Numerous types of dissociation exist, ranging from a normative type of forgetting or “spacing out,” to a 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 90% of 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 Depression Major depressive disorder (MDD) is highly comorbid with PTSD, with large epidemiological studies demonstrating a PTSD–MDD comorbidity rate of 48% to 55% (as reviewed in Price & van Stolk-Cooke, 2015; van Minnen et al., 2015). MDD is characterized by the following occurring for at least two weeks: Depressed mood (i.e., feeling sad or hopeless) more often than not, loss of interest or pleasure, sleeping and eating disturbances, diminished attention, feelings of worthlessness, and suicidal ideation (American Psychological Association [APA], 2013). Negative affect in particular has been shown to be a primary symptom that is associated with the overlap of PTSD and depression (Contractor et al., 2018; Price et al., 2019). The association between PTSD and MDD most commonly results from either a shared etiology or symptom overlap (Flory & Yehuda, 2022). Though depression may, at times, seem to come out of nowhere or result from a chemical imbalance, it can also be caused by traumatic life events. Exposure to traumatic events increases the risk for developing both PTSD and MDD (Price & van Stolk-Cooke, 2015). According to the shared etiology model of comorbidity, both PTSD and MDD may be caused by the same trauma. In the case of MDD, trouble managing painful experiences such as trauma can lead to depression (Hudenko et al., 2021, p. 1). For example, in addition to being traumatic, combat and war may also result in feelings of guilt, regret, and loss (Hudenko et al., 2021). Additionally, it is notable that there is considerable overlap in the DSM-5 criteria for PTSD and MDD, which may play a role in the high levels of comorbidity (Flory & Yehuda, 2022). The shared etiological relationship between depression and PTSD can be so strong that some researchers believe PTSD should be considered a subtype of MDD (Zhang et al., 2022), while others speculate there is a subtype of PTSD for some individuals who present with both diagnoses (Flory & Yehuda, 2022).
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. symptoms might be self-medicated with continued substance use (van Minnen et al., 2015). 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). Although the shared etiology model demonstrates that it is entirely possible to have both depression and PTSD at the same time, it is also possible that an individual can be misdiagnosed with either MDD or PTSD due to symptom overlap. According to a review by van Minnen and colleagues (2015), PTSD and MDD “share many diagnostic symptoms, including anhedonia” (p. 4), attentional difficulties, sleep disturbances (insomnia or hypersomnia in depression; insomnia and recurring nightmares in PTSD), reduced pleasure in things previously enjoyed, disinterest in being around others, and increased irritability (APA, 2013; van Minnen et al., 2015). The disorders even exhibit similar biological changes, such as increased activation from the amygdala (the fear–response system of the brain; van Minnen et al., 2015). Differentiating whether an individual’s symptoms are primarily linked to the elevated arousal of PTSD or the persistent internal negative state of MDD may help in targeting interventions. Case Example Chris engaged in services primarily because he was experiencing a multitude of somatic symptoms. He was generally fatigued and unable to go to the gym or get through the workday without tiring. He was having difficulty describing his fatigue, suggesting that at times it felt like he was just worn down, in the same way he might be if he were sick. However, he also reported that his sleep patterns were erratic; at times he struggled to fall asleep and other times he would sleep 11 hours in a row. He was not eating much, and he was having difficulty concentrating at work. He also reported feeling down most of the day and unable to connect with his friends. The client’s symptom presentation suggested depression, but after some intake sessions that assessed childhood history, Chris disclosed that he had been sexually abused when he was a child.
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