Driven to distraction: Childhood trauma and dissociation, but not PTSD symptoms, are related to threat avoidance

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Research Paper

Driven to distraction: Childhood trauma and dissociation, but not PTSD symptoms, are related to threat avoidance Sarah Herzog a,*, Jonathan DePierro b, Wendy D’Andrea a a

Department of Psychology, The New School, New York, NY, 80 5th Ave, 6th Flr, 10011 New York, NY, USA New York University School of Medicine, New York, NY, World Trade Center Health Program Clinical Center of Excellence, 530 First Avenue, 10016 New York, NY, USA

b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 15 July 2017 Received in revised form 6 March 2018 Accepted 11 March 2018 Available online xxx

Introduction. – Mixed findings with respect to attention biases in traumatized samples may reflect heterogeneity in Posttraumatic Stress Disorder (PTSD) presentations. Dissociation symptoms in particular, have been associated with decreased awareness of threat and may account for variability in prior findings. Objective. – The present study examined relationships among self-reported PTSD and dissociative symptom domains, attention biases, and lifetime traumatization. Method. – Seventy-eight adult participants recruited via crowdsourcing website Amazon MTurk were assessed on trauma history, PTSD and dissociative symptoms; and completed a modified dot-probe task. Results. – Findings indicated that early trauma exposure and dissociative derealization were associated with greater avoidance of threat. There was a significant interaction among trauma exposure and dissociation, such that those with early lifetime neglect and derealization had greater threat avoidance. Conclusion. – Results highlight the complex relations among early trauma characteristics, dissociation, and attention. Future studies with longitudinal designs are needed to bolster observed findings.

C 2018 Elsevier Masson SAS. All rights reserved.

Keywords: Attention bias Dot-probe Dissociation PTSD symptoms Threat avoidance Childhood trauma

1. Introduction The ability to flexibly allocate attention in the face of danger cues is essential to survival, and the disruption of these attentional processes is implicated in the onset and maintenance of many disabling psychological symptoms, most prominently those of anxiety disorders and posttraumatic stress (PTSD) (Aupperle, Melrose, Stein, & Paulus, 2012; Litz & Keane, 1989; MacLeod, Mathews, & Tata, 1986). Information-processing models of PTSD theorize that attention biases to threatening material emerge in symptomatic individuals as a consequence of readily activated fear networks that result from persistent and intrusive re-experiencing of traumatic imagery, thoughts, and sensations (Litz & Keane, 1989). While intrusive re-experiencing is one of the hallmark symptoms of PTSD, post-traumatic symptoms are fairly heterogenous and include symptoms of hypervigilance, avoidance, alterations in mood and cognition, and dissociative reactions, all of

* Corresponding author. E-mail addresses: [email protected] (S. Herzog), [email protected] (W. D’Andrea).

which might have seperable affects on attention. Indeed, mixed findings on attention biases in traumatized samples might in part be related to the heterogeneity of posttraumatic symptoms (DePierro, D’Andrea, & Pole, 2013). Thus, the current study will examine PTSD and related dissociative symptoms in the context of attention biases, and their relations to patterns of trauma exposure across the lifetime. Dysfunction in attention allocation, or attention biases, can manifest as either selective attention toward threat cues, which indicates hypervigilance (MacLeod et al., 1986), or a bias away from threatening material, indicating avoidance (Koster, Crombez, Verschuere, & De Houwer, 2004; Price et al., 2012). More precisely, selective avoidance of threat represents a lack of attentional engagement with the threatening stimulus (Koster, Crombez, Verschuere, Van Damme, & Wiersema, 2006). While both patterns of biased attention are implicated in the prediction or perpetuation of PTSD symptoms (Wald, Shechner et al., 2011), avoidance of threat might compromise processing of environmental threat cues, thus conferring added risk of harm (Fani, Bradley-Davino, Ressler, & McClure-Tone, 2011). Much of the research on attention biases employs a dot-probe paradigm that measures vigilance or

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Please cite this article in press as: Herzog, S., et al. Driven to distraction: Childhood trauma and dissociation, but not PTSD symptoms, are related to threat avoidance. European Journal of Trauma & Dissociation (2018), https://doi.org/10.1016/j.ejtd.2018.03.001

