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Peritraumatic Reactions and Post traumatic Stress Disorder in Psychiatrically Impaired Youth

As Originally published in Journal of Traumatic Stress, February 2012.

By: Dr. Jeffrey Sugar & Julian D. Ford
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Although peritraumatic dissociation and other subjective peritraumatic reactions, such as emotional distress and arousal, have been shown to affect the relationship between a traumatic event and the development of posttraumatic stress disorder (PTSD) in adults, systematic studies with youth have not been done. In a mixed ethnic and racial sample of 90 psychiatrically impaired youth (ages 10-18, 56% boys), we investigated the contributions of peritraumatic dissociation, emotional distress, and arousal to current PTSD severity after accounting for the effects of gender, trauma history, trait dissociation, and psychopathology (attention-deficit/hyperactivity disorder and depression). Peritraumatic dissociation emerged as the only peritraumatic variable associated with current PTSD severity assessed both by questionnaire and interview methods (ß = .30 and .47 p < .01). Peritraumatic dissociation can be rapidly assessed in clinical practice and warrants further testing in prospective studies as a potential mediator of the trauma-PTSD relationship in youth.

Psychological trauma and clinically significant posttraumatic stress disorder (PTSD) symptoms are prevalent among children in community samples (Copeland, Keeler, Angold, & Costello, 2007; Costello, Erkanli, Fairbank, & Angold, 2002) and children with psychiatric disorders (Mueser & Taub, 2008). Empirically validated risk moderators for PTSD in youth include female gender, exposure to abuse or interpersonal violence, physical injury, caregiver exposure to threat and distress, and diminished protective factors before and after traumatic exposure (Brom, Pat-Horenczyk, & Ford, 2008; Fairbank, Putnam, & Harris, 2007).

Peritraumatic reactions, including dissociation, have predicted PTSD in adult studies (Breh & Seidler, 2007; Lensvelt-Mulders et al., 2008; Ozer, Best, Lipsey,&Weiss, 2003), and studies with healthy children have found peritraumatic dissociation to predict PTSD following serious accidents (Schafer, Barkmann, Riedesser, & Schulte- Markwort, 2004), terrorism (Pfefferbaum et al., 2002), and injury-related hospitalization (Bui et al., 2010; Daviss et al., 2000; Kassam-Adams & Winston, 2004). Peritraumatic dissociation, however, has not been studied with psychiatrically impaired children. Therefore, the present study examined the relationship between peritraumatic reactions and PTSD in a sample of psychiatrically impaired youth.

Peritraumatic dissociation is the most extensively studied peritraumatic reaction in adults, defined as "alterations in perception of time, place, and person, which reflect a sense of unreality," during or immediately following a traumatic event (Zoellner, Alvarez-Conrad, & Foa, 2002, p. 49). Peritraumatic dissociation involves a range of reactions from confusion, disorientation, or emotional shock to loss of reality orientation and fragmentation of consciousness and self (Lensvelt-Mulders et al., 2008). Peritraumatic dissociation is conceived as a mental state occurring close to a traumatic event, then diminishing, while trait dissociation is conceptualized as a stable and persistent disruption of normally integrated experience (Spitzer et al., 2006). Although distinct constructs, peritraumatic and trait dissociation may be correlated (Giesbrecht, Smeets, & Merckelbach, 2008). Although peritraumatic dissociation has been described as an epiphenomenon of trait dissociation (Lensvelt-Mulders et al., 2008), even if correlated, trait and peritraumatic dissociation may each independently contribute to PTSD. Trait dissociation assessed in preservice law enforcement training predicted both subsequent peritraumatic dissociation and PTSD severity, but after accounting for prior trauma history, peritraumatic dissociation independently predicted PTSD severity (McCaslin et al., 2008). A study in an adult community sample added the concept of "ongoing dissociation" to describe dissociation that begins peritraumatically and persists, and did not find a primary role for peritraumatic dissociation alone (Briere, Scott, & Weathers, 2005).

Prospective studies with adults have not always supported peritraumatic dissociation as a predictor of PTSD severity (van der Velden & Wittmann, 2008). Similarly, a prospective study of hospitalized injured children found that although severity of peritraumatic emotional distress and prior traumatization and psychopathology predicted posthospitalization PTSD, peritraumatic dissociation did not (Daviss et al., 2000). In another prospective study of hospitalized injured children, both peritraumatic arousal and dissociation predicted PTSD, but neither low peritraumatic arousal nor low peritraumatic dissociation identified children who did not develop PTSD; that is, they had low specificity (Kassam-Adams & Winston, 2004). Peritraumatic dissociation has been shown to correlate with other peritraumatic responses, including peritraumatic emotional distress (Fikretoglu et al., 2006; Marmar, Weiss, & Metzler, 1998) and arousal (Fikretoglu et al., 2007; Sterlini & Bryant, 2002). Dyb et al. (2008) found peritraumatic dissociation, arousal, and emotional distress scores in traumatized adolescents were intercorrelated and each strongly correlated with current PTSD severity. Peritraumatic dissociation and emotional distress were the strongest unique correlates of PTSD severity. In studies with adult accident and terrorism survivors, peritraumatic dissociation, arousal (assessed by elevated heart rate), and initial PTSD severity were independent prospective predictors of PTSD severity (Shalev & Freedman, 2005; Shalev, Peri, Canetti, & Schreiber, 1996). Prospective studies of law enforcement personnel (McCaslin et al., 2008) and industrial disaster survivors (Birmes, Daubisse, & Brunet, 2008) have shown that peritraumatic dissociation and independently predict subsequent PTSD severity. Therefore, in addition to assessing peritraumatic dissociation's relationship to PTSD, it is important to examine effects of peritraumatic arousal and emotional distress.

