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the level of dissociation (Draijer, Langeland 1999). This implies the importance of object relations and attachment in the diagnosis and treatment of patients with dissociative disorders. Secure attachment rests on the basis of emotion regulation and insecure, especially disorganized, attachment, together with trauma, may profoundly disturb affect regulation.
DSM-5 did not include dissociative disorders (DD) under the Trauma- and Stressor-Related Disorders, as the diagnostic criteria for dissociative disorders do not include a stressor criterion (Criterion A), although the DDs in DSM-5 were deliberately placed just after the Trauma- and Stressor-Related Disorders group to indicate that most DD are associated with traumatic experiences (Reinders et al. 2014, Spiegel et al. 2013).
Since 2009, attempts to introduce the diagnosis of complex posttraumatic stress disorder for adults in the DSM-5 have been made, defined as Developmental Trauma Disorder among the disorders with onset in childhood and adolescence (Sar 2011). Complex PTSD presents with clinical features of full or partial PTSD together with symptoms from three additional clusters, namely problems in emotional regulation, negative self-concept, and problems in interpersonal relations (Marinova, Maercker 2015). Complex PTSD is proposed as a new diagnostic entity in ICD-11 and typically occurs after prolonged and complex trauma.
Effects on the brain
Carlson et al. (2010) regard learning as the process by which experiences change the nervous system and behavior accordingly. Learning is crucial to human survival. If we could not form memories as infants, we could not learn to do anything or benefit from experience. Early stress signals the nascent brain to develop along an alternative pathway adapting itself to survive and reproduce in a malevolent stress-filled world (Teicher, Tomoda & Andersen 2006). In psychotrauma, protection against the overwhelming exposure of threatening stimuli may be realized by inhibiting information processing. The DSM-5 definition (Spiegel et al. 2013, American Psychiatric Association 2013) of dissociation along with the general clinical assumption (Van der Hart, Nijenhuis & Steele 2006) suggest that individuals who experience high levels of dissociation, will show information processing dysfunction, such as disturbances in attention and memory, provoked by the implied defensive
GENERAL INTRODUCTION
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