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avoidance of threatening material by indexing faciliated or slowed responding to probes in the location of the threatening stimulus (Koster et al., 2006). Several studies using the dot-probe task have supported the finding of facilitated allocation of attention for threatening material in individuals with PTSD (Bryant & Harvey, 1997; Fani et al., 2012), while others have found PTSD to be associated with selective threat avoidance (Bar-Haim et al., 2010; DePierro et al., 2013; Elsesser, Sartory, & Tackenberg, 2004; Pine et al., 2005; Wald, Lubin et al., 2011; Wald, Shechner et al., 2011). Bryant and Harvey (1997) found that motor-vehicle accident survivers with PTSD demonstrated facilitated attention toward mildly threatening words, while particpants with subclinical PTSD symptoms and controls did not. In contrast to findings of facilitated attention to threat, Elsesser et al. (2004) found that severity of trauma-related intrusion symptoms were related to a bias away from threat in recently traumatized adults. Pine et al. (2005) examined attention biases in a sample of maltreated children, all of whom had been exposed to severe domestic abuse, and a control group of children with no history of maltreatment. They found that bias away from threat was inversely correlated with physical abuse severity and PTSD symptoms. Still other studies have found conflicting attentional profiles across severity of PTSD (Thomas, Goegan, Newman, Arndt, & Sears, 2013), and others no evidence of threatrelated bias at all (Dalgleish et al., 2003; Fani et al., 2011; Reichert, Segal, & Flannery-Schroeder, 2015). We propose that divergent findings on attention biases in PTSD are a consequence of the symptom heterogeniety of this disorder, and that slowed responding to threat in traumatized populations might result from post-traumatic symptoms such as numbness, avoidance, and dissociative reactions. Dissociation has been defined as an alteration or disturbance in the normally integrated functions of identity, perception, consciousness, and memory (American Psychiatric Association, 2013). In contrast to the deliberate avoidance of trauma-related stimuli that might accompany PTSD, attentional deflection in dissociation can be conceptualized as an involuntary and automatic avoidant response. Dissociative processes can function as a defense against the overwhelming distress that accompanies trauma by reducing awareness of trauma-relevant information. Children, in particular, are prone to dissociate as a means of coping with abuse and maltreatment (Arata, 2002; Hulette, Kaehler, & Freyd, 2011). In instances of pervasive and chronic trauma in early life, a persistent tendency to dissociate in threatening contexts might emerge over time (Howell, 2013, p. 25). Indeed, trait dissociation is often greater among individuals exposed to multiple traumas, or those exposed to trauma at earlier ages (Steuwe, Lanius, & Frewen, 2012). The tendency to dissociate under stress, however, might have the adverse effect of slowing processing of threat-related cues (Kluft, 1990), or decelerating rapid responding to danger, making trauma survivors more vulnerable to continued exposure to potentially traumatic events (Sandberg, Matorin, & Lynn, 1999). Consistent with this, early trauma exposure is a significant predictor of subsequent trauma exposure, including non-interpersonal traumas (Cloitre, Scarvalone, & Difede, 1997) such as accidents, where attention may play a key role (D’Andrea, Spinazzola, van der Kolk, Ford, & Stolbach, 2010). Thus, in addition to examining the role of dissociation in attentional avoidance of threat, the role of these two constructs in the relationship between early exposure to trauma and trauma later in life warrants investigation. Dissociation is comprised of a number of related processes, some of which might impair coherence or awareness of internal cues, and others that impede processing of external stimuli. In the context of attention, the latter such symptoms are of particular relevance to altered processing of external threat cues. One such symptom cluster of dissociation is derealization, which is

characterized by the experience of one’s surroundings as foggy, unreal, detached or distorted (American Psychiatric Association, 2013). Derealization can function to lower awareness of environmental danger, and might therefore be expected to slow processing of threatening stimuli. Another dissociative symptom relevant to cognitive processing and attention biases is disengagement. In contrast to derealization, which is specific to the perception of one’s surroundings, dissociative disengagement implies a more general withdrawal, reduction in awareness, or feeling of detachment from the external environment (Briere, 2002). Dissociative disengagement reflects a lapse of processing due not to boredom, but rather, to emotional arousal (Amrhein, Hengmith, Maragkos, & Hennig-Fast, 2008), and thus reflects ‘‘bottom up’’ processes that are largely stimulus-driven, and disrupt the ability to sustain attention. Research findings on dissociation and threat perception are consistent with this reasoning: both state and trait dissociation were associated with lower ratings of dangerousness on an acquaintance-rape videotape, suggesting that participants were missing important threat cues (Sandberg, Lynn, & Matorin, 2001). Waller and Quinton (1995) assessed processing of threatening information in women with either high or low trait dissociation scores, and found that those high on dissociation were significantly slower to identify threatening words as compared to those with low dissociation. However, additional research is required to clarify the particular dissociative processes that might impact attention. Nonetheless, these findings suggest that dissociation might inhibit engagement with threat cues, hindering efficient processing and responding. Few studies have examined attentional biases in conjunction with dissociative symptoms and/or early, cumulative trauma exposure. One related study found slower responding for negative versus neutral words in participants with Dissociative Identity Disorder (Dorahy, Middleton, & Irwin, 2005). Individuals high in trait dissociation were also found to experience greater attentional interference on a standard color-naming Stroop task as compared to those with low dissociation (Freyd, Martorello, Alvarado, Hayes, & Christman, 1998). Studies examining dissociative and PTSD symptoms together with measures of attention biases to threatening stimuli are likewise scant. DePierro et al. (2013) found PTSD symptoms, but not dissociative symptoms, were associated with bias away from threatening words. Nonetheless, this study was limited in that it had a small, all-female sample. Naim et al. (2014) assessed PTSD symptoms and state dissociation in emergency department patients within twenty-four hours of a motor-vehicle accident and found small but significant effects for both with bias toward threat (r = .10 and r = .12, respectively). This study, however, did not assess trauma history, and the proximity of assessment to trauma exposure makes it difficult to draw conclusions about the effects of trauma exposure on attention over time. 1.1. The present study The present study addresses gaps in the literature with regard to attention biases and PTSD symptoms by examining the impact of trauma-related dissociative processes, specifically, derealization and disengagement, on attention to threatening material; and consider their role in patterns of retraumatization across the lifetime. Childhood and lifetime trauma history of both an interpersonal and non-interpersonal nature, and trait dissociative symptoms, were measured alongside attentional bias, indexed through the use of a visual dot-probe paradigm. The dot-probe has advantages over the Stroop task in that it measures attention bias more directly, rather than measuring attentional interference, and it allows for examination of the directionality of bias (Mogg &

Please cite this article in press as: Herzog, S., et al. Driven to distraction: Childhood trauma and dissociation, but not PTSD symptoms, are related to threat avoidance. European Journal of Trauma & Dissociation (2018), https://doi.org/10.1016/j.ejtd.2018.03.001

