Trauma, Dissociation,and High-Risk Behaviors


avatar Mohsen Kianpoor 1 , * , avatar Nour-Mohammad Bakhshani 1

Department of Psychiatry and clinical Psychology, Research center for health of adolescents and children, Zahedan University of medical sciences, Zahedan, IR Iran

how to cite: Kianpoor M, Bakhshani N. Trauma, Dissociation,and High-Risk Behaviors. Int J High Risk Behav Addict. 2012;1(1): 9-13.


Epidemiological studies and clinical findings have shown an association between trauma and dissociation; dissociative experiences are also more prevalent among select populations such as substance dependent individuals and criminal offenders. In the present non-systematic review, we explored the association between trauma, dissociation, and high-risk behaviors. We aimed to find if the presence of dissociative symptoms could lead us to better understand and recognize those who are prone to high-risk behaviors, among individuals exposed to psychological trauma.\r\nThe present overview indicated a substantial relationship between dissociation and high-risk behaviors. We concluded that designing and establishing appropriate studies regarding the relationship between trauma, dissociation, and high-risk behaviors would enable health professionals to have a better understanding and recognition of people prone to high-risk behaviors, as well as implement more effective strategies to prevent high-risk behaviors among at-risk populations.

1. Introduction

Substance use disorders (SUDs), HIV risk behavior, violence, and other high-risk behaviors are major health problems in our country, especially among the younger population. Both high-risk behaviors and dissociation have been found to be related to psychological trauma (1). In the present paper,to see if we could determine which populations are prone to high-risk behaviors, we explored the nature of this relationship through a non-systematic review of the relevant literature. This would allow for the development of better preventive and treatment programs, by applying the trauma and dissociation theories of psychopathology.

We will define trauma, high-risk behavior, and dissociation in the initial paragraphs and subsequently discuss the main studies on the relationship between trauma, dissociation, and well-known high-risk behaviors. Finally, some suggestions for further study are provided.

1. 1. Psychological Trauma

The word “trauma” means a serious shock or injury to the body. Psychologically, it is defined as a single experience, or an enduring or repeating event that threatens one’s physical integrity, sense of self, safety, survival, or the physical safety of one loved one. Trauma can be experienced as a result of different circumstances, including the following (1).

1) Abuse, especially in childhood

2) Exposure to domestic violence

3) Natural disaster

4) War

5) Abandonment

6) Personal attack by another person or animal

7) Witnessing catastrophic accidents or violence to others

8) Becoming a victim of kidnapping, rape, or torture

9) Experiencing a medical procedure, accident, or serious illness

Trauma affects many levels of functioning—somatic, emotional, cognitive, behavioral, and characterlogical. More specifically, exposure to trauma during childhood and adolescence has been shown to be directly linked to psychiatric disorders, such as dissociative disorder (2, 3), borderline personality disorder (4, 5),and SUD (6, 7), as well as behavioral problems such as self-mutilation (8), alcohol use, and other risk-taking behaviors such as violence, delinquency, teen pregnancy, and higher HIV risk behavior (9-14).

1. 2. High-Risk Behavior

High-risk behaviors are defined as volitional behaviors with an uncertain outcome that entail negative consequences (15). Although it may be seen during any period of life, adolescents are more prone to high-risk behaviors such as the use of illicit drugs, heavy drinking, delinquency, dangerous driving, and HIV-risk behavior (16-18). Other forms of high-risk behaviors are violence (9, 10), teen pregnancy, and weapon carrying (9, 11).Suicidal attempts and self-mutilating behavior, or deliberate self-harm (DSH), is also frequent among adolescents (8).

Adolescents are confronted with the task of defining their own identities, roles, and social functions during this stage of development. It is often during this transitional stage of life that the youth begin to express their discomfort through their bodies, enacting risky behaviors that function to release and express aversive emotional distress and tension. In other words, high-risk behaviors that often begin in adolescence may function as ways to escape or regulate painful emotions (8). Other authors such as Goldich (12) have attributed the association between psychological trauma and high-risk behavior to the tendency toward behavioral enactment, which is described as the repetition of the actions, performed or imagined, that occurred during the traumatic event (19). From this perspective, high-risk behavior is conceptualized as a way of remembering, or as an unconscious attempt to gain mastery over the trauma (12, 20). As mentioned above, many authors have shown the strong dose-response relationship between trauma and high-risk behavior (21) and have suggested that a history of maltreatment or other forms of psychological trauma is a precursor to health-risk behaviors in both adolescence and adulthood (17).

