Background: The dissociative subtype of posttraumatic stress disorder (D-PTSD) was introduced in the DSM-5 to identify individuals with PTSD who experience dissociative symptoms, such as derealization and depersonalization. The Dissociative Subtype of PTSD Scale (DSPS) was developed to assess these symptoms but has yet to be validated in Ukrainian, a necessity due to the psychological impact of the ongoing conflict in Ukraine.Objective: This study aimed to develop and validate the Ukrainian version of the DSPS, examining its psychometric properties in a sample of trauma-exposed Ukrainian individuals.Methods: 1,119 Ukrainian participants, recruited using convenience and snowball sampling, took part in an online study assessing dissociative symptoms with the DSPS as well as symptoms of PTSD, depression, generalized anxiety disorder, somatic symptom disorder, and fear of sleep with established questionnaires. DSPS factor structure, internal consistency, and convergent and discriminant validity were assessed.Results: Confirmatory factor analysis confirmed the three-factor structure of the DSPS (derealization/depersonalization, loss of awareness, and psychogenic amnesia) with acceptable model fit indices for both lifetime and current severity items. Internal consistency was high for lifetime and current total scales (Cronbach's alpha = 0.83-0.87). Significant correlations with PTSD, depression, anxiety, and somatic symptoms were in the expected size-ranges, supporting convergent and discriminant validity.Conclusions: The Ukrainian DSPS demonstrated robust psychometric properties, validating its use as a reliable and valid tool for assessing dissociative symptoms in individuals exposed to war-related trauma. Its adaptation fills a critical gap in the diagnostic landscape, enabling timely intervention for trauma-exposed populations in Ukraine.

Chronic pain frequently co-occurs with posttraumatic stress disorder (PTSD). One theory proposes that some chronic pain may reflect pain reexperiencing (i.e., reactivation of somatosensory trauma memories). Although some research supports this theory, evidence from clinical survey studies is limited and methodologically constrained. In this study, 330 trauma survivors reported chronic pain and retrospectively reported peritraumatic pain using digital body maps (108 predefined regions). To reduce confounding from tissue damage-related pain, chronic pain assessment was confined to pain unattributed to injury/illness, and the role of peritraumatic injuries was evaluated. Participants were assessed for PTSD symptoms, age at first trauma exposure, and beliefs about trauma-related origins of their pain. Approximately 67% of participants reported peritraumatic pain, 50% reported chronic pain, and 11% reported chronic pain in the same region(s) as peritraumatic pain (i.e., spatial overlap). Multilevel logistic regression across participants and regions indicated a strong association between peritraumatic and same-region chronic pain, OR = 2.94, independent of trauma-related injuries. PTSD symptom severity and earlier age at trauma were associated with a higher likelihood of spatial overlap. Participants with overlapping pain were particularly likely to endorse a trauma-related pain origin. Results demonstrate spatial associations between peritraumatic and chronic pain, especially among individuals with elevated PTSD symptoms and earlier age at trauma, not attributable solely to injuries. The observed pattern provides support for the pain reexperiencing theory and highlights areas warranting further research. It may be clinically important to distinguish between pain reexperiencing and other posttraumatic pain, as specific trauma-informed approaches may be required.

Background: Posttraumatic stress disorder (PTSD) and chronic pain frequently co-occur. Growing evidence suggests that this comorbidity may be partly attributable to pain-intrusions, defined as chronic pain manifesting in the same body regions as the pain experienced during the traumatic event. This positions chronic pain as potential PTSD re-experiencing symptoms. However, little is known about how chronic pain, and especially pain-intrusions, relate to re-experiencing and other PTSD symptoms. Objective: The present study used a network modeling approach to examine how chronic pain and pain-intrusions are embedded within the established DSM-5 PTSD symptom network consisting of criteria B-E (re-experiencing, avoidance, negative alterations in cognitions and mood, and hyperarousal). Methods: A total of 330 trauma survivors reported on PTSD symptoms and peritraumatic and chronic pain in 108 body regions. Chronic pain was separated into chronic pain in trauma-related (i.e., pain-intrusions) vs. non-trauma-related body regions. We estimated two network models using a Gaussian graphical model approach: (1) with chronic pain in general and (2) with pain-intrusions and non-trauma-related chronic pain as distinct constructs. Results: Chronic pain in general was linked to hyperarousal. When pain-intrusions and non-trauma-related chronic pain were examined as separate constructs, pain-intrusions were associated with re-experiencing, while non-trauma-related chronic pain was associated with hyperarousal. Neither pain construct was related to avoidance or negative alterations in cognitions and mood. Discussion: These findings support the view that pain-intrusions represent a somatosensory component of re-experiencing in PTSD. In contrast, chronic pain in non-trauma-related body regions may reflect broader, more stress-related physiological processes such as autonomic arousal and heightened muscle tension. Results highlight the importance of considering the spatial correspondence between peritraumatic and chronic pain to better identify the underlying mechanisms of posttraumatic chronic pain and to tailor interventions to these processes.