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Bradley, 1998). Reaction time on the dot-probe can be computed to index difficulty disengaging from threat (i.e., attentional interference), in addition to vigilance for threat, thus providing a more refined measure of the attentional processes involved in biased responding (Koster et al., 2004). Participants were sampled from the community via Amazon’s Mechanical Turk (MTurk), an online crowdsourcing platform for efficient data collection. MTurk yields data equivalent to face-toface testing (Buhrmester, Kwang, & Gosling, 2011; Casler, Bickel, & Hackett, 2013), with clinical symptoms and rates of trauma exposure that mirror the general population (Shapiro, Chandler, & Mueller, 2013). Researchers have found MTurk samples to be as or more attentive to instructions and tasks as compared to off-line subjects (Hauser & Schwarz, 2016; Paolacci, Chandler, & Ipeirotis, 2010). Sampling via MTurk, we anticipated that trauma exposure would match the rates found in the general population. Recent assessments of exposure to DSM-IV/5 Criterion A lifetime traumatic events suggest that approximately 90% of the general population experience one or more events, and the majority of trauma-exposed individuals endure multiple traumatic events (Breslau et al., 1998; Kilpatrick et al., 2013; Ogle, Rubin, Berntsen, & Siegler, 2013). Estimates of early childhood exposure demonstrate that between 52 to 66% of community samples experience at least one adverse childhood event (Felitti et al., 1998; Giovanelli, Reynolds, Mondi, & Ou, 2016). Based on the reviewed literature, we hypothesize there would be a positive correlation between childhood trauma severity and dissociative derealization and disengagement symptoms. With regard to threat bias, we hypothesize that dissociative derealization and disengagement symptoms, and PTSD symptoms, would be differentially related to threat bias: dissociative symptoms would be related to selective avoidance of threat, and PTSD symptoms associated with vigilance toward threat. We expect that severity of childhood trauma exposure to predict a greater bias away from threat. Finally, derealization/disengagement symptoms are expected to moderate the relationship between childhood trauma exposure and avoidance of threat.

2. Method 2.1. Measures and materials 2.1.1. Traumatic Events Screening Inventory-Brief Report Form (TESIBR) Lifetime trauma was assessed on the TESI-BR, a 12-item scale assessing exposure to potentially traumatic events such as natural disasters, illness, accidents, injuries, violence, and sexual assault (Ford et al., 2002; Ford & Fournier, 2007). The TESI-BR also assessed the earliest and most recent experience of listed traumatic events. TESI scores have converged with post-traumatic symptom severity in prior work (Ford & Smith, 2008). We computed a TESI-BR summary score (e.g. the total number of different types of traumatic events across the lifetime), the earliest age of trauma exposure, the sum of traumatic events before age 16 (childhood trauma), and the sum of traumatic events experienced in adulthood (at age 16 or older). 2.1.2. Childhood Trauma Questionnaire (CTQ) The CTQ is a 28-item retrospective self-report measure for exposure to childhood abuse and neglect, assessing severity of exposure across five domains: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect; a sixth validity scale refers to minimization of any family difficulties (Bernstein & Fink, 1998). Using a Likert scale of 1–5, total scores for each of the five subscales range from 5–25; total scores on the CTQ range from

3

25 (low) to 125 (severe). The CTQ has shown excellent test–retest reliability, as well as convergence with clinician-administered interview measures of childhood trauma (Bernstein et al., 1994). Internal consistency for the present study was good for the overall scale (a = .88), and ranged from .80 to .98 for individual subscales. 2.1.3. Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5) The PTSD Checklist for DSM-5 (PCL-5) is a 20-item self-report inventory measuring symptoms of PTSD listed in the DSM-5, with four subscales: intrusive symptoms, avoidance symptoms, negative cognition and mood, and hyperarousal (Weathers et al., 2013). Participants rate each item they have experienced in the past month on a scale of intensity from 0 (not at all intense) to 4 (extremely intense). These ratings were used to compute subscale means and a total score for overall symptoms, ranging from 0–80, with higher scores indicating greater symptom severity. Groups were created for probable presence or absence of PTSD using a recommended cut-off score of 38 (Weathers et al., 2013). Internal consistency for the present study was high (a = .96). 2.1.4. Multiscale Dissociation Inventory (MDI) The MDI is a 30-item measure of trait dissociation (Briere, 2002) that assesses six domains: depersonalization, derealization, disengagement, emotional constriction, memory disturbance, and identity dissociation. Each item is measured on a frequency scale of 1 (never) to 5 (very often). Total raw scores range from 30 to 150, with higher scores indicating greater frequency of dissociating symptoms. For descriptive purposes, the MDI was used to create groups for presence or absence of dissociative PTSD, based on whether participants met criteria on the PCL-5 while simultaneously having a T-score of 80 or above on either the depersonalization or derealization subscales (Briere, 2002). Internal consistency for the present study was high (total score a = 97). 2.1.5. The Brief Symptom Inventory (BSI) The BSI is a 53-item inventory of psychopathology and psychological distress rated on a 1 to 5 scale of intensity and assesses 9 symptom dimensions: anxiety, depression, somatization, obsessive-compulsivity, interpersonal sensitivity, hostility, phobic anxiety, paranoid ideation, and psychoticism (Derogatis & Melisaratos, 1983). We computed the probable presence of clinically significant levels of anxiety, depression, and somatization based on the recommended cut-off of 63 T (Derogatis & Spencer, 1993). BSI internal consistency was high across subscales, ranging from a = 91–.93. 2.1.6. Visual dot-probe Stimuli used were forty pictures selected from the International Affective Picture System (Lang, Bradley, & Cuthbert, 1999) according to normative ratings for valence and arousal, including five highly threatening images (e.g. ‘‘mutilated face’’), five mildly threatening images (e.g. ‘‘man with knife’’), and thirty neutral pictures (e.g. ‘‘hair dryer’’). Normed mean ratings on valence for high threat, mild threat and neutral images were, respectively, 1.99 (SD = 0.44), 3.80 (SD = 0.60), and 5.01 (SD = 0.21). Mean arousal ratings were, respectively, 6.57 (SD = 0.62), 5.21 (SD = 0.87), and 2.91 (SD = 0.59). ANOVAs and post-hoc tests on the normative data indicated differentiable valence and arousal ratings by condition for selected pictures. Each image was presented an equal number of times. 2.2. Procedure Participants were recruited via an ad for a larger study on ‘‘stressful or traumatic events’’ which was posted on Amazon MTurk. By clicking on the ad, participants were directed to an

