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Childhood Traumatic Experiences, Dissociative Symptoms, and Dissociative Disorder Comorbidity Among Patients With Panic Disorder: A Preliminary Study a
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Cenk Ural MD , Hasan Belli MD , Mahir Akbudak MD & Abdulkadir Tabo MD
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Department of Psychiatry, Bagcilar Education and Research Hospital, Istanbul, Turkey b
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Department of Psychiatry, Bakırkoy Mazhar Osman Education and Research Hospital for Mental Health and Neurological Diseases, Istanbul, Turkey Accepted author version posted online: 26 May 2015.
To cite this article: Cenk Ural MD, Hasan Belli MD, Mahir Akbudak MD & Abdulkadir Tabo MD (2015) Childhood Traumatic Experiences, Dissociative Symptoms, and Dissociative Disorder Comorbidity Among Patients With Panic Disorder: A Preliminary Study, Journal of Trauma & Dissociation, 16:4, 463-475, DOI: 10.1080/15299732.2015.1019175 To link to this article: http://dx.doi.org/10.1080/15299732.2015.1019175
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Journal of Trauma & Dissociation, 16:463–475, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1529-9732 print/1529-9740 online DOI: 10.1080/15299732.2015.1019175
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Childhood Traumatic Experiences, Dissociative Symptoms, and Dissociative Disorder Comorbidity Among Patients With Panic Disorder: A Preliminary Study CENK URAL, MD, HASAN BELLI, MD, and MAHIR AKBUDAK, MD Department of Psychiatry, Bagcilar Education and Research Hospital, Istanbul, Turkey
ABDULKADIR TABO, MD Department of Psychiatry, Bakırkoy Mazhar Osman Education and Research Hospital for Mental Health and Neurological Diseases, Istanbul, Turkey
This study assessed childhood trauma history, dissociative symptoms, and dissociative disorder comorbidity in patients with panic disorder (PD). A total of 92 psychotropic drug–naive patients with PD, recruited from outpatient clinics in the psychiatry department of a Turkish hospital, were involved in the study. Participants were assessed using the Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID-D), Dissociation Questionnaire, Panic and Agoraphobia Scale, Panic Disorder Severity Scale, and Childhood Trauma Questionnaire. Of the patients with PD, 18 (19%) had a comorbid dissociative disorder diagnosis on screening with the SCID-D. The most prevalent disorders were dissociative disorder not otherwise specified, dissociative amnesia, and depersonalization disorders. Patients with a high degree of dissociation symptoms and dissociative disorder comorbidity had more severe PD than those without ( p < .05). All of the childhood trauma subscales used were correlated with the severity of symptoms of dissociation and PD. Among all of the subscales, the strongest relationship was with childhood emotional abuse. Logistic regression analysis showed that emotional abuse and severity of PD were independently associated with dissociative disorder. In our study, a significant proportion of the patients with Received 24 September 2014; accepted 6 February 2015. Address correspondence to Hasan Belli, MD, Ba˘gcılar E˘gitim ve Ara¸stırma Hastanesi, Pskiyatri Klini˘gi, Ba˘gcılar/I˙ stanbul, Turkey. E-mail: [email protected] 463
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PD had concurrent diagnoses of dissociative disorder. We conclude that the predominance of PD symptoms at admission should not lead the clinician to overlook the underlying dissociative process and associated traumatic experiences among these patients.
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KEYWORDS childhood trauma, dissociative disorders, panic disorder
dissociative
symptoms,
Dissociative disorders are considered common both in clinical populations and in the community in general (Sar, 2011). According to recent research, their frequency is estimated to be 5.6% to 10% in the general population (Dell & O’Neil, 2011). Despite the fact that they fall into a separate diagnostic category, dissociative symptoms are observed together with almost all other psychiatric disorders. They can affect the clinical stream during treatment for the psychiatric disorders with which they are found (Sar & Ross, 2006). Dissociative symptoms are frequently associated with borderline personality disorder (Sar, Akyüz, Kugu, Ozturk, & Ertem-Vehid, 2006; Sar et al., 2003), conversion disorder (Sar, Akyüz, Kundakçı, Kızıltan, & Dogan, 2004), obsessive-compulsive disorder (Rufer et al., 2006), and substance use disorder (Karadag et al., 2005). Dissociative subtypes of posttraumatic stress disorder and schizophrenic disorder are increasingly accepted by clinicians and researchers as valid constructs (Lanius et al., 2010; Ross, 1997; Sar et al., 2010). The relationship between panic disorder (PD) and dissociation is well known (Ball, Robinson, Shekhar, & Walsh, 1997; Cassano et al., 1989; Márquez, Seguí, García, Canet, & Ortiz, 2001; Miller, Brown, DiNardo, & Barlow, 1994; Muris, Merckelbach, & Peeters, 2003). Panic attack has a dissociative symptom as a criterion, although the diagnosis may also be given in the absence of depersonalization or derealization (Marshall, Schneier, & Lin, 2000). PD is common to anxiety disorders and is a significant marker of risk for the broader development and manifestation of psychopathology. Thus, panic attacks may be utilized as a specifier or as a dimension across all Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV ) diagnoses (Ball et al., 1997; Cassano et al., 1989; Márquez et al., 2001; Miller et al., 1994; Muris et al., 2003). Some studies have shown that dissociative experiences reduce response to treatment in patients with PD (Ball et al., 1997; Gulsun, Doruk, Uzun, Turkbay, & Ozsahin, 2007; Michelson, June, Vives, Testa, & Marchione, 1998). However, only a subgroup of PD patients experience depersonalization or derealization during panic attacks (Marshall et al., 2000). Moreover, studies screening for dissociative disorders among subjects with PD are lacking. In the etiology of dissociation, traumatic experiences, especially childhood abuse, play an important role. Dissociation functions as the
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autohypnotic defense mechanism that defends the psychological wholeness of the individual against these traumas (Dancu, Riggs, Hearst-Ikeda, Shoyer, & Foa, 1996; Draijer & Langeland, 1999; Kaplow, Saxe, & Putnam, 2006; Keaney & Farley, 1996; Lochner et al., 2002; Mulder, Beautrais, & Joyce, 1998; Zlotnick, Shea, Pearlstein, & Simpson, 1996; Zlotnick et al., 1995). In addition, childhood trauma and dissociation are independently associated with other indicators of mental health disturbance, such as suicidality and self-mutilation (Zoroglu, Tuzun, Sar, & Tutkun, 2003). The relationship between traumatic childhood experiences and dissociation can be linked to psychiatric disorders such as schizophrenia (Sar et al., 2010), posttraumatic stress disorder (Evren, Sar, Dalbudak, Cetin, & Durkaya, 2011), and conversion disorder (Sar et al., 2004). Childhood trauma has also been reported as a risk factor for PD (Kessler, Davis, & Kendler, 1997; Stein et al., 1996; Walker et al., 1992). Dissociative symptomatology can be a key factor in failure to respond to treatment. This condition can involve not only resistance to psychotherapy but also an adequate response to pharmacotherapy (Gulsun et al., 2007; Michelson et al., 1998). Thus, consideration of the relationship between dissociation, PD, and childhood trauma is not merely related to diagnosis but also relevant to treatment. To determine the scope of this relationship, the present study sought to determine the prevalence of diagnosis of a DSM–IV dissociative disorder among patients who were suffering from PD. We postulate that the severity of PD could be correlated with the level of dissociation and childhood trauma experiences.