Background: Neuroscientific and survey studies have pointed to the existence of ´pain-intrusions´ in posttraumatic stress disorder (PTSD), i.e., medically unexplained re-experiencing of peritraumatic pain in the same body regions as during the traumatic event, possibly explaining the high comorbidity between PTSD and chronic pain. Previous survey studies in trauma-survivors have assessed pain-intrusions by directly asking about pain as a re-experience of the traumatic event—an approach susceptible to expectancy effects. Objective: Here, we systematically assessed chronic and peritraumatic pain to investigate to what degree chronic pain occurs in the same body regions as during the traumatic event. To shed further light on chronic pain as a re-experiencing symptom, we analyzed the role of PTSD symptoms and established predictors of intrusive re-experiencing (e.g., cumulative traumatic experiences, younger age at the earliest traumatic event, peritraumatic distress and dissociation, and trait rumination and anxiety sensitivity). Method: In a pre-registered online study, survivors of psychologically traumatizing events (N=330) reported chronic and peritraumatic pain in 108 predefined body regions, PTSD symptoms, and re-experiencing predictors. Results: Eleven percent of participants experienced pain-intrusions (i.e., chronic pain in the same body region as during the traumatic event). Experienced (vs. non-experienced) peritraumatic pain increased the likelihood of chronic pain in the same (odds-ratio=2.94), but not across all (odds-ratio=1.36) body regions. PTSD symptom severity and all assessed re-experiencing risk factors predicted pain-intrusion occurrence. Most participants with pain-intrusions were convinced of a trauma-related origin. Conclusion: Results support the notion that posttraumatic chronic pain may in part constitute pain re-experiencing associated with PTSD symptomatology, and that these pain-intrusions share risk factors with other re-experiencing symptoms.

Background: Peritraumatic dissociation is thought to contribute to posttraumatic symptoms like intrusions and memory disturbances. However, trauma-analogue studies that examined effects of experimental dissociation-induction on intrusions and memory were inconclusive. To better understand this, a necessary first step is to more systematically compare various induction methods.Objective: We evaluate different dissociation-induction-methods regarding their effectiveness, the intensity and quality of induced dissociation, and their effects on intrusions and memory in a pre-registered randomised-controlled online experiment.Method: Healthy participants (N = 213) were randomised to one of six dissociation-induction-methods: audio-photic stimulation, hypnotic-suggestion, or spiral-staring, each for one-minute or three-minute duration. Participants also completed two further conditions: a non-dissociation-inducing picture task (control condition) and the comparison dissociation-induction-method dot-staring (benchmark condition). Each condition was followed by an aversive ('trauma') film. Peri-film dissociation intensity (measured using an adapted version of the Peritraumatic Dissociative Experiences Questionnaire) and quality, as well as film-specific intrusion-load and memory performance, were assessed. Dissociation-induction-methods were deemed successful if they elicited dissociation levels higher than the control condition and at least as high as the benchmark condition. Only successful dissociation-induction-methods were examined further.Results: Three minutes of hypnotic-suggestion and one minute of spiral-staring successfully induced dissociation during the film, while other methods did not meet the effectiveness threshold. Hypnotic-suggestion led to a greater increase in dissociation intensity than spiral-staring, dissociation induced by spiral-staring was perceived as more uncontrollable and unpleasant. Results did not support an adverse effect of dissociation-induction or dissociation intensity on intrusion-load, but they did support an adverse effect on self-reported and objectively assessed memory performance.Conclusions: Results indicate that hypnotic-suggestion and spiral-staring constitute effective, easy-to-implement, and in principle, neuroimaging-compatible dissociation-induction-methods that allow studying dissociation in the laboratory. The present data did not support the notion that dissociation fosters intrusion formation but provides causal support for effects of dissociation on trauma memory.