Please cite this article in press as: Herzog, S., et al. Driven to distraction: Childhood trauma and dissociation, but not PTSD symptoms, are related to threat avoidance. European Journal of Trauma & Dissociation (2018), https://doi.org/10.1016/j.ejtd.2018.03.001

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online survey website to complete the study. A minimum age of 18 and residence in the United States were required for inclusion. Following provision of informed consent, participants proceeded to the questionnaires and then completed the dot-probe task. After completion of the task they were redirected to the Amazon MTurk website and paid $ 1.00. The dot-probe task was hosted online on Amazon MTurk and administered using Inquisit 4 Web Version (Millisecond Software, LLC; Seattle, WA). The task was adapted from, and identically structured to, the version created by Miller and Fillmore (2010). The task includes 16 practice trials and 80 experimental trials consisting of 40 neutral trials (N-N), 20 mild-threat trials (MT-N), and 20 high-threat trials (HT-N). Trials began with the presentation of a fixation cross for 500 ms, followed by a pair of images (N-N, MT-N, or HT-N, in random order) presented side by side for 1000 ms, consistent with timeframes used to study complex images (Miller & Fillmore, 2010). Presentation of the paired images was immediately replaced by a probe either in the position of the threatening image (congruent trials) or in the position of the neutral image (incongruent trials), for a duration of 1000 ms. Task directions (presented prior to beginning the practice trials) instructed participants to rapidly respond to the position of the probe on the screen by using the right or left keyboard arrows of the keyboard. For each of the threatening trial types, probe position was alternated to create congruent (i.e. probe in threat position) and incongruent trials (probe in neutral position), and images were alternated on each side of the screen, resulting in 20 trials per threat condition (5 images  2 probe position  2 image position). Bias toward threat is indicated when participants’ reaction times are shorter for congruent trials than incongruent trials. Thus, a negative score in reaction time indicates bias away from threat and a positive score indicates a bias toward threat. The resulting formula was as follows: Threat Bias = Mean Incongruent Trial RT Mean Congruent Trial RT (Koster et al., 2004). Threat bias scores were computed for high-threat condition and mild threat conditions. In order to differentiate attentional bias from attentional interference (i.e. vigilance/avoidance of threat versus difficulty/ease disengaging from threat), scores were computed to represent difficulty diverting attention from threat. This was accomplished by comparing reaction times of trials with neutral pictures only to incongruent trials, i.e. trials containing threatening images with the probe in the neutral position. The resulting formula was: Difficulty Disengaging from Threat = Mean Incongruent Trial RT Mean Neutral Trial RT. 2.3. Data preparation and analysis 2.3.1. Sample reduction Two hundred and fifty-two individuals initiated the survey; 138 participants (56 male, 81 female, 1 transmale) completed the questionnaires and 94 of those participants also completed the dot-probe task. Chi-square analyses and independent samples ttests demonstrated no significant differences on any demographic or psychological variables between the 94 full-study completers and the 44 self-report only completers. Logged completion times for remaining respondents were consistent with engagement with tasks and measures. Dot-probe data was then screened in accordance with standard practice to ensure data integrity. Trials with reaction times less than 100 ms (Mogg, Mathews, & Eysenck, 1992), ‘‘lapses’’, (i.e., trials with reaction times exceeding the 1000 ms presentation of the probe) and ‘‘errors’’ (i.e., incorrect responses to probe position) were all excluded. Participants whose excluded trials exceeded 10% of total trials were removed from the final analysis. In the current sample, 16 participants of 94 were thus excluded, leaving a total of 78 participants in the final

analysis. The 16 excluded participants did not differ from the final sample on any demographic variables, but did have significantly higher mean scores on the MDI, PCL-5 Avoidance, and BSI DEP. 2.3.2. Data analyses Analyses were performed using SPSS 21.0 software. To perform tests of interactions, we used PROCESS, an add-on macro for SPSS that implements moderation and mediation analysis using a path analysis framework (Hayes, 2012). PROCESS also quantifies the direct and indirect effects using bias-corrected bootstrapped samples of 1000, and conditional effects for moderation analyses. We used PROCESS Model 1 (Hayes, 2015). Symptom measures and trauma history were analyzed continuously, but categorical data is provided in Table 1 for descriptive purposes. 3. Results 3.1. Participant characteristics The final sample (N = 78) consisted of 35 males, 42 females, and one transmale. Participants were largely Caucasian (n = 68; 87%) and heterosexual (n = 66; 85%), with a mean age of 35.87 (SD = 12.69; Range 19–66). Socioeconomic status for household of origin clustered around lower-middle (n = 20; 26%) and middle income (n = 33; 42%). Most participants had either some postsecondary education (n = 30; 38%) or a bachelor’s degree (n = 25; 32%) (Table 1). 3.2. Trauma history and symptoms Trauma history data was missing for 4 participants. For lifetime trauma on the TESI, the reported average age at first trauma was 12.6 years (SD = 9.4). Eighty-nine percent (n = 66) of the current sample reported at least one potentially traumatic event on the TESI; 28% (n = 21) reported 1–2 events, 46% (n = 34) reported 3–5 events, and 15% (n = 11) reported 6–10 events (see Table 1 for distribution by trauma type). Sixty-nine percent of participants (n = 51) endorsed at least one category of childhood maltreatment on the CTQ. Thirteen participants (16%) met criteria for probable PTSD, 10 participants (13%) met criteria for probable clinically significant dissociation, and six of those with dissociation simultaneously met criteria for PTSD (i.e., dissociative PTSD; see Table 1). Lifetime trauma, defined as endorsement of any trauma on the TESI, was related to elevated anxiety, depression, dissociation, PTSD, somatization, and global psychiatric distress (see Table 2 for correlations). On the TESI, sixty percent of participants (n = 47) endorsed a trauma in childhood, while 81% (n = 63) endorsed a trauma in adulthood. Ninety-percent of those who endorsed a childhood trauma (n = 41) also endorsed trauma in adulthood. There were no statistically significant differences by race or gender for trauma exposure, dissociative and other symptom variables, and dot probe performance. 3.2.1. Lifetime trauma and dissociation The cumulative number of discrete traumas experienced before age 16 as reported on the TESI, hereon referred to as childhood trauma, correlated positively with MDI derealization (r[69] = .31, P = .009, 95% CI [ .11, .68]) and disengagement subscales (r[69] = .34, P = .005, 95% CI [.02, .62]). Correlational analyses demonstrated a relationship between the number of categories of early childhood exposure endorsed on the CTQ (i.e., physical abuse, sexual abuse, etc.), and MDI derealization (r[74] = .29, P = .014, 95% CI [.07, .47], but not disengagement (r[74] = .08, P = .51, 95% CI [ .17, .30]. An independent samples t-test was performed to determine whether those with childhood trauma experienced greater