MATERIAL AND METHODS All patients admitted for the first time to the Psychiatric Outpatient Unit of Bagcilar Education and Research Hospital in Istanbul, Turkey, during an 11-month period (from May 5, 2012, to April 10, 2013) and who had a clinical diagnosis of PD (with or without agoraphobia) were considered for participation in the study (n = 101). Patients were diagnosed by experienced clinicians as presenting PD according to DSM-IV criteria. Exclusion criteria included age younger than 18 years, presence of severe physical illnesses, neurologic diseases (particularly seizure disorders), major affective and psychotic disorders, and substance abuse or dependence disorders. Four patients were excluded according to these criteria, and five patients chose not to participate. In all, 92 psychotropic drug–naive patients participated in this study. Written consent was obtained from the patients once they had been informed of the aim of the study and the methods involved. Approval for the research was obtained from the Ethics Committee of Bagcilar Education and Research Hospital.
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Four clinical researchers interviewed the patients. Demographic data, including current age, education level, current employment status, and onset age of the illness, were obtained. First the patients were diagnosed according to the DSM–IV, Panic Disorder Severity Scale (PDSS), Panic and Agoraphobia Scale (PAS), Dissociation Questionnaire (DIS-Q), Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID-D), and Childhood Trauma Questionnaire (CTQ-53). This process was undertaken by several different clinicians. PD and agoraphobia symptoms were assessed using both the PDSS and PAS. The DIS-Q was used to measure dissociative symptoms, and the CTQ53 measured traumatic experiences. Most interviews included in the study were conducted by two psychiatrists, though the SCID-D interviews were conducted by three. All interviewers had extensive experience in the administration of the interviews and were blind to the results of the other assessments.
Study Measures SCID-D. The SCID-D is a semistructured interview tool developed by Steinberg (1994). It is used to explore and determine dissociative disorders according to the DSM–IV. Using this interview tool, one can diagnose dissociative identity disorder, depersonalization disorder, dissociative amnesia, dissociative fugue, and dissociative disorder not otherwise specified (DDNOS). Because the dissociative identity disorder diagnosis can involve symptoms of all other diagnosis categories, it is typically established on its own. If this diagnosis is established, then generally no other diagnoses are given. The Turkish version of the SCID-D was investigated in a study of 36 patients with a dissociative disorder and 36 control subjects; it yielded 100% agreement for the presence and absence of a dissociative disorder (Kundakci, Sar, Kiziltan, & Yargic, 2014). DIS-Q. This scale, which was developed by Vanderlinden, Van Dyck, Vandereycken, Vertommen, and Jan Verkes (1993), is used to screen for dissociative experience and disruptions and to measure their severity. It can be used for patients with psychiatric disorders and traumatic experiences and for general screening purposes. Instructions are given in the introduction section of the scale, and patients are asked to mark the most appropriate option for their condition. The measure consists of a total of 63 questions, and the subject marks one option for each question. Each item is scored between 1 and 5 points; the mean score is obtained by dividing the total score by 63 (Svedin, Nilsson, & Lindell, 2004). Cronbach’s alpha coefficient for the scale, which was evaluated for validity and reliability in Turkey by Sar, Kiziltan, Kundakci, Bakim, and Yargic (1997), is .98. This scale can distinguish subjects with dissociative disorder from healthy individuals, patients with schizophrenia, or those with bipolar mood disorder. There is a high
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correlation between the Dissociative Experience Scale score and DIS-Q score (r = .90, p < .001). According to the results of the Turkish study, there is a high probability of dissociative disorder in individuals demonstrating a total score of 2.5 or greater. PDSS. This scale was developed by Shear et al. (1997), was tested for reliability and validity (Shear et al., 2001), and has been given evidencebased guidelines for interpreting the scores (Furukawa et al., 2009). The PDSS is a simple, efficient way for clinicians to rate severity in patients with established diagnoses of PD. The PDSS has excellent interrater reliability, moderate internal consistency, and favorable levels of validity and sensitivity to change. Individual items showed good convergent and discriminant validity. Analysis suggested that a two-factor model fits the data best. Validity and reliability in Turkey was evaluated by Monkul et al. (2004). PAS. The PAS is a scale that serves to measure PD intensity, based on observer and personal statements, on a five-point Likert scale consisting of 14 questions each. It is compatible with the DSM–IV diagnostic systems. The PAS was developed for the evaluation of clinical studies investigating the efficacy of drug and psychological therapies (Bandelow, 1995) and has been adapted into the Turkish language (Tural, Fidaner, Alkin, & Bandelow, 2000). CTQ-53. The CTQ is a 53-item self-report instrument developed by Bernstein, Fink, and Handelsman (1994). It evaluates emotional, physical, and sexual abuse during childhood as well as childhood physical and emotional neglect. Possible scores for each type of childhood trauma range from 1 to 5. The sum of the scores derived from each trauma type provides the total score, ranging from 5 to 25. The measure also includes a three-item Minimization/Denial scale indicating the potential underreporting of maltreatment. The three items composing the Minimization/Denial scale are dichotomized (never = 0, all other responses = 1) and summed; a total of 1 or greater “suggests the possible underreporting of maltreatment” (false negatives). Validity and reliability in Turkey was tested by Sar, Ozturk, and Ikikardes (2012).
