Assessing DSM-5 latent subtypes of acute stress disorder dissociative or intrusive?
Introduction
Dissociative symptoms were first formally included in the Diagnostic and Statistical Manual of mental disorders (DSM) nosology in 1994 with the release of the 4th edition, and the introduction of acute stress disorder (American Psychiatric Association, 1994). The ASD diagnosis was introduced with two purposes; the first was to recognize acute posttraumatic symptoms occurring within the first month of traumatic exposure (American Psychiatric Association, 1994, Cardena and Carlson, 2011) and the second was for the early identification of victims at risk of developing posttraumatic stress disorder (PTSD; only diagnosable after a one month period) (American Psychiatric Association, 1994). The diagnostic criteria for both required symptoms of intrusion, avoidance, and arousal, with ASD additionally requiring dissociative symptom endorsement (American Psychiatric Association, 1994). The most recent version of the DSM; the DSM-5 (American Psychiatric Association, 2013), now includes a dissociative-PTSD subtype within its nomenclature; thus acknowledges the potential presence of dissociative symptomatology in longer term traumatic responding. Several studies have empirically supported the presence of a dissociative-PTSD subtype (Armour et al., 2014b, Blevins et al., 2014, Wolf et al., 2012a, Wolf et al., 2012b). The current study investigates the presence of a similar dissociative-ASD subtype by investigating ASD profiles via Latent Profile Analysis (LPA).
Dissociation can be defined as “an experienced loss of information or control over mental processes, that under normal circumstances, are available to conscious awareness, self-attrition, or control, in relation to the individual׳s age and cognitive development” (Cardena and Carlson, 2011, p. 251). Thus, dissociation can be regarded as an inner distancing mode allowing the individual to momentarily phase out reality (Breh and Seidler, 2007). Numerous studies have shown that dissociation plays an important role in the aftermath of traumatic exposure (Breh and Seidler, 2007, Gershuny and Thayer, 1999, Ozer et al., 2003) and thus propose that dissociative features should be characteristic of psychiatric morbidities detailing posttraumatic responding.
In the newly released DSM-5 the importance of dissociative symptoms are acknowledged in both the ASD and PTSD diagnoses. In the former it is acknowledged by additional dissociative symptoms integral to the ASD disorder whereas in the latter it is acknowledged as a dissociative PTSD subtype characterized by the presence of dissociative items of depersonalization and derealization (American Psychiatric Association, 2013). Of note, it would appear that dissociation now has a less central role in DSM-5 ASD criteria compared to that of the DSM-IV criteria (cf. Bryant, 2011, van der Velden and Wittmann, 2008); largely attributable to ASD׳s limited predictability on PTSD (Bryant, 2011). Moreover, research has indicated that peritraumatic dissociation is not an independent predictor of PTSD (van der Velden and Wittmann, 2008). This body of research has led to changes in the ASD diagnostic criteria from DSM-IV to DSM-5; the former required the presence of at least three out of five dissociative symptoms, whereas the latter only requires the presence of nine out of 14 symptoms irrespective of symptom categories (i.e. intrusion, negative mood, arousal, dissociation, and avoidance).Thus, DSM-5 ASD diagnostic criteria can be met without the endorsement of a single dissociative symptom (American Psychiatric Association, 2013).
With regard to PTSD, several studies have identified different latent profiles including the dissociative subtype (c.f. Armour et al., 2014b, Wolf et al., 2012a, Wolf et al., 2012b). However, research on ASD has generally focused on the predictably of ASD on PTSD (Bryant, 2011), and the latent structure of ASD using confirmatory factor analysis (CFA) (cf. Hansen et al., 2012, Wang et al., 2012). Shevlin et al. (2014) however recently conducted a LPA on mean scores of the four ASD symptom clusters to determine if latent profiles differed quantitatively or qualitatively. They revealed a high ASD class, a low ASD class, and two intermediate classes which were relatively consistent in dissociative and intrusion symptom endorsements but differed in avoidance and arousal symptom endorsements; one intermediary class was characterized by low avoidance and high arousal (corresponding to the higher dissociative endorsement) and the other by high avoidance and low arousal (corresponding to the lower dissociative endorsement). This study, combined with a limited body of research suggests that ASD subtypes are likely to exist (cf. Cardena and Carlson, 2011, Isserlin et al., 2008). This has been incorporated into the proposed ICD-11 criteria for ASD symptoms, in which a series of subtypes have been recommended; including a dissociative subtype (WHO, 2014). Notably, this has not been the case in the newly revised DSM-5 (American Psychiatric Association, 2013).
Due to the close relationship and similarities between ASD and PTSD diagnostic criteria (American Psychiatric Association, 2013) and severity (c.f. Classen et al., 1998, Fuglsang et al., 2004, Hansen and Elklit, 2013), it is likely that the dissociative PTSD subtype hypothesis also applies to ASD. The limited capacity of the ASD diagnosis to predict the PTSD diagnosis (Bryant, 2011) does not preclude that symptoms of the two diagnoses are strongly related and have similar latent structures. Indeed, CFA studies based on DSM-IV ASD and PTSD criteria have indicated that both have a similar latent structure when disregarding the dissociative criterion (Hansen et al., 2012, Wang et al., 2012). Therefore, it stands to reason that this will apply to DSM-5 criteria given the two diagnoses have been made more similar with the inclusion of the dissociative PTSD subtype (American Psychiatric Association, 2013).
