As they say in The Music Man, “You can talk all you want…but you gotta know the territory.” To really understand what peritraumatic dissociation is all about, you gotta know the territory — namely, peritraumatic dissociation’s historical context and its role in several important debates.
About a decade before peritraumatic dissociation was ‘discovered’ in California. [Where else! :-)], Russell Noyes published a series of articles about “transient depersonalization syndrome” (Noyes, Hoenk, Kuperman & Slyman, 1977). Noyes was a near-death researcher; he studied motor vehicle accident victims and those who had experienced near-drownings, near-fatal falls, heart attacks, and so on.
A significant proportion of Noyes’ subjects reported that their brush with death was characterized by a sense of detachment, unreality, time-slowing, emotional calm, and accelerated thought. Noyes, by the way, was the scholar who retrieved, translated, and republished Heim’s (1892) account of the experiences of mountain climbers who had survived potentially fatal falls. As we noted in an earlier post, Heim’s mountain climbers who fell had experienced the same phenomena that Noyes described.
Because there had been little academic interest in dissociation for decades, Noyes’ articles about near-death depersonalization experiences largely ‘took place in a void.’ There was no ‘hook’ on which to hang his findings — except the fringe area of near-death experiences. Hey! It was the seventies!
The Battle Over PTSD
During the late 1960s and the entire 1970s, the Veterans Administration treatment system was flooded with Vietnam veterans who were angry, emotionally reactive, and haunted by recurrent memories and flashbacks about their time in Vietnam. The diagnosis of PTSD did not yet exist (it would not enter the DSM until 1980).
Prior to 1980 (and afterwards, as well) an intense political battle surrounded the diagnosis and treatment of Vietnam veterans. The ‘old guard’ claimed that these veterans were largely psychotic and that they should be treated as such. The ‘new wave’ insisted that these veterans were suffering from “Post-Vietnam syndrome,” a consequence of their wartime trauma. The ‘old guard’ would have none of it. They insisted that war does not cause mental illness — unless the soldier had a preexisting psychological problem or weakness.
A lengthy political battle ensued. The new wave won the debate and Posttraumatic Stress Disorder became part of the DSM. Prior to that, however, opponents of PTSD sought to minimize the number of PTSD diagnoses by seeking a restrictive Criterion A (which defines trauma in PTSD) in DSM-III. They lost that battle, too. DSM-III’s Criterion A for PTSD was quite broad. It defined trauma as:
“a recognizable stressor that would evoke significant symptoms of distress in almost everyone.” Criterion A further stated that a trauma is a stressor that “is generally outside the range of usual human experience.” (DSM-III)
The important point about this DSM-III definition of trauma is that it suggests that traumatic events will cause PTSD “in almost everyone.” Time and research data has shown that assumption to be incorrect.
Across all kinds of trauma, only about 25% of trauma survivors succumb to PTSD. Some kinds of trauma (e.g., physical and sexual assault) produce higher levels of PTSD. Nevertheless, it is now crystal clear that trauma (even rape) does not cause PTSD “in almost everyone.”
As a consequence of such findings, the DSM-IV Criterion A is much more restrictive:
“(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person’s response involved intense fear, helplessness, or horror.” (DSM-IV, emphasis added)
Notice that Criterion A2 requires a specific peritraumatic reaction (Aha! Peritraumatic reaction!). The person is required to experience “intense fear, helplessness, or horror” at the time of the traumatic event. In part, this peritraumatic diagnostic requirement is designed to distinguish between the 25% of trauma survivors who develop PTSD and the 75% who don’t.
The Trauma Field’s Belated Interest in Dissociation
During the struggle to define and defend PTSD, the trauma field had little interest in dissociation. In fact, it is probably accurate to say that the trauma field was actively disinterested in dissociation. After all, dissociation is weird and it’s connected to multiple personality disorder which is even weirder. Certainly, few paid much attention to Noyes’ articles about “transient depersonalization syndrome.”