Please cite this article in press as: Herzog, S., et al. Driven to distraction: Childhood trauma and dissociation, but not PTSD symptoms, are related to threat avoidance. European Journal of Trauma & Dissociation (2018), https://doi.org/10.1016/j.ejtd.2018.03.001

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EJTD-59; No. of Pages 9 S. Herzog et al. / European Journal of Trauma & Dissociation xxx (2018) xxx–xxx Table 1 Descriptive and demographic information. Variable Age Gender Men Women Other Sexual orientation Heterosexual Gay or lesbian Bisexual Other SES Lower income Low mid income Middle income Upper mid income Upper income Education HS degree Some college AA/AS/AAS Bachelor’s degree Post-Bac Ed Master’s degree Doctoral degree Taking psychotropic meds Yes No Psychiatric diagnoses endorsed Depression Anxiety Bipolar D/O Schizophrenia Substance abuse Eating disorder AD/HD Anger problems Other Symptom diagnostic threshold BSI depression BSI anxiety BSI somatization PCL-5 PTSD MDI dissociation Race/ethnicity White/Caucasian Asian Hispanic/Latino African American Mixed race Childhood trauma (CTQ) Physical abuse Sexual abuse Emotional neglect Physical neglect Emotional abuse Lifetime trauma (TESI) Physical assault Sexual assault Traumatic death/illness Traumatic injury Traumatic accident Witnessed accident Natural disaster Other

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Table 2 Correlations between psychological variables. n = 78 (%)

M (SD)

Psychological variables

1

2

3

4

5

6

7

8

35.87 (12.7)

1 2 3 4 5 6 7 8 9

.23 .38b .17 .75b .20 .64b .63b .74b

.70b .89b .23a .30a .22 .28a .29a

.47b .35b .46b .32b .38b .39b

.13 .15 .10 .19 .19

.36b .76b .81b .67b

.29a .37b .21

.64b .53b

.73b

35 (44.9) 42 (53.8) 1 (1.3) 66 3 5 4

(85.6) (3.8) (6.4) (5.1)

14 20 33 10 1

(17.9) (25.6) (42.3) (12.8) (1.3)

2 24 6 25 5 12 4

(2.6) (30.77) (7.7) (32.1) (6.4) (15.4) (5.1)

Correlations with TESI Child are n = 69; TESI Adult, n = 67; CTQ, n = 74; CTQ by TESI Child, n = 66; CTQ by TESI Adult, n = 64; all remaining correlations are n = 78. a Correlation is significant at the 0.05 level (2-tailed). b Correlation is significant at the 0.01 level (2-tailed).

Table 3 Dot-probe bias scores and reaction times. Mean (SD) HT Bias Score MT Bias Score HT Difficulty Disengaging Score MT Difficulty Disengaging Score HT RT Incongruent HT RT Congruent MT RT Incongruent MT RT Congruent Neutral RT

9 (11.5) 69 (88.5) 25 18 5 1 5 3 4 2 2

(32.1) (23.1) (6.4) (1.3) (6.4) (3.8) (5.1) (2.6) (2.6)

22 15 17 13 10

(28.2) (19.2) (21.8) (16.7) (12.8)

68 2 4 3 1

(87.2) (2.4) (5.1) (3.8) (1.3)

22 16 47 26 36

(28.2) (20.5) (60.3) (33.3) (46.2)

29 16 30 19 31 23 30 20

(37.2) (20.5) (38.5) (24.4) (39.7) (29.5) (38.5) (25.6)

MDI Total TESI Total TESI Child TESI Adult PCL-5 Sum CTQ Total BSI Depression BSI Anxiety BSI Somatization

3.41 (41.07) 0.17 (32.88) 14.62 (35.28) 9.17 (31.61) 453.90 (85.18) 450.49 (80.59) 430.11 (68.56) 429.94 (69.90) 434.96 (66.86)

HT: high threat, MT: mild threat, RT: reaction time. Scores are based on final behavioral data sample (n = 78). All reaction times are reported in milliseconds.