Moreover, other factors, both pre- and posttraumatic, including psychopathology, trait dissociation, and prior trauma exposure (Ozer, Best, Lipsey, &Weiss, 2008) have consistently correlated with subsequent PTSD severity, and thus may account for much of the observed relationship between peritraumatic dissociation and PTSD (Ozer et al., 2008; van der Velden & Wittmann, 2008). In addition to the internalizing disorders commonly identified in studies of childhood peritraumatic dissociation and PTSD, externalizing disorders (Ford & Connor, 2009; Ford et al., 2000) and severe psychiatric disorders (e.g., bipolar disorder, psychosis; Mueser&Taub, 2008) are also either highly comorbid with PTSD or associated with PTSD severity in children.

Childhood sexual abuse is the trauma exposure most consistently associated both with child psychopathology (Mueser&Taub, 2008) and with trait dissociation in adults (Briere & Elliott, 2003), adolescents (Plattner et al., 2003), and children (Putnam, Helmers, & Trickett, 1993). Retrospectively recalled childhood peritraumatic dissociation was associated with risk of adult sexual and physical victimization and PTSD severity, and peritraumatic dissociation was the unique correlate of PTSD severity, depression, and dissociative symptoms among women survivors of childhood sexual abuse (Johnson, Pike, & Chard, 2001). Peritraumatic dissociation in sexually abused girls was related to self-harm and sexual revictimization 9 years later (Noll, Horowitz, Bonanno, Trickett, & Putnam, 2003). Sexual abuse victims report elevations of both trait and peritraumatic dissociation (Noll et al., 2003; Putnam, 2003). Physical abuse is less consistently associated with dissociative symptomatology, but physically abused children (Pelcovitz et al., 1994) and chronically ill adults with histories of childhood physical abuse (Spinhoven et al., 2004) reported elevated trait dissociation. Parental emotional abuse in childhood has been equally-or more strongly-associated with trait dissociation in young adults than either physical or sexual abuse (Teicher, Samson, Polcari, & McGreenery, 2006). Despite these strong associations with trait dissociation, after accounting for physical and sexual abuse, peritraumatic dissociation in a sample of college women remained associated with PTSD severity (Hetzel & McCanne, 2005).

In addition to abuse, childhood exposure to other traumatic stressors is associated with psychopathology including PTSD. Witnessing domestic (Teicher et al., 2006) or community violence (McKelvey et al., 2011), and exposure to traumatic accidents (Schafer, Barkmann, Riedesser, & Schulte-Markwort, 2006) are associated with PTSD. Therefore, these additional exposures were included in this study.

Female gender is consistently associated both with peritraumatic dissociation severity and prevalence in adults (Olff, Langeland, Draijer, & Gersons, 2007; Seedat, Stein, & Carey, 2005). Among children, girls report more severe peritraumatic dissociation (Dyb et al., 2008; van der Velden & Wittmann, 2008) and more prevalent and severe PTSD (Copeland et al., 2007) than boys. Gender may also influence the moderating effect of family conflict on the relationship between community violence exposure and child psychopathology (McKelvey et al., 2011).

Taken together, the literature suggests that peritraumatic dissociation and other peritraumatic reactions may be associated with subsequent PTSD, but studies need to examine all peritraumatic reactions simultaneously and account for effects of gender, trauma history, trait dissociation, and psychopathology. Although there is good support for a correlation between peritraumatic dissociation and PTSD in children, the specific predictive power of peritraumatic dissociation remains uncertain. Based on this review of variables associated with PTSD, we tested the hypothesis that peritraumatic dissociation will be associated with PTSD severity among psychiatrically impaired children after accounting for effects of gender, trauma history, trait dissociation, psychopathology, and other peritraumatic reactions. To determine if these relationships were robust across measurement methods, PTSD symptom severity was assessed separately by interview and questionnaire measures.


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Jeffrey A. Sugar, MD has been a practicing Psychiatrist for over 20 years. Dr. Sugar is board certified both in Child and General Psychiatry. He is Past President of the Southern California Society of Child and Adolescent Psychiatry. He is an Assistant Professor of Clinical Psychiatry at USC, and has been an Assistant Clinical Professor of Psychiatry at UCLA.

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