Statistical Analysis SPSS Version 17 was used for statistical analysis. Groups were compared using either the chi-square test or Student’s t test. Student’s t test and oneway analysis of variance were used for quantitative data comparison between groups with normally distributed parameters. To compare groups when data were not normally distributed, we used the Mann–Whitney U test and Kruskal–Wallis test. Logistic regression analysis was used to identify relevant factors associated with dissociative disorder. Adjusted odds ratios and the corresponding Wald confidence intervals were calculated using regression coefficients. The threshold of statistical significance was set at p < .05.
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RESULTS All patients were between 18 and 52 years of age; the average age of the participants was 31.98 ± 7.32 years. The majority of patients (n = 58, 63%) were female, and 37% (n = 34) of the patients were male. The mean onset age of the disorder was 27.5 ± 8.1 years (range = 14–52 years). The mean duration of the last PD episode was 3.0 ± 2.8 months (range = 1–15 months). Finally, 48% (n = 44) of the patients had graduated from middle school, and 65% (n = 60) were married (see Table 1). Distributions of SCID-D diagnoses are shown in Table 2. A total of 18 (19%) of the patients with PD had a diagnosis of comorbid dissociative disorder on screening with the SCID-D. The most common diagnosis was DDNOS, with nine patients (9.8%) diagnosed as having this. Four patients (4.3%) were diagnosed with dissociative amnesia, three patients (3.3%) were diagnosed with depersonalization disorder, and two patients (2.2%) were diagnosed with dissociative identity disorder (see Table 2). PDSS scores ranged from 7 to 23, and the mean was 14.5 ± 4.1. PAS scores ranged from 11 to 41, and the mean was 24.5 ± 7.6. DIS-Q scores ranged from 1.1 to 3.9, with a mean of 2.2 ± 0.8. CTQ-53 scores ranged from 5.25 to 11.98, and the mean was 7.58 ± 1.49. There was a statistically significant difference in all scores between patients diagnosed dissociative disorder and nondiagnosed (p < .05; see Table 3). Both the PAS and PDSS scores of patients with dissociative disorder revealed that these patients had more severe PD than patients without TABLE 1 Comparison of Sociodemographic Variables Between Patients With and Without Dissociative Disorder
Variable Age, M ± SD (years) Onset age of the PD, M ± SD (years) Duration of the PD episode, M ± SD (months) Sex, n (%) Female Male Marital status, n (%) Married Single Education level, n (%) Primary Middle High
Overall (n = 92)
Dissociative disorder absent (n = 74)
Dissociative disorder present (n = 18)
p
31.98 ± 7.32 27.46 ± 8.05
32.35 ± 7.58 27.91 ± 8.23
30.44 ± 6.04 25.61 ± 7.19
.378 .272
3 ± 2.88
2.90 ± 2.95
3.39 ± 2.61
.125
58 34
63.0 37.0
44 30
59.5 40.5
14 4
77.8 22.8
.149
60 32
65.2 34.8
49 25
66.2 33.8
11 7
61.1 38.9
.784
30 44 18
32.6 47.8 19.6
21 36 17
28.4 48.6 23.0
9 8 1
50.00 44.4 5.6
.112
Notes: Mann–Whitney U, Kruskal–Wallis, and Student’s t tests were used. PD = panic disorder.
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TABLE 2 Structured Clinical Interview for DSM–IV Dissociative Disorders Comorbidity Among Patients With Panic Disorder (n = 18) Comorbid diagnosis
n
%
Dissociative disorder not otherwise specified Amnesia Depersonalization Dissociative identity disorder
9 4 3 2
9.8 4.3 3.3 2.2
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TABLE 3 Comparison of Scale Scores Between Patients With and Without Dissociative Disorder Overall (n = 92) Scale
Range
M ± SD
Dissociative disorder present (n = 18) Range
M ± SD
Dissociative disorder absent (n = 74) Range
PDSS 7−23 14.53 ± 4.14 13−23 17.44 ± 3.01 7−23 p .001 PAS 11−41 24.53 ± 7.62 17−41 31.00 ± 6.49 11−38 p .000 DIS-Q 1.12−3.85 2.08 ± 0.79 2.77−3.85 3.27 ± 0.27 1.12−3.68 p .000 CTQ-53 5.25−11.98 7.58 ± 1.49 5.93−11.98 9.46 ± 1.62 5.25−9.35 p .000
M ± SD 13.82 ± 4.08 22.96 ± 7.05 1.78 ± 0.57 7.12 ± 1.03
Notes: Mann–Whitney U and Student’s t tests were used. PDSS = Panic Disorder Severity Scale; PAS = Panic and Agoraphobia Scale; DIS-Q = Dissociation Questionnaire; CTQ-53 = Childhood Trauma Questionnaire.
this disorder (p < .05). Similarly, patients with more severe symptoms of dissociation disorder had more pronounced PD (p < .05). There was a statistically significant positive correlation between PAS scores and DIS-Q scores (r = .58, p < .05). Furthermore, the positive correlation between PDSS scores and DIS-Q scores was also significant (r = .43, p < .05). Likewise, the positive correlation between CTQ-53 and DIS-Q scores was significant (r = .57, p < .05). The quantitative measures demonstrated that patients with dissociative disorder had significantly higher scores for all types of abuse and neglect as well as a higher score for total childhood trauma (see Table 4). A stepwise logistic regression analysis was conducted with the presence of dissociative disorder comorbidity as the dependent variable. At the same time, we entered all significant variables in a single multivariate model involving five childhood trauma scores derived from the CTQ and PDSS scores. The emotional abuse trauma scores (odds ratio = 10.5, 95% confidence interval [2.7, 41.2], p < .05) and severity of PD (odds ratio = 1.4, 95% confidence interval [1.2, 1.8], p < .05) were the two independent variables associated with dissociative disorder in the sample of patients with PD.