54.60 51.90 50.97 16.94 42.75

(11.29) (11.74) (10.7) (17.9) (16.5)

7.45 7.32 12.34 7.70 10.05

(3.8) (5.4) (5.6) (3.5) (5.6)

amounts of trauma in adulthood than those without childhood trauma. Results indicated that participants with childhood trauma reported greater numbers of traumas in adulthood than those without childhood trauma, t(2,65.00) = 2.65, P = .010, d = 0.55. Younger age at first trauma was related to higher number of traumas experienced in adult life (r[65] = .25, P = .041, 95% CI [ .43, .07]. CTQ subscales for emotional abuse and physical abuse

were both associated with greater adult trauma (r[66] = .29, P = .02, 95% CI [.03, .51] and r[66] = .28, P = .03, 95% CI [.04, .50], respectively). This model was replicated while substituting MDI disengagement with derealization as the moderating variable. The overall model was significant (F[3,63] = 6.59, P < .001) and explained 24% of the variance in adult trauma. While neither childhood trauma, derealization, nor the trauma by derealization interaction were significant predictors in the model, the test of conditional effects of childhood trauma on adult trauma at the level of derealization yielded significant results. At the level of the sample mean for derealization (M = 6.98, SD = 3.12), the effect of childhood trauma on adult trauma was .45 (P = .002), and increased to .52 at one standard deviation above the mean (M = 10.10, P < .001). 3.3. Dot-probe analyses A repeated measures ANOVA with a Greenhouse-Geiser correction demonstrated a main effect for reaction times across trial types, F(1.74,134.33) = 32.82, P < .001, hp2 = .30. Bonferonnicorrected pairwise comparisons indicated that participants were significantly slower to respond to high threat images compared to both neutral (P < .001) and mild threat trials (P < .001). See Table 3 for summary of scores. Since no associations were found between the self-report variables and bias to the mildly threatening condition, hereafter all associations reported refer to the highthreat condition. 3.3.1. Correlations between self-report and threat bias As stated previously, variables that correlate in a positive direction with threat bias indicate vigilance for threat, while negative correlations indicate an avoidance, or bias away from threat. Consistent with stated hypotheses, the derealization subscale of the MDI was significantly and negatively correlated with threat bias, r(78) = .25, P = .027, 95% CI [ .55, .04]. However,

Please cite this article in press as: Herzog, S., et al. Driven to distraction: Childhood trauma and dissociation, but not PTSD symptoms, are related to threat avoidance. European Journal of Trauma & Dissociation (2018), https://doi.org/10.1016/j.ejtd.2018.03.001

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6 Table 4 Self-report and dot-probe correlations.

Childhood trauma CTQ Total CTQ Emotional Neglect CTQ Physical Neglect CTQ Emotional Abuse CTQ Physical Abuse CTQ Sexual Abuse CTQ Minimization TESI Childhood Trauma Symptoms PCL-5 Total PCL-5 Intrusion PCL-5 Avoidance PCL-5 Negative Cognition & Mood PCL-5 Hyperarousal MDI Derealization MDI Disengagement BSI Depression BSI Anxiety BSI Somatization

High threat bias

Mild threat bias

Difficulty disengaging HT

Difficulty disengaging MT

.25a [ .45, .01] .29a [ .47, .08] .26a [ .49, .06] .14 [ .33, .05] .15 [ .33, .05] .16 [ .40, .10] .31b [.10, .51] .01 [ .24, .17]

.19 .21 .05 .21 .01 .19 .10 [ .17

.14 .14 .06 .18 .05 .10 .20 [ .09

[ .35, .06] [ .34, .07] [ .25, .10] [ .38, .04] [ .22, .12] [ .32, .14] .03, .38] [ .32, .10]

.16 .16 .01 [ .20 .04 .11 .07 [ .04

[ .40, .12] [ .40, .10] .28, .28] [ .41, .03] [ .30, .23] [ .31, .10] .15, .28] [ .25, .15]

.11 .14 .05 .08 .13 .12 .07 .11 .19 .09

[ .32, .10] [ .31, .03] [ .26, .17] [.30, .17] [ .34, .08] [ .36, .08] [ .29, .15] [ .35, .11] [ .39, .02] [ .31, .13]

.10 .14 .06 .05 .09 .07 .17 [ .07 .18 .10

[ [ [ [ [ [

.17 [ .20 [ .13 [ .19 [ .10 [ .25a [ .16 [ .11 [ .08 [ .12 [

.41, .10] .41, .07] .31, .08] .43, .06] .36, .17] .54, .04] .37, .07] .31, .10] .34, .14] .38, .14]

[ .40, .03] [ .41, .03] [ .25, .14] [ .39, .00] [ .19, .18] [ .41, .06] .13, .33] [ .37, .05]

.10 [ .28, .10] .14 [ .30, .02] .03 [ .22, .16] .08 [ .28, .12] .10 [ .31, .14] .01 [ .17, .21] .11 [.00, .12] .05 [ .34, .14] .16 [ .35, .04] .09 [ .27, .12]

.30, .14] .37, .09] .30, .16] .27, .18] .32, .15] .29, .15] .03, .35] [ .30, .18] [ .41, .08] [ .30, .10]

Sample sizes for CTQ correlations are n = 71, and n = 78 for PCL-5 and MDI. a Correlation is significant, 0.05 level (2-tailed). b Correlation is significant at the 0.01 level (2-tailed).

MDI disengagement was not significantly correlated with threat bias, r[78] = .16, P = .16, 95% CI [ .36, .07]. PTSD symptoms on the PCL-5 were also not significantly correlated with threat bias, nor were BSI subscales for depression, anxiety, and somatization (see Table 4 for complete correlational data). Total scores on the CTQ correlated negatively with threat bias, r(74) = .24, P = .044, 95% CI [ .45, .00], with small to medium effect sizes across significant correlations. CTQ emotional and physical neglect demonstrated a similar pattern (see Table 4 for correlations). CTQ subscales of emotional, physical, and sexual abuse were not related to threat bias. Scores for difficulty disengaging from threat were not significantly correlated with PTSD symptoms, dissociation, other psychological symptoms, or trauma exposure (Table 4). 3.3.2. Interactions between dissociative symptoms and childhood trauma predicting threat bias A moderation analysis was performed to ascertain the role of dissociative derealization in the relationship between childhood trauma and threat bias. Since the correlational analysis only yeilded significant associations between CTQ childhood neglect variables with threat bias, we collapsed these two variables and entered the combined neglect variable as the predictor. Threat bias was entered as the outcome variable, and MDI derealization as the moderating variable. The model accounted for 18% of the variance in threat bias, F(3,74) = 5.56, P = .002. There were no significant effects for derealization (b = 6.19, t[74] = 1.53, P = .13) or childhood neglect (b = 1.51, t[74] = 1.24, P = .23). The analysis yielded a significant interaction for dissociative derealization by childhood neglect on threat bias (DR2 = .06, F[1,74] = 5.71, P = .02) such that those with early lifetime neglect and derealization had greater avoidance of threat. This model was replicated using disengagement as the moderating variable in place of derealization. The model accounted for 10% of variance in threat bias, F(3,74) = 2.89, P = .04, with no significant effects for disengagement (b = 0.80, t[74] = 0.28, P = .78), or childhood trauma (b = 0.20, t[74] = 0.34, P = .89). The effect for the interaction between childhood trauma and disengagement was similarly non-significant, DR2 = .01, F[1,74] = 0.66, P = .42.