Background Intrusive re-experiencing of trauma is a core symptom of posttraumatic stress disorder. Intrusive re-experiencing could potentially be reduced by 'rewinding', a new treatment approach assumed to take advantage of reconsolidation-updating by mentally replaying trauma fast-backward.Methods The present analogue study was the first to investigate 'rewinding' in a controlled laboratory setting. First, 115 healthy women watched a highly aversive film and were instructed to report film-related intrusions during the following week. Twenty-four hours after film-viewing, participants reporting at least one intrusion (N = 81) were randomly allocated to an intervention (fast-backward, or fast-forward as active control condition) or a passive control condition. Intervention groups reactivated their trauma memory, followed by mentally replaying the aversive film either fast-backward or fast-forward repeatedly.Results Results indicate that replaying trauma fast-backward reduced intrusion load (intrusion frequency weighted for intrusion distress) compared to the passive group, whereas replaying fast-forward did not. No above-threshold differences between fast-backward and fast-forward emerged.Conclusion Present findings strengthen the view that 'rewinding' could be a promising intervention to reduce intrusions.

Background: The fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced the dissociative subtype of posttraumatic stress disorder (D-PTSD). To assess this subtype, the Dissociative Subtype of PTSD Scale (DSPS), a 15-item self-report measure to identify lifetime and current dissociative symptoms of D-PTSD, was developed. However, so far, the scale has only been validated in war veterans. Moreover, criterion validity and diagnostic utility have not been examined yet.Objective: We aimed to validate the DSPS in two samples of civilian trauma-exposed German-speaking participants.Methods: In Study 1, a pre-registered online study, participants with and without PTSD symptoms (N = 558) answered questionnaires about traumatic experiences, dissociation, PTSD, depression, generalized anxiety disorder, somatic symptom disorder, alcohol use disorder, absorption, and dissociative responding to trauma-related questionnaires. In Study 2, which used secondary data of a pre-registered clinical study, participants with a PTSD diagnosis (N = 71) answered questionnaires about traumatic experiences, dissociation, PTSD, depression, generalized anxiety disorder, somatic symptom disorder, and dissociative responding to standardized trauma exposure. Moreover, PTSD, D-PTSD, and other diagnoses were assessed with structured clinical interviews.Results: Analyses confirmed a three-factor structure as well as high internal consistency, and high convergent, discriminant, and criterion validity of the DSPS. Moreover, the scale was able to identify a latent D-PTSD group and individuals with D-PTSD diagnosis.Conclusions: The DSPS constitutes a reliable and valid tool to assess D-PTSD symptoms in clinical practice and research and thereby may contribute to a better understanding of these debilitating symptoms.

While research has elucidated processes underlying dissociative symptoms in patients with posttraumatic stress disorder, little is known about the circumstances under which trauma-related dissociation initially arises. To experimentally investigate causes and concomitants of peritraumatic dissociation, we subjected sixty-nine healthy women to aversive-audiovisual and painful-electrical stimulation in a 2(aversive/neutral film) x 2(pain/no pain) within-subject design while recording psychophysiological and fMRI-BOLD responses. Afterwards, participants rated negative-affect, pain, and dissociation for each condition. Using Bayesian multilevel regression models, we examined (1) whether aversive-audiovisual and painful-electrical stimulation elicit higher dissociation-levels than control conditions and (2) whether stronger negative-affect and pain responses (operationalized via self-report, psychophysiological, and neural markers) correlate with higher dissociation-levels. Several key findings emerged: Both aversive-audiovisual and painful-electrical stimulation elicited dissociation. Dissociation was linked to higher self-reported negative-affect, but we did not find enough evidence linking it to psychophysiological and neural negative-affect markers. However, dissociation was associated with higher levels of self-reported pain, a skin-conductance-response-based pain marker, and the fMRI-BOLD-based Neurologic-Pain-Signature. Results indicate that both aversive-audiovisual and painful stimuli can independently cause dissociation. Critically, pain responses captured via self-report, psychophysiological, and neural markers were consistently linked to higher dissociation-levels suggesting a specific, evolutionary meaningful, contribution of pain to the rise of dissociation.