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TABLE 4 Mean Severity of Childhood Trauma Among Panic Disorder Patients Overall and by Dissociative Disorder Status
Variable
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CTQ-53 total score Emotional neglect Physical abuse Emotional abuse Physical neglect Sexual abuse Minimization
Overall (n = 92) 7.58 2.42 1.27 1.56 1.23 1.09 0.37
± ± ± ± ± ± ±
1.49 0.70 0.39 0.56 0.31 0.36 0.60
Dissociative disorder present (n = 18) 9.46 2.87 1,59 2.17 1.42 1.40 0.33
± ± ± ± ± ± ±
1.62 0.69 0.57 0.67 0.40 0.75 0.59
Dissociative disorder absent (n = 74)
t
p
± ± ± ± ± ± ±
7.60 3.16 2.77 6.02 2.39 2.15 0.28
.000 .002 .012 .000 .026 .046 .779
7.12 2.31 1.20 1.41 1.18 1.02 0.38
1.03 0.66 0.28 0.42 0.27 0.07 0.61
p
Notes: CTQ-53 = Childhood Trauma Questionnaire.
DISCUSSION This is a study of the overlap between PD and dissociative psychopathology in relation to abuse in early life. In our study, 18 (19%) of the patients with PD had a comorbid dissociative disorder diagnosis on screening with the SCID-D. The most prevalent disorders were DDNOS, dissociative amnesia, and depersonalization disorder. A stepwise logistic regression analysis conducted on quantitative scores demonstrated that emotional abuse and severity of PD had a statistically significant effect on dissociation scores in patients. In addition, patients with severe dissociation symptoms had more pronounced PD. An earlier study also found that 18% of patients with obsessivecompulsive disorder had at least one dissociative disorder diagnosis on screening with the SCID-D (Belli, Ural, Vardar, Yesılyurt, & Öncü, 2012). Other work has shown that lifetime prevalence rates of dissociative disorders were around 10% both in clinical populations and in the community (Sar, 2011). Many individuals with dissociative disorder present with a comorbid disorder. Dissociative symptoms may accompany almost all psychiatric disorders. However, for some of these psychiatric disorders, comorbid dissociation may also be considered a concurrent diagnosis depending on the complexity of the prevailing dissociative symptom pattern (Sar & Ross, 2006). Alteration in memory and consciousness due to dissociation may affect the presentation symptoms of comorbid disorders. Patients with dissociative disorders have a relatively high number of comorbid diagnoses, which may prevent clinicians from recognizing the dissociative disorder in the overall picture (Ginzburg, Somer, Tamarkin, & Kramer, 2010). In our study, a significant proportion of the patients with PD had a concurrent diagnosis of dissociative disorder. In general clinical practice, patients with severe PD symptoms may present with comorbid dissociative disorder and a high level of dissociative symptoms. They may conceal, or may not be fully aware of, disruptions in consciousness, amnesia, or other
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dissociative symptoms. These findings suggest that, at least for a subgroup of patients, PD is part of a dissociative process that reveals complex dissociative disorders such as DDNOS. The most parsimonious explanation, particularly for the more severe dissociative disorders, would be misdiagnosis. Another explanation is that PD symptoms may be a consequence of an undiagnosed dissociative disorder. Information gathered from family and suspicious symptoms may be helpful in diagnosis. High scores on DIS-Q-like scales should alert the clinician to the possibility of more complicated conditions in patients with PD. Though DIS-Q-like scales are very easy to implement in patients, implementation of the SCID-D is more difficult and requires relevant clinical experience. Some authors suggest that a high dissociation level is also a predictor of a worse response to cognitive behavior therapy in PD (Ball et al., 1997; Gulsun et al., 2007). In our study, all of the childhood trauma subscales were correlated with the severity of symptoms of dissociation and PD. Among all of the subscales, the strongest relationship was with childhood emotional abuse. Our findings indicate the importance of therapies targeting childhood traumatic memories among patients with a high frequency of dissociative symptoms. Childhood trauma has also been reported as a risk factor for PD (Kessler et al., 1997; Stein et al., 1996; Walker et al., 1992). Memory of traumatic experiences is associated with functional somatic symptoms and somatization habits. These experiences might be presented with somatization mechanisms in the mind. The patient might deal with the traumatic memories using dissociation (Tutkun, Savas, Zoroglu, & Esgi, 2004). Those with childhood traumas and dissociative symptoms usually experience affect dysregulation (van der Kolk, Pelcovitz, & Roth, 1996). These fluctuations occur with a series of painful introspective mechanisms (Somer, 2002). We propose that dissociation is a defense mechanism against traumatic memories, and this leads to emotional dysregulation, somatization, anxiety associated with panic attacks, and expectation anxiety. The main strengths of our study are that the patients were interviewed and assessed thoroughly, and the SCID-D was used to explore and determine the dissociative disorders according to the DSM–IV. Therefore, complicated dissociative disorders could be detected. But we did not screen somatoform symptoms as an important subgroup, though they may be linked to functional dissociative and PD symptoms. Moreover, our study is limited by its relatively small sample size, which made the evaluation of different subgroups of PD and its cross-sectional nature impossible. New studies involving large numbers of patients are now required. This study should be regarded as a preliminary one, and our findings should be consolidated with those of large-scale cohort studies. We conclude that dissociative comorbidity, symptoms, and childhood traumatic experiences among patients with PD should alert clinicians to the severity and complexity of the disorder. The predominance of PD
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symptoms in patients at admission should not lead the clinician to overlook the underlying dissociative process and traumatic experiences among these patients. Therapists should also address intrapsychic and developmentally acquired stress-inducing factors, including conflicts, existential traumas, and occasionally even dissociated personality elements.