4. Discussion The present study set out to investigate associations between childhood trauma exposure, PTSD and dissociative symptoms, and their impact on threat-related attentional bias and retraumatization in adulthood. We hypothesized that early trauma exposure would be associated with elevated levels of dissociative symptoms, particularly derealization and disengagement, and that both would be related to a selective avoidance of threat. Indeed, more severe childhood physical and emotional neglect were both associated with a bias away from threat, suggesting that maltreatment in early childhood might result in alterations in cognition that involve selective avoidance of threatening cues. Furthermore, attention bias was differentiated from attentional interference (i.e., difficulty disengaging from threat), which was not associated with childhood trauma or symptoms in the current sample. Pine et al. (2005) found similar results with regard to attention biases in a sample of children, wherein severity of physical abuse and a diagnosis of PTSD were related to avoidance of threatening material on a visual dot-probe task. Contrary to our hypothesis, bias toward threat in our sample was not related to PTSD symptoms, but as expected, avoidance of threat was associated with elevated rates of dissociation. Both dissociation and threat avoidance were associated with the number of categories of childhood traumas endorsed, suggesting a cumulative effect of childhood trauma vis-a`-vis threat-related bias and dissociation. Null findings with regard to non-dissociative PTSD symptoms and attentional bias have been found in other samples as well. Iacoviello et al. (2014) found no evidence for attentional bias in combat-exposed soldiers with and without PTSD, but instead found greater variability in attentional bias across the task in those with acute PTSD symptoms. Elsesser et al. (2004) found no group-wise differences in attention biases between participants with chronic PTSD and controls. Taken together, these findings may challenge the traditional conceptualization of PTSD as primarily characterized by hypervigilance. One explanation for the range in attention bias findings in samples with PTSD (i.e., vigilance, avoidance, or no threat-related bias) might be the heterogeneity found in PTSD symptoms, which can manifest in symptoms of avoidance, intrusion, negative

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cognitions, mood disturbances, and hyperarousal. PTSD as a disorder has been characterized by vacillation between extreme approach and withdrawal states (Stein & Paulus, 2009), or fluctuation between periods of re-experiencing and effortful avoidance (Horowitz, 1976). This instability in symptom presentation might create varying patterns in attention allocation. Specifically, the presence of derealization and disengagement may create an attentional style that selectively avoids threatening information. In the context of interpersonal traumas, for instance, dissociative symptoms might inhibit engagement with early signs of developing threat, leaving individuals locked into dangerous situations past the point of return. In more rapidly unfolding situations requiring immediate action, dissociative processes might take the form of a frozen response much like tonic immobility, a defense reaction associated with greater severity of PTSD symptoms (Abrams, Nicholas Carleton, Taylor, & Asmundson, 2009; Kalaf et al., 2015). Indeed, in our sample, dissociative derealization moderated the relationship between childhood trauma and threat bias, providing preliminary evidence for the role of dissociation in attention biases in traumatized samples, which has heretofore been linked in the literature almost exclusively to non-dissociative symptoms of PTSD. The associations between dissociative symptoms, bias away from threat, and trauma exposure demonstrated in this study have important theoretical and clinical implications. Avoidance of threat might be related to the study of risk-detection, the ability to take cues from the environment in order to identify potential threat and danger, in retraumatized individuals (Chu, DePrince, & Mauss, 2014). Messman-Moore and Brown (2006) examined sexual revictimization in a female college sample using an acquaintance-rape written vignette to assess risk-perception and response, and found that revictimized women showed delayed responding to danger and were more vulnerable to later victimization at 8-month follow-up. The bulk of research on revictimization and threat perception, however, has focused exclusively on sexual abuse, to the exclusion of other types of interpersonal and non-interpersonal childhood traumas. Future longitudinal studies are needed to examine how early adversity may impact threat processing, which would then bear upon revictimization. With respect to dissociation-based findings, the present study suggests that these symptoms may be a crucial point of intervention for adults with histories of childhood trauma, or trauma-exposed children. Treatments focusing on promoting awareness of and tolerance for internal and external threat cues may in turn facilitate faster and more adaptive responding. The treatment of attentional biases and avoidance of threat through attentional retraining, cognitive therapy, or psychodynamic techniques that bring awareness to attentional processes might also have a positive impact on survivors of childhood trauma (D’Andrea & Pole, 2012). Attention bias modification has been demonstrated to reduce PTSD symptoms (Kuckertz et al., 2014), and may similarly impact attendant dissociative, depressive, and anxiety symptoms. 4.1. Limitations The alterations in attention inherent in dissociative symptoms present significant challenges to the study of these symptoms in relation to behavioral tasks such as the dot-probe. In the current study, 16 participants (11% of dot-probe respondents) were excluded due to their high error rates on the task. The excluded sample was generally more symptomatic, had high mean levels of dissociation and trauma in adulthood. Eliminating the more severely dissociative individuals likely restricted the range of our analyses. It is plausible that task errors were related to dissociative