Dissociative symptoms, such as depersonalization and derealization, are experienced by about half of individuals with posttraumatic stress disorder (PTSD). Theoretical models propose that acute dissociation is accompanied by specific behavioral, physiological, and experiential alterations and contributes to unfavorable PTSD symptom course. Yet, empirical evidence is scarce. Here, we explored associations between dissociative and behavioral, physiological, and experiential threat responses as well as effects of dissociative responding on PTSD symptom course. Individuals with PTSD (N = 71) participated in a preregistered script-driven imagery study including exposure to standardized, detail-enriched trauma, and neutral scripts. Stabilometry, eye-tracking, facial electromyography, autonomic psychophysiology, and self-report data were collected. Moreover, PTSD symptoms were assessed before and 3 months after testing. Analyses did not link acute dissociation to bodily and facial immobility or staring in response to trauma scripts. However, dissociation displayed an inverted U-shaped relationship with heart rate and was linked to higher nonspecific skin conductance fluctuation and higher high-frequency heart rate variability in response to trauma scripts. Moreover, acute dissociation was linked to higher self-reported negative affect responses to trauma scripts and displayed a U-shaped relationship with unfavorable PTSD symptom course. While results did not confirm hypothesized behavioral markers of dissociation, they do support defense-cascade model assumptions of an inverted U-shaped relationship between dissociation and psychophysiological arousal resulting from a progression of parasympathetic versus sympathetic dominance with increasing dissociation. On an experiential level, results did not confirm posttraumatic dissociation-induced emotional numbing, questioning theoretical notions. The observed nonlinear associations may help explain the heterogeneity of prior findings and might inform an updated conceptualization of posttraumatic dissociation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The current study investigated heart rate (HR) and heart rate variability (HRV) across day and night in patients with disorders of consciousness (DOC). We recorded 24-h electrocardiography in 26 patients with DOC (i.e., unresponsive wakefulness syndrome (UWS; n = 16) and (exit) minimally conscious state ((E)MCS; n = 10)). To examine diurnal variations, HR and HRV indices in the time, frequency, and entropy domains were computed for periods of clear day- (forenoon: 8 a.m.–2 p.m.; afternoon: 2 p.m.–8 p.m.) and nighttime (11 p.m.–5 a.m.). The results indicate that patients’ interbeat intervals (IBIs) were larger during the night than during the day, indicating HR slowing. The patients in UWS showed larger IBIs compared to the patients in (E)MCS, and the patients with non-traumatic brain injury showed lower HRV entropy than the patients with traumatic brain injury. Additionally, higher HRV entropy was associated with higher EEG entropy during the night. Thus, cardiac activity varies with a diurnal pattern in patients with DOC and can differentiate between patients’ diagnoses and etiologies. Moreover, the interaction of heart and brain appears to follow a diurnal rhythm. Thus, HR and HRV seem to mirror the integrity of brain functioning and, consequently, might serve as supplementary measures for improving the validity of assessments in patients with DOC.

Intrusions, a key symptom of posttraumatic stress disorder (PTSD), can occur as classically conditioned responses to trauma-related cues, both in the form of images and pain sensations. Women are more vulnerable to experiencing intrusions, and gonadal hormones may underlie this sex difference. Yet so far, particularly estradiol’s influence on intrusions is unclear, as PTSD-symptom studies suggesting a vulnerable window for intrusions during the high estradiol-progesterone phase diverge from fear-conditioning studies suggesting a protective role of estradiol. Here, we aim to address this discrepancy and examine the effects of estradiol on intrusions while also considering stress as potential moderator.Forty free-cycling women participated in an ecologically informed trauma-pain-conditioning (TPC) paradigm, using trauma-films and pain as unconditioned stimuli. Predictors were salivary estradiol and stress indexed by salivary cortisol and self-reported state-anxiety during TPC. Outcomes were film- and pain-intrusions occurring during daily-life in the week following TPC and a memory-triggering-task in response to conditioned stimuli 24h after TPC.Estradiol yielded time- and stress-dependent effects on film-intrusions during daily-life: women with higher estradiol showed initially greater probability of experiencing film-intrusions, switching to lower probability toward the end of the week. This late protective effect of estradiol on film-intrusions only held for higher state-anxious women. In contrast, estradiol showed consistent protective effects on pain-intrusions during daily-life and memory-triggering-task. Together, these data suggest that high estradiol during trauma may shield women from long-term audiovisual trauma intrusions, as well as from pain-intrusions, and thereby possibly constitute a protective factor for PTSD and potentially also for chronic pain.

While research has started to elucidate the processes underlying chronic dissociative symptoms in patients with posttraumatic stress disorder, little is known about the circumstances under which trauma-related dissociation initially arises, i.e., the triggers of and mechanisms behind peritraumatic dissociation. Here, we expanded the analogue trauma-film approach by pain stimulation to increase ecological validity and examined effects on dissociation.