Recently a growing body of latent class analysis (LCA) or latent profile analysis (LPA) research has investigated the existence of a dissociative PTSD subtype and associated covariates (Armour et al., 2014a, Armour et al., 2014b, Steuwe et al., 2012; Wolf et al., 2012a, Wolf et al., 2012b). Three studies of veteran samples (Armour et al., 2014b, Wolf et al., 2012a, Wolf et al., 2012b), a study of victims of childhood abuse (Steuwe et al., 2012), and a study of rape victims (Armour et al., 2014a) have supported the existence of the dissociative PTSD-subtype. In general 3–5 profiles of individuals have been identified across the studies; one of which was dissociative (representing 6–25% of the total sample). Studies have found that individuals with the dissociative PTSD subtype profile reported significantly more childhood and adulthood sexual trauma (Armour et al., 2014b; Wolf et al., 2012b), higher scores related to physical and sexual abuse (Steuwe et al., 2012), and a greater number of current diagnoses (i.e. major depression, specific phobia, anxiety, and sleeping difficulties, Armour et al., 2014a, Steuwe et al., 2012) compared to the other latent groups. Interestingly, a replication study of the dissociative PTSD subtype in which males and females were separated suggested that a number of these may pertain specifically to dissociative PTSD in females. Female sex in particular may be predictive of membership in a dissociative subtype given such is often associated with a greater degree of symptomatology and given that females are more likely to endorse the emotional and cognitive items of the PTSD diagnoses compared to males (Tolin and Foa, 2006). Previous research therefore suggests that female sex, comorbid disorders, prior traumatic exposure, and sexual and physical assault in particular may constitute significant risk factors for developing the dissociative PTSD subtype. Although not previously investigated, due to the close relationship between ASD and PTSD, these risk factors may also be relevant to a dissociative subtype of ASD.
The current study assessed ASD profiles and specifically the existence of a dissociative subtype using LPA. Based on previous PTSD research utilizing LPA, the proposed ICD-11 criteria, and ASD research indicating the existence and need of ASD subtypes, we expected to find a distinct class of victims suffering from particularly high levels of dissociation and high levels of the other ASD symptoms. Second, we assessed several risk factors of the ASD subtypes; prior traumatic exposure, female sex, somatization, peritraumatic panic, and social support. These risk factors may be pertinent given the previously reported LPA PTSD research, and research finding these risk factors associated with both posttraumatic symptoms and dissociation. The female sex has repeatedly been found associated with increased risk of PTSD and higher levels of both ASD and dissociation compared to males (c.f. Armour et al., 2011, Bryant and Harvey, 2003). Additionally, somatization has also been found to be positively associated with both PTSD and dissociation (Spindler and Elklit, 2003, Elklit and Christiansen, 2009). Several studies have found that peritraumatic panic is positively associated with the development of posttraumatic symptoms following different forms of traumatic exposure and dissociation (Bryant and Panasetis, 2001, Bryant, 2011). Finally, lack of social support have been found to be positively associated with a wide range of psychiatric disorder and symptoms including PTSD and dissociation (cf. Brewin et al., 2000, Ozer et al., 2003, Simeon et al., 2005). Thus, we expected that female sex, higher levels of somatization and peritraumatic panic, and lower levels of social support will increase the risk of membership to the most symptomatic class; perhaps the dissociative ASD subtype.
Section snippets
Method
Participants were all bank robbery victims from a Danish bank robbery cohort questionnaire survey conducted in collaboration with the Danish Bankers Association, the National Bank of Denmark, all Danish Banks, and the University Southern of Denmark. All bank employees exposed to bank robbery in Denmark (N=614) from April 2010 to April 2011 received the questionnaire. A total of 450 employees (73%) filled out the questionnaire a week after the robbery (T1, M=9.89 days, S.D.=6.30). Participation
Results
Approximately half of the participants reported at least one symptom of intrusion according to the DSM-5 criteria (52.7%, n=237), whereas 22% (n=99) reported the one symptom of negative mood. A total of 185 participants (41.1%) reported at least one symptom of dissociation, 159 participants (35.3%) reported at least one symptom of avoidance, and 286 participants (63.6%) reported at least one symptom of arousal. The estimated prevalence rate of ASD according to the DSM-5 (e.g. the presence of at
Discussion
The current study investigated the latent structure of ASD with a particular interest in whether a dissociative ASD subtype would be uncovered, akin to the dissociative PTSD subtype included in the DSM-5 nomenclature. A secondary aim was the investigation of whether a number of factors would increase the probability of membership in certain latent profiles compared to a profile characterized by low overall ASD symptomatology; thus a baseline profile. To achieve these aims we utilized data from
Conclusion
The current study is the first to investigate the latent profiles of the DSM-5 ASD diagnosis using all 19 ASD indicators within the latent models. We were specifically interested in whether a dissociative ASD subtype would be uncovered akin to the recently proposed dissociative PTSD subtype. We hypothesized that the ASD subtype would, like the PTSD subtype, be characterized by high dissociative symptomatology and high alternative ASD symptomatology. We did find two groupings represented by high
Acknowledgments
The authors thank the Danish Bankers Association and the National Bank of Denmark for co-financing this study.