1. 3. Dissociation

Dissociation is the main characteristic of dissociative disorder, and it is defined as a conscious and/or unconscious separation of mental processes that are ordinarily integrated into and accessible to conscious awareness. This may manifest as an adaptation to stress in a healthy or pathological manner (22). The DSM-IV defines dissociation as “a disruption of the usually integrated functions of consciousness, memory, identity or perception of the environment.”

The main pathological dissociative symptoms include feeling like everything is unreal (derealization); feeling disconnected from one’s body or feeling (depersonalization); amnesia for personal information or events that are too extensive to be explained by ordinary forgetfulness (dissociative amnesia); and finding evidence of, or learning from others about activities of alternate identities, feeling possessed or controlled, and experiencing internal images and voices (identity alteration) (23). In contemporary psychology and psychiatry, the term dissociation can pertain to (a) symptoms; (b) a presumed cause of symptoms, including the presumed function such as psychological defense; and (c) normal and pathological alteration of consciousness including hypnosis (24).

Theoretically, the association between trauma and dissociation was first noted by the pioneers of psychology such as Janet and Freud (25),and has been supported by many studies (24). In an attempt to declare the possible mechanisms behind this association, Terr hypothesized that dissociation begins as an individual’s defense against an overwhelming negative experience. If the negative experience recurs, then this pattern of behavior becomes entrenched over time in one’s behavioral repertoire as an automatic and uncontrollable response to stress. This theory has received general support from empirical research, in which the level of dissociation has been consistently related to both chronicity and severity of trauma in retrospective self-report studies (25). During a traumatic experience, dissociation allows a person to observe the event as a spectator, limits feelings of pain or distress, and protects against awareness of the full impact of what has occurred (26).

2. Trauma, Dissociation, and SUD

Much researches have shown a positive correlation between history of psychological trauma, frequency of dissociative experiences, and SUD (27-34). In a more recent study, Tamor-Gurol et al. (34) showed that among 104 consecutive patients at an addiction treatment center, 37 patients had scores ≥ 30, compared with 21 patients with scores<10 on the Dissociative Experience Scale (DES), while 59.3% of 27 patients who had co-morbid dissociative disorder reported that dissociative experiences had existed prior to substance use. They also found that a history of attempted suicide or childhood emotional abuse were significant predictors of a dissociative disorder.

In an Iranian study on Shiraz prisoners, Kianpoor et al. (31) found that 74% of prisoners with SUD versus 43% of those without it had DES scores greater than 30. in their study, depersonalization and absorption/ derealization subscale symptoms were more frequent as a whole, the symptoms that are aggravated by using opioids as its main effect on thought and emotion of users. It was concluded that at least for a group of prisoners, or people under unbearable stress, using substances is a way to control emotional pain by amplifying old problematic dissociative strategies.

It has been proposed that drug use is an attempt at self-medication, or a chemical means of achieving a dissociative state (chemical dissociation) (35).

