James A. Chu

Patterns of dissociation in clinical and nonclinical samples

Research has consistently found elevated mean dissociation scores in particular diagnostic groups. In this study, we explored whether mean dissociation scores for different diagnostic groups resulted from uniform distributions of scores within the group or were a function of the proportion of highly dissociative patients that the diagnostic group contained. A total of 1566 subjects who were psychiatric patients, neurological patients, normal adolescents, or normal adult subjects completed the Dissociative Experience Scale (DES). An analysis of the percentage of subjects with high DES scores in each diagnostic group indicated that the diagnostic groups mean DES scores were a function of the proportion of subjects within the group who were high dissociators. The results contradict a continuum model of dissociation but are consistent with the existence of distinct dissociative types.

Treatment Implications of Past Trauma in Borderline Personality Disorder

&NA; Recent research and clinical experience have shown childhood trauma to be common in the histories of patients with borderline personality disorder. This article reviews the association between borderline personality disorder and early trauma, and how an awareness of the role of trauma may improve the treatment of patients with this disorder. Particularly when early trauma is in the form of childhood abuse, clinicians may be better able to understand the difficulties these patients experience in relational skills, affect tolerance, behavioral control, self‐identity, and self‐worth. Clinicians may be able to facilitate a stronger therapeutic alliance through acknowledgement of the patients victimization and empathy with the effects of early trauma on the patients life. Reframing the patients experience as a consequence of childhood trauma is essential, especially when making traditional interventions such as interpretation and confrontation. The role of trauma in the development of borderline personality disorder suggests the need for modification of models of individual, family, and group psychotherapies that may allow more productive and successful treatment.

Adverse drug events and medication errors in psychiatry: methodological issues regarding identification and classification.

Adverse drug events and medication errors have received extensive study recently in a variety of clinical populations, though compared to many other areas relatively little work has focused on this area in psychiatry, especially with respect to the contribution of error to harm. The goal of this paper is to discuss methodological issues around measurement of medication safety in psychiatric patients. Against the background of a systems approach, a modern perspective of error management is discussed, and a multidimensional procedure for detection and classification of incidents related to the medication process is presented. This method has proven successful in non-psychiatric settings yielding the current best estimate of error rates and providing insight into the underlying causes. While this general approach can be adapted to the psychiatric setting, a number of issues make measurement especially challenging in psychiatry. These include the fluctuating course of psychiatric disorders, reduced patient adherence to the medication process, adverse effects which are often similar to symptoms of the underlying disorder, the frequent use of wide dose intervals depending on the clinical situation, and the presence of many drug–drug interactions. Data collected by means of the presented approach provide a basis for the development of effective strategies to reduce the risk of medication errors and thus improve patient safety in psychiatric care.

Trauma-A Fourth Paradigm for the Third Millennium

Perched at the threshold of the twenty-first century, psychiatry and psychology are in the throes of shifting paradigms for understanding and treating mental illnesses. The paradigm that undergirds this journal–the relationship of psychiatric symptoms to psychological trauma–is hardly a new hypothesis. More than one-hundred years ago, Sigmund Freud proposed that the sexual abuse of children later resulted in hysteria, before disavowing this ‘‘seduction hypothesis’’ in favor of psychoanalysis and repressed Oedipal sexual fantasies (Ellenberger, 1970, pp. 500-510). In the same era, Pierre Janet wrote foundational material that connected trauma to the diverse symptoms including dissociation, affective disturbances, anxiety, and somatoform symptoms (Ellenberger, 1970, pp. 331-417; Janet, 1907). Yet, as the twentieth century ends, the trauma paradigm again finds itself competing for the attention of mental health professionals as if it was a newcomer rather than a century-old theory. The established three paradigms for mental illness–psychoanalytic, behavioral and psychobio-

Measuring fragmentation in dissociative identity disorder: the integration measure and relationship to switching and time in therapy

Background Some people with dissociative identity disorder (DID) have very little communication or awareness among the parts of their identity, while others experience a great deal of cooperation among alternate identities. Previous research on this topic has been sparse. Currently, there is no empirical measure of integration versus fragmentation in a person with DID. In this study, we report the development of such a measure. Objective The goal of this study was to pilot the integration measure (IM) and to address its psychometric properties and relationships to other measures. The IM is the first standardized measure of integration in DID. Method Eleven women with DID participated in an experiment that included a variety of tasks. They filled out questionnaires about trauma and dissociation as well as the IM. They also provided verbal results about switching among alternate identities during the study sessions. Results Participants switched among identities an average of 5.8 times during the first session, and switching was highly correlated with trauma. Integration was related to switching, though this relationship may be non-linear. Integration was not related to time in psychotherapy. Conclusions The IM provides a useful beginning to quantify and study integration and fragmentation in DID. Directions for future research are also discussed, including expanding the IM from this pilot. The IM may be useful in treatment settings to assess progress or change over time.