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Journal of Trauma & Dissociation Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjtd20
Childhood Traumatic Experiences, Dissociative Symptoms, and Dissociative Disorder Comorbidity Among Patients With Panic Disorder: A Preliminary Study a
a
a
Cenk Ural MD , Hasan Belli MD , Mahir Akbudak MD & Abdulkadir Tabo MD
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Department of Psychiatry, Bagcilar Education and Research Hospital, Istanbul, Turkey b
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Department of Psychiatry, Bakırkoy Mazhar Osman Education and Research Hospital for Mental Health and Neurological Diseases, Istanbul, Turkey Accepted author version posted online: 26 May 2015.
To cite this article: Cenk Ural MD, Hasan Belli MD, Mahir Akbudak MD & Abdulkadir Tabo MD (2015) Childhood Traumatic Experiences, Dissociative Symptoms, and Dissociative Disorder Comorbidity Among Patients With Panic Disorder: A Preliminary Study, Journal of Trauma & Dissociation, 16:4, 463-475, DOI: 10.1080/15299732.2015.1019175 To link to this article: http://dx.doi.org/10.1080/15299732.2015.1019175
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Journal of Trauma & Dissociation, 16:463–475, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1529-9732 print/1529-9740 online DOI: 10.1080/15299732.2015.1019175
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Childhood Traumatic Experiences, Dissociative Symptoms, and Dissociative Disorder Comorbidity Among Patients With Panic Disorder: A Preliminary Study CENK URAL, MD, HASAN BELLI, MD, and MAHIR AKBUDAK, MD Department of Psychiatry, Bagcilar Education and Research Hospital, Istanbul, Turkey
ABDULKADIR TABO, MD Department of Psychiatry, Bakırkoy Mazhar Osman Education and Research Hospital for Mental Health and Neurological Diseases, Istanbul, Turkey
This study assessed childhood trauma history, dissociative symptoms, and dissociative disorder comorbidity in patients with panic disorder (PD). A total of 92 psychotropic drug–naive patients with PD, recruited from outpatient clinics in the psychiatry department of a Turkish hospital, were involved in the study. Participants were assessed using the Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID-D), Dissociation Questionnaire, Panic and Agoraphobia Scale, Panic Disorder Severity Scale, and Childhood Trauma Questionnaire. Of the patients with PD, 18 (19%) had a comorbid dissociative disorder diagnosis on screening with the SCID-D. The most prevalent disorders were dissociative disorder not otherwise specified, dissociative amnesia, and depersonalization disorders. Patients with a high degree of dissociation symptoms and dissociative disorder comorbidity had more severe PD than those without ( p < .05). All of the childhood trauma subscales used were correlated with the severity of symptoms of dissociation and PD. Among all of the subscales, the strongest relationship was with childhood emotional abuse. Logistic regression analysis showed that emotional abuse and severity of PD were independently associated with dissociative disorder. In our study, a significant proportion of the patients with Received 24 September 2014; accepted 6 February 2015. Address correspondence to Hasan Belli, MD, Ba˘gcılar E˘gitim ve Ara¸stırma Hastanesi, Pskiyatri Klini˘gi, Ba˘gcılar/I˙ stanbul, Turkey. E-mail: [email protected] 463
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PD had concurrent diagnoses of dissociative disorder. We conclude that the predominance of PD symptoms at admission should not lead the clinician to overlook the underlying dissociative process and associated traumatic experiences among these patients.
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KEYWORDS childhood trauma, dissociative disorders, panic disorder
dissociative
symptoms,
Dissociative disorders are considered common both in clinical populations and in the community in general (Sar, 2011). According to recent research, their frequency is estimated to be 5.6% to 10% in the general population (Dell & O’Neil, 2011). Despite the fact that they fall into a separate diagnostic category, dissociative symptoms are observed together with almost all other psychiatric disorders. They can affect the clinical stream during treatment for the psychiatric disorders with which they are found (Sar & Ross, 2006). Dissociative symptoms are frequently associated with borderline personality disorder (Sar, Akyüz, Kugu, Ozturk, & Ertem-Vehid, 2006; Sar et al., 2003), conversion disorder (Sar, Akyüz, Kundakçı, Kızıltan, & Dogan, 2004), obsessive-compulsive disorder (Rufer et al., 2006), and substance use disorder (Karadag et al., 2005). Dissociative subtypes of posttraumatic stress disorder and schizophrenic disorder are increasingly accepted by clinicians and researchers as valid constructs (Lanius et al., 2010; Ross, 1997; Sar et al., 2010). The relationship between panic disorder (PD) and dissociation is well known (Ball, Robinson, Shekhar, & Walsh, 1997; Cassano et al., 1989; Márquez, Seguí, García, Canet, & Ortiz, 2001; Miller, Brown, DiNardo, & Barlow, 1994; Muris, Merckelbach, & Peeters, 2003). Panic attack has a dissociative symptom as a criterion, although the diagnosis may also be given in the absence of depersonalization or derealization (Marshall, Schneier, & Lin, 2000). PD is common to anxiety disorders and is a significant marker of risk for the broader development and manifestation of psychopathology. Thus, panic attacks may be utilized as a specifier or as a dimension across all Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV ) diagnoses (Ball et al., 1997; Cassano et al., 1989; Márquez et al., 2001; Miller et al., 1994; Muris et al., 2003). Some studies have shown that dissociative experiences reduce response to treatment in patients with PD (Ball et al., 1997; Gulsun, Doruk, Uzun, Turkbay, & Ozsahin, 2007; Michelson, June, Vives, Testa, & Marchione, 1998). However, only a subgroup of PD patients experience depersonalization or derealization during panic attacks (Marshall et al., 2000). Moreover, studies screening for dissociative disorders among subjects with PD are lacking. In the etiology of dissociation, traumatic experiences, especially childhood abuse, play an important role. Dissociation functions as the
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autohypnotic defense mechanism that defends the psychological wholeness of the individual against these traumas (Dancu, Riggs, Hearst-Ikeda, Shoyer, & Foa, 1996; Draijer & Langeland, 1999; Kaplow, Saxe, & Putnam, 2006; Keaney & Farley, 1996; Lochner et al., 2002; Mulder, Beautrais, & Joyce, 1998; Zlotnick, Shea, Pearlstein, & Simpson, 1996; Zlotnick et al., 1995). In addition, childhood trauma and dissociation are independently associated with other indicators of mental health disturbance, such as suicidality and self-mutilation (Zoroglu, Tuzun, Sar, & Tutkun, 2003). The relationship between traumatic childhood experiences and dissociation can be linked to psychiatric disorders such as schizophrenia (Sar et al., 2010), posttraumatic stress disorder (Evren, Sar, Dalbudak, Cetin, & Durkaya, 2011), and conversion disorder (Sar et al., 2004). Childhood trauma has also been reported as a risk factor for PD (Kessler, Davis, & Kendler, 1997; Stein et al., 1996; Walker et al., 1992). Dissociative symptomatology can be a key factor in failure to respond to treatment. This condition can involve not only resistance to psychotherapy but also an adequate response to pharmacotherapy (Gulsun et al., 2007; Michelson et al., 1998). Thus, consideration of the relationship between dissociation, PD, and childhood trauma is not merely related to diagnosis but also relevant to treatment. To determine the scope of this relationship, the present study sought to determine the prevalence of diagnosis of a DSM–IV dissociative disorder among patients who were suffering from PD. We postulate that the severity of PD could be correlated with the level of dissociation and childhood trauma experiences.