3. Trauma, Dissociation, Sexual and Other High-Risk Behaviors

Past history of trauma in the form of physical/sexual abuse during childhood or any other period has been found to be significantly related to sexual risk behaviors, in both clinical and community-based samples (36). In describing the results of interviews with 2,676 men enrolled in a multi-level HIV prevention trial, Dilorio et al. found that men who reported trauma from childhood sexual abuse also reported greater frequency of risky sexual behavior and HIV infection (36). These results were replicated in a study on 827 men and women attending a sexually transmitted disease clinic (37), and in many other studies (38). Injection drug use was also shown to be associated with traumas from childhood abuse (39), exposure to violence, and lifetime sexual abuse (17). These and many other authors tried to explain the mechanism or mediator that specifically associates trauma from childhood and lifetime sexual abuse, as well as violence victimization, to HIV-risk behavior. For example, in a longitudinal multicenter study on 1,288 women infected with HIV, and 357 uninfected women, Cohen et al. concluded that childhood sexual abuse was strongly associated with a lifetime history of domestic violence, as well as an increased frequency of behaviors that led to HIV infection (40). More than any other mediator, dissociation has been the focus of such research. From this point of view, both the ongoing distress related to trauma and the avoidance via dissociation to overcome intrusive and aversive memories may maintain these patterns of sexual risk behavior and increase risk for STD/HIV infection. In other words, this model suggests that early traumatic experiences in family contexts are related to victims’ use of dissociative and avoidant responses to keep threatening information below awareness (41). The study by Shutterland clearly confirmed this theory; This study on 189 women suggested that dissociation and intimate partner sexual coercion are important mediators of childhood sexual abuse and sexually transmitted infection diagnosis. Other studies have implied the role of alcohol and illicit drug use to allow victims to escape from the painful emotions of unbearable traumatic experiences through “chemical dissociation” (17, 42-44).

4. Trauma, Dissociation, Violence, Self-Destructive and Other High-Risk Behaviors

In her book, “Prologue to Violence: Child Abuse, Dissociation and Crime,” Abbey Stein says that all stories of violence are stories of dissociation, both large and small. This book introduces dissociation as the mediator of the etiological association between psychological trauma and violence, and suggests that any form of rehabilitation that does not take into account the profoundly dissociative nature of most forms of violence is doomed to failure (45). The clearest relationship between dissociative stress, psychomotor agitation and violent behaviors is seen in culture-bound trance and possession states, such as brief dissociative stupor or madness attacks. According to Zar and Djinnati (46), Kianpoor and Rhoades have also found the presence of psychological trauma in the form of childhood sexual abuse in the past history of presented cases.

Many other studies have proclaimed the association of DSH in patterns of self-mutilating behavior and repeated suicide attempts with dissociative experiences. Cerutti et al. (8), in a study on 234 adolescents in an Italian secondary school, revealed that those with a history of DSH and specific life stressors reported higher rates of pathological dissociation. They concluded that the dissociative process might play a role in both the development and maintenance of DSH. Foote et al. (47) also found in their study on 231 psychiatric outpatients that the presence of a dissociative disorder was strongly associated with all measures of self-harm and repeated suicide attempts. Self-mutilating behavior was also shown to be frequently associated with dissociation both in patients with dissociative disorder (22), and those with borderline personality disorder who had higher dissociative experiences (23).

Other high-risk behaviors shown to be related to psychological trauma and dissociation are aggressive behavior, eating disorders, and teen pregnancy (48-50).

5. Discussion

As van der Kolk explained, traumatized people employ a variety of methods to cope with stressful situations. These methods are often self-destructive and bizarre and present themselves as high-risk behaviors including SUDs, unusual and unsafe sexual practices, self-mutilation, and repeated suicidal attempts (26). We reached the same conclusion after reviewing the studies mentioned above. Overall, many studies found that dissociation acts as a mediator between psychological trauma and high-risk behaviors.

This review, however, intentionally followed the notion that dissociation can be considered a mediator, as it primarily co-occurs with trauma and high-risk behavior.

As mentioned, many authors have proposed that drug use is an attempt at self-medication, or a chemical means of achieving a dissociative state to avoid the memories and feelings associated with the trauma (35, 48). The positive psychological effects of alcohol and illicit drugs, such as stress reduction through the potentiation of dissociation as a defense, might be particularly rewarding to individuals with high levels of psychological stress (17, 31).

Researchers have pointed out that despite having the apparent knowledge and skills necessary to avoid risk of HIV infection, many at-risk people continue to manifest high-risk sexual behaviors (50). It is likely that such people employ maladaptive coping responses, such as avoidance via substance abuse and dissociation, in situations that trigger intrusive and aversive memories (41).

Dissociation has also been shown to be related to DSH (8, 22). The subjective sense of dissociation that primarily may have helped self-mutilators to cope with their psychological trauma is also quite a dysphoric experience (26). Indeed, many self-mutilators feel little or no physical pain during the act and feel more real and much better following their self-mutilation and other DSH behaviors (22), even after engaging in other high-risk behaviors.

