A fully integrated memory can include both nonstressful and stressful events. A positive integrated memory might be the recollection of eating a delicious chocolate birthday cake last week at a birthday party: “I remember the whole family sitting around the dining room table as Dan brought in the cake [behaviors] and feeling surprised, pleased, and a little self-conscious when they sang ‘Happy Birthday’ [affect]. Tasting the chocolate frosting, feeling the smoothness of it on my tongue, and smelling the aroma of brewed coffee has my mouth watering right now as I remember [sensation]. I remember that it happened last Friday in honor of my 40th birthday” [knowledge]. An integrated memory of a stressful event might be: “I remember running down to the basement with my children as the winds picked up and the radio announced that the hurricane was almost here [behavior]. I felt frightened, anxious, and worried [affect]. I remember having a knot in the pit of my stomach, noticing a sour taste in my mouth, and Conclusion Understanding dissociation is a key element of trauma treatment. It can be conceptualized as an unconscious defensive response of the body–mind system under a combination of conditions of overwhelming stress, extreme pain, and terror, with no avenue for escape. Under these conditions, there is a physiological response and the body releases stress hormones. This release of stress hormones activates either the hyperfocus or the amnesiac response, depending on what the individual senses is necessary for survival. Dissociation is a separation of awareness and a compartmentalization of the experience. Numerous types of dissociation exist, ranging from a normative type of forgetting or “spacing out,” to a
feeling the sensation of hugging my three children close to my chest [sensations]. I remember that two trees were uprooted from our yard and they crashed against the house, breaking a window during the storm. I know that it has been about a week since the hurricane and they have jus t gotten around to removing the trees that fell” [knowledge]. With dissociation, these four components become separated from each other. The client might experience a sour taste in her mouth but not know why or feel jumpy and anxious on a windy day but not make the connection with the winds from the hurricane. Using the BASK system can also be a way for the clinician to assess the extent of dissociation. Resolution of dissociated trauma material involves the integration of dissociated behaviors (actions: Who did what and when?), affect (feelings: What were the emotions at the time of the events?), sensations (associated body states), and knowledge (cognitions, self-perceptions, and meaning- making). These factors will be discussed more fully in the chapters on treatment. temporary ability to put something out of one’s mind, to the fragmentation of self and separation of different aspects of one’s core identity. DID represents the far end of this spectrum. Conditions of severe and ongoing abuse during early childhood are generally recognized as preconditions for the development of this disorder. Healing of dissociated experiences typically involves a reintegration of the split-off and fragmented self parts. One formulation that describes the necessary components for reintegration is the BASK model (Braun, 1988). Within this model, behavior, affect, sensation, and knowledge are reunified to produce a meaningful understanding and assessment of the traumatic events.
CO-OCCURRING CHALLENGES
The impact of trauma on psychological and physical functioning is complex and multifaceted. Some individuals are resilient and remain relatively unscathed by their experiences, while others go on to develop posttraumatic stress disorder (PTSD). However, rarely is it as simple as a binary split between resilience or PTSD as an outcome. Often, practitioners are faced with clients who simultaneously present with both PTSD and other comorbidities. Estimates suggest that as high as 80% to Theoretical Models of Comorbidity According to van Minnen and colleagues, “comorbidity technically refers to two” (2015, p. 2) disorders occurring simultaneously, with separate etiologies. However, the relationship between PTSD and various comorbidities is rarely as reductive as mere coincidence. Several explanatory models exist to illuminate the uncharacteristically high comorbidity rates found with PTSD. In some cases, PTSD may mediate the experience of trauma and some other problem (van Minnen et al., 2015). For instance, traumatization results in PTSD symptoms, which lead to insomnia. Some models propose a shared etiology, whereby PTSD and a co-occurring condition are caused by the same underlying factor (van Minnen et al., 2015). For example, sexual trauma is known to be causally associated with both PTSD and depression. Reciprocal models suggest that PTSD and a comorbid problem affect each other in a bidirectional manner. For example, increased substance use may confer a heightened risk for dangerous and traumatic experiences and then PTSD symptoms might be self-medicated with continued substance use (van Minnen et al., 2015).
90% of individuals diagnosed with PTSD have a comorbid mental health condition, and 60% have at least two comorbid diagnoses (van Minnen et al., 2015; Walter et al., 2018). Depression, substance abuse, and suicidality are among the prominent conditions and maladaptive behaviors associated with PTSD. This chapter will review frequently occurring PTSD comorbidities to better inform practice and assessment when treating trauma. Epigenetics may shed light on how one’s environment (and potentially trauma exposure) influences the expression of genetic predispositions (Blacker et al., 2019). Finally, in some instances, certain disorders are symptomatically similar or prone to symptom overlap (e.g., sleep disturbances in both PTSD and depression; van Minnen et al., 2015). Disentangling the various associations between PTSD and comorbidities is essential to integrative, holistic, and effective trauma treatment. Practitioners unaware of the common PTSD comorbidities may misdiagnose trauma- related problems or fail to treat essential contributing factors that exacerbate symptoms and prevent healing. “Thus, gaining greater understanding of how these conditions overlap and the interrelations among their symptom structures holds promise to improve the current diagnostic system” (Price & van Stolk-Cooke, 2015, p. 149).
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