Then fate took a hand. Card-carrying members of the trauma field discovered that many trauma victims dissociated during trauma: e.g., Are Holen (1993), David Spiegel (1991), Charles Marmar (1994). More importantly, Holen’s (1993) longitudinal study of the survivors of a North Sea oil rig disaster found that dissociation during the disaster predicted the subsequent development of PTSD. With that, the trauma field suddenly developed an interest in what quickly came to be called peritraumatic dissociation. This interest dove-tailed with the effort to define trauma and traumatization in terms of peritraumatic emotional reactions (Remember “intense fear, helplessness, or horror”?).
But the ambivalence of the trauma field about dissociation soon returned — for two reasons. First, as we have discussed in previous posts, research on the relationship between peritraumatic dissociation and PTSD has produced inconsistent findings. Second, Acute Stress Disorder became a lightning rod for attacks on dissociation.
Acute Stress Disorder
Amid the interest about peritraumatic reactions, a new diagnostic entity was born: Acute Stress Disorder.
According to the DSM diagnostic criteria, PTSD cannot be diagnosed unless the person has been symptomatic for 30 days. Thus, even if trauma survivors were intensely symptomatic during the 30 days after the trauma, they could receive no diagnosis or treatment until reaching the 30-day mark. This ‘gap’ in the nosology led David Spiegel and colleagues to propose a new diagnostic entity that would ‘fill the gap’ between the day of the trauma and PTSD’s 30-day diagnostic requirement.
Spiegel’s proposal was accepted (mostly) and DSM-IV ushered in a new diagnosis — Acute Stress Disorder. Unlike PTSD, a diagnosis of acute stress disorder requires that a person be very symptomatic for only 2 days (but for less than 4 weeks). Why less than 4 weeks? Because 4 weeks + 2 days = 30 days; at which point, a symptomatic person could receive a diagnosis of PTSD.
So what does acute stress disorder have to do with peritraumatic dissociation? A great deal. Spiegel was one of the fathers of peritraumatic dissociation (Spiegel, 1991). Acute stress disorder is the direct progeny of peritraumatic dissociation. In fact, Spiegel originally proposed that this disorder be called “Acute Dissociative Disorder.”
In keeping with this idea, Spiegel proposed a set of diagnostic criteria that emphasized dissociative symptoms. His proposed diagnostic criteria were mostly accepted, but his proposed name was not. Opponents said that the name made little sense because a person would have a dissociative disorder (Acute Dissociative Disorder) for a few weeks and then, suddenly, would switch to having an anxiety disorder (PTSD). Accordingly, the disorder was named acute stress disorder and, like PTSD, classified as an anxiety disorder.
The diagnostic criteria for acute stress disorder (ASD) are quite similar to those of PTSD (i.e., reexperiencing symptoms, avoidance symptoms, and hyperarousal symptoms), but with the addition of dissociative symptoms. Overall, ASD has fared reasonably well in subsequent research, but its dissociative diagnostic criteria have not. Just as peritraumatic dissociation has been an inconsistent predictor of PTSD, so too, have the dissociative symptoms of ASD proved to be an inadequate predictor of PTSD (e.g., Bryant, 2007; Marshall, Spitzer & Liebowitz, 1999).
The Territory of Peritraumatic Dissociation
Over the last 35 years, the territory of peritraumatic dissociation has ranged from (a) near-death experiences (Noyes’ transient depersonalization syndrome), to (b) the question, “Does peritraumatic dissociation predict PTSD?” (Answer: Not very well), to (c) the shift from the question, “What is a trauma?”, to the question, “What constitutes traumatization?” (According to DSM-IV: peritraumatic emotional reactions [i.e., "intense fear, helplessness, or horror"]), to (d) inspiring the creation of a new diagnostic entity (acute stress disorder).
My own contribution to this territory consists of asking two questions: (1) “What is peritraumatic dissociation, really?” and (2) “How much of it is a normal, hard-wired animal defense?” We will take a closer look at these two questions in my next post.