Glossary-may be a prominent part of the trauma response in certain cultures, and that those syndromes may influence PTSD symptom salience and comorbidity. CONCLUSIONS: The DSM-IV-TR PTSD category demonstrates various types of validity. Criteria modification and textual clarifications are suggested to further improve its cross-cultural applicability.

A critical review of dissociative trance and possession disorders: etiological, diagnostic, therapeutic, and nosological issues.

OBJECTIVE: Although the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, acknowledges the existence of dissociative trance and possession disorders, simply named dissociative trance disorder (DTD), it asks for further studies to assess its clinical utility in the DSM-5. To answer this question, we conducted the first review of the medical literature. METHOD: The MEDLINE, CINAHL, and PsycINFO databases were searched from 1988 to 2010, seeking case reports of DTD according to the DSM or the International Classification of Diseases definitions. For each article, we collected epidemiologic and clinical data, explanatory models used by authors, treatments, and information on the outcome. RESULTS: We found 28 articles reporting 402 cases of patients with DTD worldwide. The data show an equal proportion of female and male patients, and a predominance of possession (69%), compared with trance (31%). Amnesia is reported by 20% of patients. Conversely, hallucinatory symptoms during possession episodes were found in 56% of patients and thus should feature as an important criterion. Somatic complaints are found in 34% of patients. Multiple explanatory models are simultaneously held and appear to be complementary. CONCLUSION: Data strongly suggest the inclusion of DTD in the DSM-5, provided certain adjustments are implemented. DTD is a widespread disorder that can be understood as a global idiom of distress, probably underdiagnosed in Western countries owing to cultural biases, whose incidence could increase given the rising flow of migration. Accurate diagnosis and appropriate management should result from a comprehensive evaluation both of sociocultural and of idiosyncratic issues, among which acculturation difficulties should systematically be considered, especially in cross-cultural settings.