MATERIAL AND METHODS All patients admitted for the first time to the Psychiatric Outpatient Unit of Bagcilar Education and Research Hospital in Istanbul, Turkey, during an 11-month period (from May 5, 2012, to April 10, 2013) and who had a clinical diagnosis of PD (with or without agoraphobia) were considered for participation in the study (n = 101). Patients were diagnosed by experienced clinicians as presenting PD according to DSM-IV criteria. Exclusion criteria included age younger than 18 years, presence of severe physical illnesses, neurologic diseases (particularly seizure disorders), major affective and psychotic disorders, and substance abuse or dependence disorders. Four patients were excluded according to these criteria, and five patients chose not to participate. In all, 92 psychotropic drug–naive patients participated in this study. Written consent was obtained from the patients once they had been informed of the aim of the study and the methods involved. Approval for the research was obtained from the Ethics Committee of Bagcilar Education and Research Hospital.
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Four clinical researchers interviewed the patients. Demographic data, including current age, education level, current employment status, and onset age of the illness, were obtained. First the patients were diagnosed according to the DSM–IV, Panic Disorder Severity Scale (PDSS), Panic and Agoraphobia Scale (PAS), Dissociation Questionnaire (DIS-Q), Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID-D), and Childhood Trauma Questionnaire (CTQ-53). This process was undertaken by several different clinicians. PD and agoraphobia symptoms were assessed using both the PDSS and PAS. The DIS-Q was used to measure dissociative symptoms, and the CTQ53 measured traumatic experiences. Most interviews included in the study were conducted by two psychiatrists, though the SCID-D interviews were conducted by three. All interviewers had extensive experience in the administration of the interviews and were blind to the results of the other assessments.
Study Measures SCID-D. The SCID-D is a semistructured interview tool developed by Steinberg (1994). It is used to explore and determine dissociative disorders according to the DSM–IV. Using this interview tool, one can diagnose dissociative identity disorder, depersonalization disorder, dissociative amnesia, dissociative fugue, and dissociative disorder not otherwise specified (DDNOS). Because the dissociative identity disorder diagnosis can involve symptoms of all other diagnosis categories, it is typically established on its own. If this diagnosis is established, then generally no other diagnoses are given. The Turkish version of the SCID-D was investigated in a study of 36 patients with a dissociative disorder and 36 control subjects; it yielded 100% agreement for the presence and absence of a dissociative disorder (Kundakci, Sar, Kiziltan, & Yargic, 2014). DIS-Q. This scale, which was developed by Vanderlinden, Van Dyck, Vandereycken, Vertommen, and Jan Verkes (1993), is used to screen for dissociative experience and disruptions and to measure their severity. It can be used for patients with psychiatric disorders and traumatic experiences and for general screening purposes. Instructions are given in the introduction section of the scale, and patients are asked to mark the most appropriate option for their condition. The measure consists of a total of 63 questions, and the subject marks one option for each question. Each item is scored between 1 and 5 points; the mean score is obtained by dividing the total score by 63 (Svedin, Nilsson, & Lindell, 2004). Cronbach’s alpha coefficient for the scale, which was evaluated for validity and reliability in Turkey by Sar, Kiziltan, Kundakci, Bakim, and Yargic (1997), is .98. This scale can distinguish subjects with dissociative disorder from healthy individuals, patients with schizophrenia, or those with bipolar mood disorder. There is a high
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correlation between the Dissociative Experience Scale score and DIS-Q score (r = .90, p < .001). According to the results of the Turkish study, there is a high probability of dissociative disorder in individuals demonstrating a total score of 2.5 or greater. PDSS. This scale was developed by Shear et al. (1997), was tested for reliability and validity (Shear et al., 2001), and has been given evidencebased guidelines for interpreting the scores (Furukawa et al., 2009). The PDSS is a simple, efficient way for clinicians to rate severity in patients with established diagnoses of PD. The PDSS has excellent interrater reliability, moderate internal consistency, and favorable levels of validity and sensitivity to change. Individual items showed good convergent and discriminant validity. Analysis suggested that a two-factor model fits the data best. Validity and reliability in Turkey was evaluated by Monkul et al. (2004). PAS. The PAS is a scale that serves to measure PD intensity, based on observer and personal statements, on a five-point Likert scale consisting of 14 questions each. It is compatible with the DSM–IV diagnostic systems. The PAS was developed for the evaluation of clinical studies investigating the efficacy of drug and psychological therapies (Bandelow, 1995) and has been adapted into the Turkish language (Tural, Fidaner, Alkin, & Bandelow, 2000). CTQ-53. The CTQ is a 53-item self-report instrument developed by Bernstein, Fink, and Handelsman (1994). It evaluates emotional, physical, and sexual abuse during childhood as well as childhood physical and emotional neglect. Possible scores for each type of childhood trauma range from 1 to 5. The sum of the scores derived from each trauma type provides the total score, ranging from 5 to 25. The measure also includes a three-item Minimization/Denial scale indicating the potential underreporting of maltreatment. The three items composing the Minimization/Denial scale are dichotomized (never = 0, all other responses = 1) and summed; a total of 1 or greater “suggests the possible underreporting of maltreatment” (false negatives). Validity and reliability in Turkey was tested by Sar, Ozturk, and Ikikardes (2012).
