Trauma, Emotional Regulation, and Coping Styles in Individuals with and without Probable Dissociative Disorders in Hong Kong

ABSTRACT

Previous studies showed that dissociation and dissociative disorders (DDs) are prevalent and are associated with considerable individual and social consequences. There are ongoing debates regarding whether dissociation is a response to betrayal trauma across cultures and whether dissociation can be explained by maladaptive coping. Additionally, little is known about the clinical features of individuals with DDs in the Chinese context. This study aimed to investigate the relationship between trauma, emotional regulation, coping, and dissociation. We analyzed baseline data from a randomized controlled trial (N = 101). Participants with dissociative symptoms in Hong Kong completed self-report assessments. Structured interviews were also conducted subsequently. Participants with probable DDs reported more traumatic events (p = .009 to .017) and exhibited significantly higher levels of dysfunctional coping (p < .001) compared to those who reported dissociative symptoms but did not have a DD. Dissociative symptoms were more strongly associated with betrayal trauma than with non-betrayal trauma. Among different emotion regulation and coping strategies, dysfunctional coping was the only significant factor associated with dissociative symptoms (β = .309, p = .003). Dysfunctional coping was a statistically significant mediator that may explain the relationship between betrayal trauma and dissociative symptoms. Although other mediation paths are also possible and further longitudinal studies are required, our findings highlight the strong link between dysfunctional coping and dissociative symptoms and suggest that coping skills training should be incorporated into interventions for betrayal trauma survivors with dissociative symptoms. Additionally, this study provides evidence for the cross-cultural validity of the betrayal trauma theory. Further studies, however, are required.

KEYWORDS:

• Betrayal trauma
• dissociation
• dissociative disorders
• coping
• emotion regulation

Dissociation, which refers to a failure in the process of integrating one’s psychophysiological experiences (e.g., emotions, memories, identities), is an officially recognized mental health condition in both DSM-5-TR and ICD-11 (American Psychiatric Association, 2022; World Health Organization, 2019). Dissociation has been operationalized using standardized and reliable measures for almost four decades (Bernstein & Putnam, 1986; Mychailyszyn et al., 2021; Ross et al., 2002). Examples of dissociative symptoms include amnesia for painful memories, depersonalization, derealization, intrusions of dissociated emotions/thoughts/memories, and identity dissociation (Dell, 2006; Fung, 2018).

Dissociative symptoms are the primary features of dissociative disorders (DDs), which include dissociative amnesia, depersonalization/derealization disorder, dissociative identity disorder (DID), and other specified dissociative disorder (OSDD) in DSM-5-TR. DID is typically considered to be the most severe form of dissociative pathology since it involves severe dissociative amnesia and identity dissociation, and is associated with highest levels of dissociative symptoms and highest rates of childhood maltreatment (Brand et al., 2012; Ross & Ellason, 2005). Nevertheless, dissociative symptoms can be present in individuals with other psychiatric conditions, such as posttraumatic stress disorder (PTSD), borderline personality disorder, and schizophrenia (Atchley & Bedford, 2021; Fung, Chien, et al., 2022; Lyssenko et al., 2018; Scalabrini et al., 2016).

Dissociative symptoms and disorders are prevalent in both clinical and nonclinical settings and are associated with considerable individual and social consequences. A review study indicated that the lifetime prevalence of DDs is about 10% in the general population (Şar, 2011). According to a recent meta-analysis, 16.6% of college students exhibit dissociative symptoms (Kate et al., 2020). Additionally, Gonzalez Vazquez et al. (2017) reported that patients with DDs require more frequent inpatient treatment and emergency consultations and exhibit a higher incidence of self-harm and suicidal tendencies compared to patients with depression. Therefore, they argued that DDs should be considered to be severe mental illness. Other studies also showed that DDs typically involve significant socioeconomic costs (Langeland et al., 2020; Myrick et al., 2017). Even in patients without a diagnosed DD, dissociative symptoms are also associated with unfavorable clinical outcomes, such as more comorbid symptoms and higher levels of impairment (Fung et al., 2020; Şar et al., 2013).

Given the high prevalence and substantial costs associated with dissociative symptoms and disorders, further research is needed to understand how to conceptualize, prevent, and manage these conditions effectively. Against this background, the present study examined the potential roles of trauma, emotion regulation, and coping in people with dissociative symptoms. The results may be able to explain a few research gaps as follows:

First, this study identified the clinical features of individuals with DDs in Hong Kong by comparing their demographic backgrounds, trauma histories, and clinical diagnoses with those who did not meet the diagnostic criteria for a DD. Although recent studies have shown that dissociative symptoms and disorders are cross-cultural phenomena and can be prevalent in Chinese populations (Chiu et al., 2017; Fung et al., 2019, 2021), there are considerably fewer studies of dissociation in the Chinese context when compared to the Western literature. A better understanding of the clinical features of individuals with DDs in the Chinese context could facilitate early identification of dissociative conditions in a cross-cultural context.