As mentioned by dynamic theoreticians, dissociation occurs when the energy of an extra psychic trauma is much greater than the psychological and biological capacity of one’s mental apparatus. This defense produces forgetting effects regarding the explicit memory between different dissociative parts of the mind. This lack of integration, however, usually comes at a price: most of these individuals are bound to re-experience their traumatizing events at some point (24).

Finally, most of the reviewed studies had some limitations, including (a) using self-report data and a lack of comprehensive measurements; (b) studying only specific populations, making generalization of the findings difficult; and (c) failing to precisely work on the role of dissociation as a mediator in the relationship between trauma and high-risk behaviors. We believe that if we could design and establish appropriate studies regarding the relationship between trauma, dissociation, and high-risk behaviors, we would be able to better understand and recognize those prone to high-risk behavior. Employing valid instruments for detecting dissociation such as the DES can help mental health workers screen those at risk of high-risk behaviors; similarly, using effective methods for dealing with trauma patients who show symptoms of dissociation would enable clinicians to provide better treatment and prevention programs.



  • 1.

    Moroz DLKJ. The Effects of Psychological Trauma on Children and Adolescents:. Report Prepared for the Vermont Agency of Human Services, Health M; 2005. June 30,2005 Contract No.: Document Number.

  • 2.

    Ross CA, Miller SD, Reagor P, Bjornson L, Fraser GA, Anderson G. Structured interview data on 102 cases of multiple personality disorder from four centers. Am J Psychiatry. 1990;147(5):596-601. [PubMed ID: 2183634].

  • 3.

    Saxe GN, van der Kolk BA, Berkowitz R, Chinman G, Hall K, Lieberg G, et al. Dissociative disorders in psychiatric inpatients. Am J Psych. 1993;150(7):1037-42. [PubMed ID: 8317573].

  • 4.

    Herman JL, Perry JC, van der Kolk BA. Childhood trauma in borderline personality disorder. Am J Psychiatry. 1989;146(4):490-5. [PubMed ID: 2929750].

  • 5.

    Ogata SN, Silk KR, Goodrich S, Lohr NE, Westen D, Hill EM. Childhood sexual and physical abuse in adult patients with borderline personality disorder. Am J Psychiatry. 1990;147(8):1008-13. [PubMed ID: 2375434].

  • 6.

    Huang S, Trapido E, Fleming L, Arheart K, Crandall L, French M, et al. The long-term effects of childhood maltreatment experiences on subsequent illicit drug use and drug-related problems in young adulthood. Addict Behav. 2011;36(1-2):95-102. [PubMed ID: 20947260].

  • 7.

    Ford ES, Anda RF, Edwards VJ, Perry GS, Zhao G, Li C, et al. Adverse childhood experiences and smoking status in five states. Prev Med. 2011;53(3):188-93. [PubMed ID: 21726575].

  • 8.

    Cerutti R, Manca M, Presaghi F, Gratz KL. Prevalence and clinical correlates of deliberate self-harm among a community sample of Italian adolescents. J Adolesc. 2011;34(2):337-47. [PubMed ID: 20471075].

  • 9.

    Sugar M, editor. Trauma and adolescence. Madison, Conn. : International Universities Press, c1999; 1999.

  • 10.

    Reijneveld SA, Crone MR, Verhulst FC, Verloove-Vanhorick SP. The effect of a severe disaster on the mental health of adolescents: a controlled study. Lancet. 2003;362(9385):691-6. [PubMed ID: 12957091].

  • 11.

    Glodich A. Traumatic exposure to violence: A comprehensive review of the child and adolescent literature. Smith College Studies in Social Work. 1998;68(3):321-45.

  • 12.

    Gore-Feltun C, Koopman C. Traumatic experiences: Harbinger of risk behavior among HIV-positive adults. J Trauma Dissociation. 2002;3(4):121-35.

  • 13.

    Stevens SJ, Murphy BS, McKnight K. Traumatic stress and gender differences in relationship to substance abuse, mental health, physical health, and HIV risk behavior in a sample of adolescents enrolled in drug treatment. Child Maltreat. 2003;8(1):46-57. [PubMed ID: 12568504].

  • 14.

    Irwin CE, Jr. The Theoretical Concept of At-Risk Adolescents. Adolesc Med. 1990;1(1):1-14. [PubMed ID: 10350697].