Statistical Analysis SPSS Version 17 was used for statistical analysis. Groups were compared using either the chi-square test or Student’s t test. Student’s t test and oneway analysis of variance were used for quantitative data comparison between groups with normally distributed parameters. To compare groups when data were not normally distributed, we used the Mann–Whitney U test and Kruskal–Wallis test. Logistic regression analysis was used to identify relevant factors associated with dissociative disorder. Adjusted odds ratios and the corresponding Wald confidence intervals were calculated using regression coefficients. The threshold of statistical significance was set at p < .05.
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RESULTS All patients were between 18 and 52 years of age; the average age of the participants was 31.98 ± 7.32 years. The majority of patients (n = 58, 63%) were female, and 37% (n = 34) of the patients were male. The mean onset age of the disorder was 27.5 ± 8.1 years (range = 14–52 years). The mean duration of the last PD episode was 3.0 ± 2.8 months (range = 1–15 months). Finally, 48% (n = 44) of the patients had graduated from middle school, and 65% (n = 60) were married (see Table 1). Distributions of SCID-D diagnoses are shown in Table 2. A total of 18 (19%) of the patients with PD had a diagnosis of comorbid dissociative disorder on screening with the SCID-D. The most common diagnosis was DDNOS, with nine patients (9.8%) diagnosed as having this. Four patients (4.3%) were diagnosed with dissociative amnesia, three patients (3.3%) were diagnosed with depersonalization disorder, and two patients (2.2%) were diagnosed with dissociative identity disorder (see Table 2). PDSS scores ranged from 7 to 23, and the mean was 14.5 ± 4.1. PAS scores ranged from 11 to 41, and the mean was 24.5 ± 7.6. DIS-Q scores ranged from 1.1 to 3.9, with a mean of 2.2 ± 0.8. CTQ-53 scores ranged from 5.25 to 11.98, and the mean was 7.58 ± 1.49. There was a statistically significant difference in all scores between patients diagnosed dissociative disorder and nondiagnosed (p < .05; see Table 3). Both the PAS and PDSS scores of patients with dissociative disorder revealed that these patients had more severe PD than patients without TABLE 1 Comparison of Sociodemographic Variables Between Patients With and Without Dissociative Disorder
Variable Age, M ± SD (years) Onset age of the PD, M ± SD (years) Duration of the PD episode, M ± SD (months) Sex, n (%) Female Male Marital status, n (%) Married Single Education level, n (%) Primary Middle High
Overall (n = 92)
Dissociative disorder absent (n = 74)
Dissociative disorder present (n = 18)
p
31.98 ± 7.32 27.46 ± 8.05
32.35 ± 7.58 27.91 ± 8.23
30.44 ± 6.04 25.61 ± 7.19
.378 .272
3 ± 2.88
2.90 ± 2.95
3.39 ± 2.61
.125
58 34
63.0 37.0
44 30
59.5 40.5
14 4
77.8 22.8
.149
60 32
65.2 34.8
49 25
66.2 33.8
11 7
61.1 38.9
.784
30 44 18
32.6 47.8 19.6
21 36 17
28.4 48.6 23.0
9 8 1
50.00 44.4 5.6
.112
Notes: Mann–Whitney U, Kruskal–Wallis, and Student’s t tests were used. PD = panic disorder.
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TABLE 2 Structured Clinical Interview for DSM–IV Dissociative Disorders Comorbidity Among Patients With Panic Disorder (n = 18) Comorbid diagnosis
n
%
Dissociative disorder not otherwise specified Amnesia Depersonalization Dissociative identity disorder
9 4 3 2
9.8 4.3 3.3 2.2
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TABLE 3 Comparison of Scale Scores Between Patients With and Without Dissociative Disorder Overall (n = 92) Scale
Range
M ± SD
Dissociative disorder present (n = 18) Range
M ± SD
Dissociative disorder absent (n = 74) Range
PDSS 7−23 14.53 ± 4.14 13−23 17.44 ± 3.01 7−23 p .001 PAS 11−41 24.53 ± 7.62 17−41 31.00 ± 6.49 11−38 p .000 DIS-Q 1.12−3.85 2.08 ± 0.79 2.77−3.85 3.27 ± 0.27 1.12−3.68 p .000 CTQ-53 5.25−11.98 7.58 ± 1.49 5.93−11.98 9.46 ± 1.62 5.25−9.35 p .000
M ± SD 13.82 ± 4.08 22.96 ± 7.05 1.78 ± 0.57 7.12 ± 1.03
Notes: Mann–Whitney U and Student’s t tests were used. PDSS = Panic Disorder Severity Scale; PAS = Panic and Agoraphobia Scale; DIS-Q = Dissociation Questionnaire; CTQ-53 = Childhood Trauma Questionnaire.
this disorder (p < .05). Similarly, patients with more severe symptoms of dissociation disorder had more pronounced PD (p < .05). There was a statistically significant positive correlation between PAS scores and DIS-Q scores (r = .58, p < .05). Furthermore, the positive correlation between PDSS scores and DIS-Q scores was also significant (r = .43, p < .05). Likewise, the positive correlation between CTQ-53 and DIS-Q scores was significant (r = .57, p < .05). The quantitative measures demonstrated that patients with dissociative disorder had significantly higher scores for all types of abuse and neglect as well as a higher score for total childhood trauma (see Table 4). A stepwise logistic regression analysis was conducted with the presence of dissociative disorder comorbidity as the dependent variable. At the same time, we entered all significant variables in a single multivariate model involving five childhood trauma scores derived from the CTQ and PDSS scores. The emotional abuse trauma scores (odds ratio = 10.5, 95% confidence interval [2.7, 41.2], p < .05) and severity of PD (odds ratio = 1.4, 95% confidence interval [1.2, 1.8], p < .05) were the two independent variables associated with dissociative disorder in the sample of patients with PD.