Franke, Laila K.a,*; Miedl, Stephan F.a; Danböck, Sarah K.a; Liedlgruber, Michaela; Grill, Markusa; Kronbichler, Martinb,c; Flor, Hertad,e; Wilhelm, Frank H.a Author Information

Psychological trauma is typically accompanied by physical pain, and posttraumatic stress disorder (PTSD) often co-occurs with chronic pain. Clinical reports suggest that pain after trauma may be part of a re-experiencing symptomatology. Classical conditioning can underlie visual re-experiencing since intrusions can occur as conditioned responses (CRs) to trauma-related cues. If individuals also experience pain to cues previously paired with, but not anymore inflicting nociceptive stimulation (CSs), conditioning could also explain re-experiencing of pain. Sixty-five participants underwent classical conditioning, where painful electrocutaneous stimulation and aversive film-clips served as unconditioned stimuli (USs) in a 2 (pain/no pain) x 2 (aversive/neutral film) design. CSs were neutral pictures depicting contextual details from the films. One day later, participants were re-exposed to CSs during a memory-triggering-task (MTT). We assessed pain-CRs by self-report and an fMRI-based marker of nociceptive pain, the neurologic pain signature (NPS); and recorded spontaneous daily-life pain-intrusions with an e-diary. During conditioning, pain-signaling CSs elicited more self-reported-pain and NPS-responses than no-pain-signaling CSs. Possibly because the aversive-film masked differences in participants’ responses to pain-signaling vs. no-pain-signaling CSs, pain-CRs during acquisition only emerged within the neutral-film condition. When participants were re-exposed to CSs during MTT, self-reported-pain-CRs during the neutral-film condition and NPS-CRs during the aversive-film condition persisted. Importantly, participants with stronger pain-CRs showed a greater probability and severity of experiencing spontaneous pain intrusions during daily-life. Our data support that pain can emerge as a CR with emotional and sensory components. Classical conditioning presents a possible mechanism explaining pain-intrusions, and more broadly, pain experienced without nociceptive input.

Background: Peritraumatic dissociation is purported to emerge together with attenuated autonomic arousal, immobility, and staring. However, empirical evidence is scarce and heterogeneous. Moreover, it is still a matter of debate whether these responses predict intrusion formation. Objective: The present trauma-analogue study examined associations between peritraumatic dissociation, autonomic activation, facial movements, staring, and intrusion formation. Method: Seventy-one healthy women watched a highly aversive film, while autonomic activation (heart rate, respiratory sinus arrhythmia, skin conductance level), facial movements (temporal variations in corrugator electromyography), and staring (fixation duration, tracklength) were assessed. Afterwards, participants rated the intensity of dissociation during film viewing and reported intrusions and associated distress in a smartphone application for 24 hours. Results: Peritraumatic dissociation was linked to higher autonomic arousal (higher heart rate and, on a trend-level, lower respiratory sinus arrhythmia), increased facial movements, and staring (lower tracklength). Peritraumatic dissociation, higher autonomic arousal (higher heart rate and lower respiratory sinus arrhythmia), staring (higher fixation duration), and, on a trend-level, more facial movements were linked to higher intrusion load (number x distress of intrusions) and together explained 59% of variance. Skin conductance level was neither linked to peritraumatic dissociation nor intrusion load. Conclusions: Our results suggest that, at low-dissociation-levels observed in trauma-analogue studies, peritraumatic dissociation may occur together with heightened autonomic arousal and facial movements, indexing increased negative affect. Staring might, irrespectively of dissociation-levels, serve as objective marker for dissociation. Together, peritraumatic dissociation and its psychophysiological correlates might set the stage for later intrusion formation.

Emotions involve response synchronization across experiential, physiological, and behavioral systems, referred to as concordance or coherence. Women are thought to be more emotionally aware and expressive than men and may therefore display stronger response concordance; however, research on this topic is scant. Using a random-order film-average design, we assessed concordance among experiential (arousal, valence), autonomic (electrodermal activity, heart rate, preejection period, respiratory sinus arrhythmia), respiratory (respiratory rate), and behavioral (corrugator and zygomatic electromyography) responses to 15 two-minute films varying in valence and arousal. We then calculated for each participant and pair of measures a within-subject correlation index using averages from the 15 films. Pronounced individual concordance of up to 0.9 was observed. Arousal-physiology and valence-behavior concordances were particularly pronounced. Women displayed higher concordance than men for almost all pairs of measures. Findings indicate stronger psychophysiological response coupling in women than men and provide novel insights into affective differences between the sexes.