Depressive Symptoms and Sleep Disturbance in Adults with Histories of Childhood Abuse

Abstract Depressive symptoms including sleep disturbance are clinically apparent in many patients with histories of childhood abuse. This study investigated the nature and severity of depressive symptoms, sleep disturbance, and trauma-related symptoms in a group of female participants with abuse histories, as compared to a non-abused group of female participants with major depression. Sixty (60) participants with a history of childhood abuse and 13 participants with major depression completed several self-report instruments which examine past life experiences, depressive symptoms, post-traumatic symptoms, dissociative symptoms, and sleep problems. To control for differences in background characteristics, a subset of participants with abuse histories were matched to and compared with the 13 depressed participants. Both the abused and depressed groups showed high levels of depressive symptoms, but there were no significant differences between the groups. The abused group had significantly more intrusive post-traumatic symptoms, more dissociative symptoms, and were more likely to be afraid of falling asleep and more anxious upon mid-sleep awakening. Severity of depressive symptoms in the abused group was correlated with severity of intrusive post-traumatic symptomatology. The investigators conclude that symptoms of major depression in some patients with abuse histories may have a post-traumatic etiology, especially since intrusive reexperi-encing of past trauma may produce severe dysphoria and hopelessness. The nature of sleep disturbance in patients with abuse histories may be a clinical tool to identify patients whose depressive symptoms may be post-traumatic in origin.

Trauma and Dissociation

Abstract The inauguration of this journal is the fruit of 20 years of modern study of trauma and dissociation that began with the publication of DSM III. Beginning with Janet and Freud, this editorial traces the growth of research, teaching and treatment in these fields and examines their close link to historic waves of social recognition and denial of child abuse in Western societies. Beginning with the womens movement of the 1960s that publicized rape and incest, followed by the undeniable traumas of American Vietnam veterans, we trace the blossoming progress of research, theory and treatment techniques in the fields of trauma and dissociation, of which this journal is one of the fruits. We note three generations of trauma treatment theory that have focused successively on abreaction, on the three-stage model of trauma treatment, and finally on integration of trauma-focused work with other theoretical models in the emerging post-memory-backlash era. As this journal is launched, our field stands at a point of unprecedented theoretical sophistication and burgeoning research on memory, trauma and dissociation to assist therapists in helping trauma survivors put their victimization in the past.

Posttraumatic Responses to Childhood Abuse and Implications for Treatment

In July 1993, the National Research Council (1993) published a comprehensive volume entitled Understanding Child Abuse and Neglect. In this volume, statistics from the US Department of Health and Human Services documented reports of child maltreatment in 1990 involving more than 2.7 million children. Not surprisingly, childhood trauma, usually in the form of childhood physical, sexual, or emotional abuse, or profound neglect, is a common feature in psychiatric patients. In recent years, clinical observations concerning childhood abuse and research studies have found that childhood physical and/or sexual abuse is reported in the histories of nearly two thirds of adult female psychiatric patients (Bryer, Nelson, Miller, & Krol, 1987; Chu & Dill, 1990; Surrey, Swett, Michaels, & Levin, 1990). Through clinical observations and recent research, the impact of both severe childhood abuse and the dysfunctional environments in which abuse occurs have increasingly become more clearly defined.

A Classic Revisited and Some Classy New Research

This issue of the Journal of Trauma & Dissociation brings a long awaited update of George Fraser’s Dissociative Table Technique paper. The original paper, “The Dissociative Table Technique: A Strategy for Working with Ego States in Dissociative Disorders and Ego-State Therapy,” was published in 1991 in Dissociation: Progress in the Dissociative Disorders, the predecessor of this journal. Fraser’s original work drew on the ideas of pioneers in the field who looked for ways to help Dissociative Identity Disorder (DID) patients find ways to negotiate and communicate internally. For example, the late Dr. David Caul, a major teacher in the Dissociative Disorders field in the 1980s, described “internal group therapy” in which alter personalities would visualize themselves sitting around a room and taking turns talking to each other. In Dr. Fraser’s original paper, DID patients were asked to visualize their alter personalities sitting around a table, and talking in turn when in a “spotlight.” This ingenious technique allowed patients to perceive

A Decline in the Abuse of Children

In the 1970s, man dated re port ing of sus pected child abuse to child pro tec tive ser vices was es tab lished. Into the 1990s, re ported cases rose steadily, reach ing 3 mil lion cases in 1995 (U.S. De part ment of Health and Hu man Ser vices, 1997). How ever, the most re cent re port for 1998 (U.S. De part ment of Health and Hu man Ser vices, 2000) shows a steady de cline in child abuse or ne glect to an in ci dence of 12.9 per 1,000 chil dren, the low est num ber in more than 10 years. The ap par ent de creas ing in ci dence of child mal treat ment is in marked con trast to the trends in the late 1980s and early 1990s. The Third Na tional In ci dence Study (NIS-3) (U.S. De part ment of Health and Hu man Ser vices, 1996), es ti mated that in 1993 1,553,800 chil dren were mod er ately or se verely harmed as a re sult of abuse or ne glect. Most were vic tims of ne glect (57%), but sub stan tial num bers ex pe ri enced sex ua l abuse (14%), phys i cal abuse (25%) and emo tional abuse (13%). An es ti mated 1,500 chil dren died as a re sult of their abuse. Com paring these sta tis tics to a sim i lar study done in 1986 (U.S. De part ment of Health and Hu man Ser vices, 1988), the num ber of abused and ne glected chil dren in 1993 was two-thirds higher than in the 1986 study. Even tak ing