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TABLE 4 Mean Severity of Childhood Trauma Among Panic Disorder Patients Overall and by Dissociative Disorder Status
Variable
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CTQ-53 total score Emotional neglect Physical abuse Emotional abuse Physical neglect Sexual abuse Minimization
Overall (n = 92) 7.58 2.42 1.27 1.56 1.23 1.09 0.37
± ± ± ± ± ± ±
1.49 0.70 0.39 0.56 0.31 0.36 0.60
Dissociative disorder present (n = 18) 9.46 2.87 1,59 2.17 1.42 1.40 0.33
± ± ± ± ± ± ±
1.62 0.69 0.57 0.67 0.40 0.75 0.59
Dissociative disorder absent (n = 74)
t
p
± ± ± ± ± ± ±
7.60 3.16 2.77 6.02 2.39 2.15 0.28
.000 .002 .012 .000 .026 .046 .779
7.12 2.31 1.20 1.41 1.18 1.02 0.38
1.03 0.66 0.28 0.42 0.27 0.07 0.61
p
Notes: CTQ-53 = Childhood Trauma Questionnaire.
DISCUSSION This is a study of the overlap between PD and dissociative psychopathology in relation to abuse in early life. In our study, 18 (19%) of the patients with PD had a comorbid dissociative disorder diagnosis on screening with the SCID-D. The most prevalent disorders were DDNOS, dissociative amnesia, and depersonalization disorder. A stepwise logistic regression analysis conducted on quantitative scores demonstrated that emotional abuse and severity of PD had a statistically significant effect on dissociation scores in patients. In addition, patients with severe dissociation symptoms had more pronounced PD. An earlier study also found that 18% of patients with obsessivecompulsive disorder had at least one dissociative disorder diagnosis on screening with the SCID-D (Belli, Ural, Vardar, Yesılyurt, & Öncü, 2012). Other work has shown that lifetime prevalence rates of dissociative disorders were around 10% both in clinical populations and in the community (Sar, 2011). Many individuals with dissociative disorder present with a comorbid disorder. Dissociative symptoms may accompany almost all psychiatric disorders. However, for some of these psychiatric disorders, comorbid dissociation may also be considered a concurrent diagnosis depending on the complexity of the prevailing dissociative symptom pattern (Sar & Ross, 2006). Alteration in memory and consciousness due to dissociation may affect the presentation symptoms of comorbid disorders. Patients with dissociative disorders have a relatively high number of comorbid diagnoses, which may prevent clinicians from recognizing the dissociative disorder in the overall picture (Ginzburg, Somer, Tamarkin, & Kramer, 2010). In our study, a significant proportion of the patients with PD had a concurrent diagnosis of dissociative disorder. In general clinical practice, patients with severe PD symptoms may present with comorbid dissociative disorder and a high level of dissociative symptoms. They may conceal, or may not be fully aware of, disruptions in consciousness, amnesia, or other
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dissociative symptoms. These findings suggest that, at least for a subgroup of patients, PD is part of a dissociative process that reveals complex dissociative disorders such as DDNOS. The most parsimonious explanation, particularly for the more severe dissociative disorders, would be misdiagnosis. Another explanation is that PD symptoms may be a consequence of an undiagnosed dissociative disorder. Information gathered from family and suspicious symptoms may be helpful in diagnosis. High scores on DIS-Q-like scales should alert the clinician to the possibility of more complicated conditions in patients with PD. Though DIS-Q-like scales are very easy to implement in patients, implementation of the SCID-D is more difficult and requires relevant clinical experience. Some authors suggest that a high dissociation level is also a predictor of a worse response to cognitive behavior therapy in PD (Ball et al., 1997; Gulsun et al., 2007). In our study, all of the childhood trauma subscales were correlated with the severity of symptoms of dissociation and PD. Among all of the subscales, the strongest relationship was with childhood emotional abuse. Our findings indicate the importance of therapies targeting childhood traumatic memories among patients with a high frequency of dissociative symptoms. Childhood trauma has also been reported as a risk factor for PD (Kessler et al., 1997; Stein et al., 1996; Walker et al., 1992). Memory of traumatic experiences is associated with functional somatic symptoms and somatization habits. These experiences might be presented with somatization mechanisms in the mind. The patient might deal with the traumatic memories using dissociation (Tutkun, Savas, Zoroglu, & Esgi, 2004). Those with childhood traumas and dissociative symptoms usually experience affect dysregulation (van der Kolk, Pelcovitz, & Roth, 1996). These fluctuations occur with a series of painful introspective mechanisms (Somer, 2002). We propose that dissociation is a defense mechanism against traumatic memories, and this leads to emotional dysregulation, somatization, anxiety associated with panic attacks, and expectation anxiety. The main strengths of our study are that the patients were interviewed and assessed thoroughly, and the SCID-D was used to explore and determine the dissociative disorders according to the DSM–IV. Therefore, complicated dissociative disorders could be detected. But we did not screen somatoform symptoms as an important subgroup, though they may be linked to functional dissociative and PD symptoms. Moreover, our study is limited by its relatively small sample size, which made the evaluation of different subgroups of PD and its cross-sectional nature impossible. New studies involving large numbers of patients are now required. This study should be regarded as a preliminary one, and our findings should be consolidated with those of large-scale cohort studies. We conclude that dissociative comorbidity, symptoms, and childhood traumatic experiences among patients with PD should alert clinicians to the severity and complexity of the disorder. The predominance of PD
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symptoms in patients at admission should not lead the clinician to overlook the underlying dissociative process and traumatic experiences among these patients. Therapists should also address intrapsychic and developmentally acquired stress-inducing factors, including conflicts, existential traumas, and occasionally even dissociated personality elements.
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