  • 15.

    Arnett JJ. Risk behavior and family role transitions during the twenties. J Youth Adoles. 1998;27(3):301-20.

  • 16.

    Bensley LS, Van Eenwyk J, Simmons KW. Self-reported childhood sexual and physical abuse and adult HIV-risk behaviors and heavy drinking. Am J Prev Med. 2000;18(2):151-8.

  • 17.

    Muuss R, Porton H. interesting risk behavior and society. Boston: Mc Graw-Hill; 1998. Available from:

  • 18.

    Pynoos RS, Nader K. Psychological first aid and treatment approach to children exposed to community violence: Research implications. J Traumatic Stress. 1988;1(4):445-73.

  • 19.

    van der Kolk BA, ducey CP. The psychological processing of traumatic experience: Rorschach patterns in PTSD. J Traumatic Stress. 1989;2(3):259-74.

  • 20.

    Ramiro LS, Madrid BJ, Brown DW. Adverse childhood experiences (ACE) and health-risk behaviors among adults in a developing country setting. Child abuse & neglect. 2010;34(11):842-55.

  • 21.

    Waller N, Putnam FW, Carlson EB. Types of dissociation and dissociative types: A taxometric analysis of dissociative experiences. Psychol Methods. 1996;1(3):300.

  • 22.

    Korzekwa MI, Dell PF, Pain C. Dissociation and borderline personality disorder: An update for clinicians. Current Psych Rep. 2009;11(1):82-8.

  • 23.

    Nijenhuis ER, van der Hart O. Dissociation in trauma: a new definition and comparison with previous formulations. J Trauma Dissociation. 2011;12(4):416-45. [PubMed ID: 21667387].

  • 24.

    Ogawa JR, Sroufe L, Weinfield NS, Carlson EA, Egeland B. Development and the fragmented self: Longitudinal study of dissociative symptomatology in a nonclinical sample. Develop Psychopathol. 1997;9(4):855-79.

  • 25.

    van der Kolk BA. The complexity of adaptation to trauma, self- regulation, stimulus discrimination, and charecterological development. In: van der Kolk A, Farlane M, Weisaeth L, editors. . New York: Guilford; 1996. p. 189-213.

  • 26.

    Dunn GE, Paolo AM, Ryan JJ, Van Fleet J. Dissociative symptoms in a substance abuse population. Am J Psychiatry. 1993;150(7):1043-7. [PubMed ID: 8317574].

  • 27.

    Curran HV, Morgan C. Cognitive, dissociative and psychotogenic effects of ketamine in recreational users on the night of drug use and 3 days later. Addiction. 2000;95(4):575-90. [PubMed ID: 10829333].

  • 28.

    Langeland W, Draijer N, van den Brink W. Trauma and dissociation in treatment-seeking alcoholics: towards a resolution of inconsistent findings. Compr Psych. 2002;43(3):195-203. [PubMed ID: 11994837].

  • 29.

    Karadag F, Sar V, Tamar-Gurol D, Evren C, Karagoz M, Erkiran M. Dissociative disorders among inpatients with drug or alcohol dependency. J Clin Psychiatry. 2005;66(10):1247-53. [PubMed ID: 16259538].

  • 30.

    Kianpoor M, Bahredar MJ, Ommizade SJ. Comparing the Level of Dissociative Experience in Prisoners with and without Opioid Dependence Disorder in Shiraz and its Relationship with Other Psychiatric Disorders. IR J of Psy Behav Sci. 2008;2(4). .

  • 31.

    Ross CA, Kronson J, Koensgen S, Barkman K, Clark P, Rockman G. Dissociative comorbity in 100 chemically dependent patients. Hosp Community Psychiatry. 1992;43(8):840-2. [PubMed ID: 1330870].

  • 32.

    Kianpoor M, Badiee H, Ghanizade A, Firoozabadi A. The association of dissociative experiences with success in abstinence among patients of Shiraz wellfare organization clinic. . 2012.

  • 33.

    Tamar-Gurol D, Sar V, Karadag F, Evren C, Karagoz M. Childhood emotional abuse, dissociation, and suicidality among patients with drug dependency in Turkey. Psychiatry Clin Neurosci. 2008;62(5):540-7. [PubMed ID: 18950373].