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processes such as derealization, disengagement and numbing, as these symptoms might increase the likelihood of lapses of attention, inaccurate responding and longer response latencies (Amrhein et al., 2008; Freyd et al., 1998). Importantly, such exclusion rates suggest that in future studies using similar designs, dissociation might ‘‘fly under the radar’’ as more severely dissociative individuals may be filtered out due to high error rates or outlying reaction times. Methodologically speaking, these findings highlight the need to address systematic factors accounting for outlying performance on cognitive tasks in clinical samples. Additionally, due to the cross-sectional nature of the study design, we cannot ascertain at what point threat biases and/ or dissociative symptoms emerge in relation to child or adult trauma. This limitation precludes the possibility of make causal inferences about the role of dissociation and threat bias in patterns of retraumatization across the lifetime. In addition to lowered levels of dissociation in our filtered sample, a number of other limitations are worthy of note. While levels of childhood trauma were low in the final sample, retraumatization rates were high; only 10% (n = 4) of participants who reported childhood trauma on the TESI did not experience a trauma as an adult, rendering it impossible to run analyses by groups, i.e., non-retraumatized versus retraumatized participants. Notably, rates of probable PTSD were elevated in comparison to national estimates of the general population (Kilpatrick et al., 2013). It may be that participants with trauma histories were more likely to proceed with the study after reviewing the consent information, which makes mention of ‘‘stressful or traumatic events.’’ This bias might render the sample less representative of the general population; however, oversampling on the basis of present symptoms is done routinely in psychopathology research. Finally, it remains possible that the null findings for attention biasPTSD relations are due to lack of power. Fani et al. (2012) found significant, albeit small, effects for PTSD and attention bias (d = .25), utilizing a slightly larger sample (n = 95) than the current study. Nevertheless, the present data demonstrate significant, small- to- moderate effects for childhood trauma exposure and dissociation in relation to threat-related bias. With regard to method, our version of the dot-probe utilized only neutral and aversive images and lacked a positive condition, and therefore biased responding might be due to a heightened level of arousal in general, and not specifically due to threat. Moreover, without the supplement of eye tracking, we are unable to state without doubt whether longer latencies in response to threat represent avoidance of attention or slowed psychomotor responses. Additionally, the use of self-report instruments, as well as online administration of the dot probe, both introduce the possibility of increased risk for errors or inaccuracies in responding across measures. Stimulus presentation duration in our study was 1000 ms, a window long enough for stimuli to be consciously perceived (supraliminal). It could be argued that this relatively long latency obscures the assessment of vigilance and attentional engagement, which might involve earlier (< 500 ms) preconscious processes (Mathews & MacLeod, 1986). However, Mogg, Bradley, De Bono, and Painter (1997) found evidence for vigilance toward threat across exposures of 100, 500 and 1500 ms, with no significant differences between durations. Several other dot-probe studies found evidence of vigilance using longer latencies ( 1000 ms) of exposure (Bradley, Mogg, White, Groom, & Bono, 1999; Dalgleish et al., 2003; Donaldson, Lam, & Mathews, 2007; Liossi, Schoth, Bradley, & Mogg, 2009; Naim et al., 2014; Price et al., 2016). Additionally, a meta-analysis of attention bias findings found that both subliminal and supraliminal presentations of threat resulted in bias in anxious individuals, with supraliminal stimuli yielding a small to moderate estimated effect size ((Bar-Haim, Lamy,

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Pergamin, Bakermans-Kranenburg, & Van Ijzendoorn, 2007). These findings would indicate that bias toward threat involves both automatic, pre-attentive processes, and more conscious strategies (Cisler & Koster, 2010). Future studies incorporating multiple exposure duration as well as eye-tracking would be necessary to parse attentional biases across various stages of processing. 5. Conclusion The present study highlights the importance of childhood trauma as a key factor in a cascade of multiple negative outcomes. Not only was childhood trauma associated with elevated rates of avoidance of threat, adult trauma and dissociation, it was also related to higher rates of depression, anxiety, somatization, and global psychiatric distress. Future studies examining the trajectories of childhood trauma in relation to threat perception and dissociation might do well to incorporate measures of autonomic arousal, as these physiological responses may play an important role in mediating the relationship between dissociation and threat reactivity following trauma exposure. Blunted autonomic reactivity, such as lowered heart rate and skin conductance, found in survivors of complex trauma, may underpin freezing and slowed response to danger in these individuals (D’Andrea, Pole, DePierro, Freed, & Wallace, 2013), with a subsequent impact on behavioral responses to manage threat. In addition, it is essential that researchers of threat reactivity and dissociation attend to the ways in which dissociative individuals might systematically be eliminated from analyses due to the very nature of dissociative symptoms themselves. Compliance with ethical standards Ethical responsibilities and approval This project was conducted at The New School in New York City, and approved by the university’s Institutional Review Board. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/ or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This manuscript is original; it has not been previously published (partly or in full) or posted online, and it is not currently under review elsewhere. If accepted, it will not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright-holder. This publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out. Informed consent Informed consent was obtained from all individual participants included in this study. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Disclosure of interest The authors declare that they have no competing interest. References Abrams, M. P., Nicholas Carleton, R., Taylor, S., & Asmundson, G. J. G. (2009). Human tonic immobility: measurement and correlates. Depression and Anxiety, 26(6), 550– 556. http://dx.doi.org/10.1002/da.20462

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Please cite this article in press as: Herzog, S., et al. Driven to distraction: Childhood trauma and dissociation, but not PTSD symptoms, are related to threat avoidance. European Journal of Trauma & Dissociation (2018), https://doi.org/10.1016/j.ejtd.2018.03.001