Second, the study examined whether dissociative symptoms would have a stronger association with betrayal trauma than with non-betrayal trauma in order to replicate and confirm the betrayal trauma theory. The betrayal trauma theory proposes that dissociation is particularly associated with betrayal trauma (i.e., a traumatic event perpetrated by a close person) and conceptualizes dissociation as a survival mechanism (Freyd, 1996, 2008). Betrayal trauma was associated with dissociative symptoms in several studies in Western cultures (e.g., Chu & DePrince, 2006; Goldsmith et al., 2012). The replication of the betrayal trauma theory in diverse sociocultural contexts may improve the cross-cultural validity of the theory and provide insights for developing preventive interventions and policy recommendations.

Third, the study assessed whether specific emotional regulation strategies and coping styles would be associated with dissociative features and explored whether they would be a statistically significant mediator in the relationship between trauma and dissociative features. The trauma model of dissociation (Freyd, 1996; Nijenhuis & Den Boer, 2009; Ross, 2007; Ross & Browning, 2017) conceptualizes dissociation as a coping mechanism. Nijenhuis and Den Boer (2009) also posit that dissociation can also be understood through learning processes, such as classical conditioning and instrumental conditioning. Theoretically speaking, individuals under trauma and stress may consciously or unconsciously dissociate when other coping methods (e.g., physical escape) are not feasible. Trauma survivors who have not learned how to regular their emotions or who lack healthy coping skills may continue to rely on dissociation as a coping mechanism even after the traumatic event. Self-regulation has also been suggested as an important factor in understanding trauma-related dissociation (Ford, 2013). Recent studies have shown that difficulties in coping with emotions were associated with greater levels of distress in betrayal trauma survivors (Choi & Kangas, 2020). Some previous studies have also found that dissociation has a moderate relationship with maladaptive domains of emotional regulation (Cavicchioli et al., 2021) and that coping self-efficacy may be a protective factor against persistent dissociation (Mahoney & Benight, 2019). In addition, dysfunctional coping, as defined as the inappropriate techniques people use to deal with stressors (Kannis-Dymand et al., 2020), may be particularly unitized by betrayal trauma survivors who lack other healthy coping strategies because they lack relevant internal and external resources (Banou et al., 2009; Cloitre et al., 2020). While these coping strategies may provide temporary relief, they can eventually lead to increased psychological distress and exacerbate trauma symptoms (Romero et al., 2020). Therefore, emotion regulation and coping skills training are often emphasized in the treatment of interpersonal trauma survivors with high levels of dissociative symptoms (Cloitre et al., 2020; Fisher, 1999; International Society for the Study of Trauma and Dissociation, 2011). Thomson and Jaque (2018) reported that individuals with depersonalization exhibited higher levels of emotional overexcitability and were less likely to employ adaptive coping mechanisms when faced with stress, as opposed to those without depersonalization. However, some researchers have challenged the trauma model of dissociation, and further challenge the hypothesis that dissociation is related to maladaptive coping (Giesbrecht et al., 2008; Lynn et al., 2022). To improve the prevention and treatment of dissociative symptoms and disorders, it is crucial to better understand the underlying causes and mechanisms of dissociation. Therefore, this study also investigated the potential roles of emotional regulation strategies and coping styles in dissociation. In particular, as informed by the theoretical assumptions (i.e., trauma can increase the risk of developing maladaptive coping and that dissociation may result from maladaptive coping or a lack of healthy coping when faced with trauma and stress) (Nijenhuis & Den Boer, 2009; Ross, 2007) as well as the cognitive behavioral model for dissociation (Vancappel & El-Hage, 2023), the study also tested the hypothesis that coping may be a potential mediator in the relationship between trauma and dissociative symptoms.

Methods

Participants

This study analyzed baseline data from a pilot randomized controlled trial to evaluate a web-based intervention program for adults with dissociative symptoms in Hong Kong. This study was approved by the institutional review board at the Chinese University of Hong Kong. Potential participants were recruited through online social media platforms (e.g., Facebook and Instagram) from March to May 2023. The recruitment poster was also circulated among local mental health service providers. In the recruitment poster, examples of dissociative symptoms are provided. Participants had to be aged 18 or above, currently living in Hong Kong, agree to provide informed consent and participate, and be able to communicate in Chinese. Participants with a clinical diagnosis of a learning/reading disability, dementia, or cognitive impairments were excluded.

A total of 165 participants completed the online registration form and provided informed consent; 120 of them screened positive for dissociative symptoms (i.e., scored 20 or above on the Chinese version of the Dissociative Experiences Scale-Taxon)(DES-T) (Fung, Choi, et al., 2018; Ross et al., 2002). All 120 participants were invited to attend a structured interview for questionnaire completion via telephone by a trained research assistant (which will be further explained in the following subsection). However, a few participants did not respond even after multiple reminders. Finally, 101 participants attended the structured interview and they were included for analysis in this study.