  • 34.

    Fuller CM, Vlahov D, Ompad DC, Shah N, Arria A, Strathdee SA. High-risk behaviors associated with transition from illicit non-injection to injection drug use among adolescent and young adult drug users: a case-control study. Drug Alcohol Dep. 2002;66(2):189-98.

  • 35.

    DiIorio C, Hartwell T, Hansen N. Childhood sexual abuse and risk behaviors among men at high risk for HIV infection. Am J Pub Health. 2002;92(2):214.

  • 36.

    Senn TE, Carey MP, Vanable PA, Coury-Doniger P, Urban MA. Childhood sexual abuse and sexual risk behavior among men and women attending a sexually transmitted disease clinic. J Consult Clinical Psychol. 2006;74(4):720.

  • 37.

    Pearce ME, Christian WM, Patterson K, Norris K, Moniruzzaman A, Craib KJP, et al. The Cedar Project: Historical trauma, sexual abuse and HIV risk among young Aboriginal people who use injection and non-injection drugs in two Canadian cities. Social Sci Med. 2008;66(11):2185-94.

  • 38.

    Ompad DC, Ikeda RM, Shah N, Fuller CM, Bailey S, Morse E, et al. Childhood sexual abuse and age at initiation of injection drug use. Am J Public Health. 2005;95(4):703-9. [PubMed ID: 15798133].

  • 39.

    Cohen M, Deamant C, Barkan S, Richardson J, Young M, Holman S, et al. Domestic violence and childhood sexual abuse in HIV-infected women and women at risk for HIV. Am J Public Health. 2000 April;90(4):560-5.

  • 40.

    Tubman JG, Montgomery MJ, Gil AG, Wagner EF. Abuse experiences in a community sample of young adults: relations with psychiatric disorders, sexual risk behaviors, and sexually transmitted diseases. Am J Community Psychol. 2004;34(1-2):147-62. [PubMed ID: 15495800].

  • 41.

    Simoni JM, Sehgal S, Walters KL. Triangle of risk: urban American Indian women's sexual trauma, injection drug use, and HIV sexual risk behaviors. AIDS Behav. 2004;8(1):33-45.

  • 42.

    Halkitis P, Parsons J. Recreational drug use and HIV-risk sexual behavior among men frequenting gay social venues. J Gay Lesbian Social Serv. 2003;14(4):19-38.

  • 43.

    Sutherland MA. Examining Mediators of Child Sexual Abuse and Sexually Transmitted Infections. Nurs Res. 2011;60(2):139.

  • 44.

    Moskowitz A. A Review of Prologue to Violence: Child Abuse, Dissociation, and Crime. 2008.

  • 45.

    Kianpoor M, Rhoades Jr GF. Djinnati, A Possession State in Baloochistan, Iran. J Trauma Pract. 2006;4(1-2):147-55.

  • 46.

    Foote B, Smolin Y, Neft DI, Lipschitz D. Dissociative disorders and suicidality in psychiatric outpatients. J Nerv Mental Disease. 2008;196(1):29.

  • 47.

    Shrier LA, Pierce JD, Emans SJ, DuRant RH. Gender differences in risk behaviors associated with forced or pressured sex. Arch Ped Adoles Med. 1998;152(1):57.

  • 48.

    Stock JL, Bell MA, Boyer DK, Connell FA. Adolescent pregnancy and sexual risk-taking among sexually abused girls. Family Plan Perspec. 1997:200-27.

  • 49.

    Paul T, Schroeter K, Dahme B, Nutzinger DO. Self-injurious behavior in women with eating disorders. Am J Psych. 2002;159(3):408-411.

  • 50.

    Jinich S, Paul JP, Stall R, Acree M, Kegeles S, Hoff C, et al. Childhood sexual abuse and HIV risk-taking behavior among gay and bisexual men. AIDS Behav. 1998;2(1):41-51.

2021-02-03 10:42:23
Dissociative identity disorder is characterized by a disturbed childhood sexual trauma that can lead to dissociative identity disorder view of reality, frequently combined with occasional memory loss or “blending” of separate identities.