References (51)
Likelihood of a model and information criteria
Journal of Econometrics
(1981)- et al.
The DSM-5 dissociative-PTSD subtype: Can levels of depression, anxiety, hostility, and sleeping difficulties differentiate between dissociative-PTSD and PTSD in rape victims?
Journal of Anxiety Disorders
(2014) - et al.
Gender differences in the factor structure of posttraumatic stress disorder symptoms in war-exposed adolescents
Journal of Anxiety Disorders
(2011) - et al.
The crisis support scale: psychometric qualities and further validation
Personality and Individual Differences
(2001) - et al.
Relations among psychological trauma, dissociative phenomena, and trauma-related distress: a review and integration
Clinical Psychology Review
(1999) - et al.
Killing and latent classes of PTSD symptoms in Iraq and Afghanistan veterans
Journal of Affective Disorder
(2013) - et al.
The independent predictive value of peritraumatic dissociation for PTSD symptomatology after type I trauma
Clinical Psychology Review
(2008) Diagnostic and Statistical Manual of Mental Disorders
(1994)Diagnostic and Statistical Manual of Mental Disorders
(2013)- et al.
The co-occurrence of PTSD and dissociation: differentiating severe PTSD from dissociative-PTSD
Social Psychiatry & Psychiatric Epidemiology
(2014)
Dissociation and posttraumatic stress disorder: a latent profile analysis
Journal of Traumatic Stress
Is peritraumatic dissociation a risk factor of PTSD?
Journal of Trauma and Dissociation
Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults
Journal of Consulting and Clinical Psychology
A dual representation theory of PTSD
Psychological Review
Acute stress disorder as a predictor of posttraumatic stress disorder
Journal of Clinical Psychiatry
Gender differences in the relationship between acute stress disorder and posttraumatic stress disorder following motor vehicle accidents
Australian and New Zealand Journal of Psychiatry
Acute stress disorder scale
Psychological Assessment
Panic symptoms during trauma and acute stress disorder
Behaviour Research and Therapy
Acute stress disorder revised
Annual Review of Clinical Psychology
Acute stress disorder as a predictor of posttraumatic stress symptoms
American Journal of Psychiatry
Developmental typology of trajectories to nighttime bladder control: epidemiologic application of longitudinal latent class analysis
American Journal of Epidemiology
SCL-90-R: Symptom Checklist-90-R Administration, Scoring and Procedures Manual
Investigating subtypes of child development: a comparison of cluster analysis and latent class cluster analysis in typology creation
Educational and Psychological Measurement
Predictive factors for somatization in a trauma sample
Clinical Practice and Epidemiology in Mental Health
The Physical Reaction Scale
Cited by (16)
Acute stress disorder
2017, Current Opinion in PsychologyDoes highly symptomatic class membership in the acute phase predict highly symptomatic classification in victims 6 months after traumatic exposure?
2016, Journal of Anxiety DisordersCitation Excerpt :Of note the results of the present study were not completely in accordance with the results of the previous LPA study conducted on a larger part of this sample (Armour & Hansen, 2015). The results of the Armour and Hansen (2015) study revealed a four-class solution with two highly symptomatic classes mainly separated by the intrusion criterion using LPA. In contrast, we only identified three classes with only one highly symptomatic class using LCA.
Assessing possible DSM-5 ASD subtypes in a sample of victims meeting caseness for DSM-5 ASD based on self-report following multiple forms of traumatic exposure
2015, Journal of Anxiety DisordersCitation Excerpt :This may also explain why the highly symptomatic class in the present study is associated with reports of high dissociation compared to the Armour and Hansen (2015) study, where only 61% of the participants were female. However, the effect of the gender distribution is not likely to be large as female sex has not been found a significant risk factor for the highly symptomatic ASD subgroup (Armour & Hansen, 2015) or the dissociative PTSD subtype (Armour, Karstoft, et al., 2014). Although it was not our original hypothesis, it is not necessarily a surprising finding that the highly symptomatic class also had high avoidance when thinking about the nature of ASD.
Patterns of post-traumatic stress symptoms in mild traumatic brain injury and their relationship with outcomes: a latent profile analysis
2023, Journal of Clinical and Experimental NeuropsychologyPatterns of Acute Stress Disorder in a Sample of Blast-Injured Military Service Members: A Latent Profile Analysis
2021, Psychological Trauma: Theory, Research, Practice, and Policy