Measures

In the online screening survey, participants completed measures on trauma exposure, emotional regulation, and coping styles, in addition to questions about demographic backgrounds. The following measures were used:

The Brief Betrayal Trauma Survey (BBTS). The BBTS, which originally had 24 items, is a reliable self-report measure which asks about exposure to betrayal and non-betrayal traumatic events before and after the age of 18 (Goldberg & Freyd, 2006). The Chinese version of the BBTS was reported to have satisfactory test-retest reliability (Cohen’s kappa = .299 to .769) (Fung, Chien, et al., 2022). In the present study, we included all 12 types of lifetime traumatic events. We classified the traumatic events as betrayal or non-betrayal according to the suggested guidelines (see Freyd, 2011). There were five items for betrayal trauma (e.g., “You were deliberately attacked that severely by someone with whom you were very close”) and five items for non-betrayal trauma (e.g., “You were deliberately attacked that severely by someone with whom you were not close”).

The Emotion Regulation Questionnaire (ERQ). The ERQ is a 10-item self-report measure of emotion regulation with two factors (i.e., cognitive reappraisal and expressive suppression); both subscales have good internal consistency and established construct validity (Gross & John, 2003). The Chinese version of the ERQ also had the same factor structure, and both subscales demonstrated good internal consistency (α = .85 and .72) and construct validity (Li & Wu, 2020). Higher scores indicate greater use of that particular emotion regulation strategy.

The Brief Coping Orientation to Problems Experienced Inventory (Brief-COPE). The Brief-COPE is a 28-item self-report measure of coping strategies (Carver, 1997). The Brief-COPE indicated good internal consistency (α = .72 to .84), test-retest reliability (r = .58 to .72) and construct validity (Cooper et al., 2008; Monzani et al., 2015). The Chinese version of the Brief-COPE demonstrated excellent internal consistency (α = .89), test-retest reliability (ICC = .876) and content validity, and three factors were identified, including active coping, dysfunctional coping, and distraction (humor and self-distraction) (Tang et al., 2021). Higher scores indicate more frequent use of that specific coping strategy.

During the telephone interviews conducted within 1–2 weeks after completion of the online self-report assessments, a structured interview was conducted. The structured interview asked about previous psychiatric diagnoses and the use of psychiatric medication and counseling/psychotherapy treatments. In addition, dissociative symptoms and disorders were assessed using selected sections from the Dissociative Disorders Interview Schedule (DDIS). The DDIS is a 132-item diagnostic interview for DSM-5 DDs (Ross & Browning, 2017; Ross et al., 1989). Since the DDIS is fully standardized, minimal training is required to administer the DDIS and it can be used for research purposes by research assistants. The DDIS includes sections which ask about dissociative symptoms (also known as secondary features associated with DID) as well as DSM-5 criteria for each DD. During the standardized interview, each DD was evaluated exactly in accordance with the DSM-5 criteria. For example, regarding Dissociative Amnesia, the interviewer inquired whether the individual had experienced “an inability to recall important personal information or traumatic events that is too extensive to be explained by ordinary forgetfulness” and if so, whether these symptoms had caused significant distress or impairment, and whether the symptoms were a result of other medical problems. The DDIS is well-validated and is available at https://rossinst.com/. The DDIS also includes other sections (e.g., Schneiderian symptoms and borderline personality disorder features), but these sections were not included in the present study. The DDIS had good diagnostic validity: The dissociative symptoms/features section of the DDIS can differentiate between psychiatric patients with and without a complex DD very well (Ross & Ellason, 2005), and the DDIS can also diagnose complex DD with excellent agreement with an expert clinical interview and with the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) (Cohen’s kappa = .71 to .74) in a blind study (Ross et al., 2002). The DDIS has been used in a number of studies among Chinese populations as an interview-administered or self-report instrument, and it also had good validity (Chiu et al., 2017; Fung et al., 2021, 2023; Fung, Choi, et al., 2018; Fung, Ho, et al., 2018; Wu et al., 2022). In the present study, the dissociative features/symptoms section and the DSM-5 DDs sections of the DDIS were used. Participants who met the DSM-5 criteria for any DD on the DDIS were considered to have probable DDs. The DDIS was administered on the phone by a master-level psychology research assistant who has published papers related to dissociation and was provided with instructions and readings about dissociative symptoms and disorders (e.g., Ross, 2015) before conducting the interviews. Since the DDIS is a fully standardized assessment tool, it does not require any clinical judgment from the interviewer, except for Item 131, which pertains to Other Specified Dissociative Disorder (OSDD). To ensure diagnostic accuracy in this research, an additional requirement was added for participants to be diagnosed with OSDD. Specifically, they must report at least five dissociative features from the “secondary features associated with DID” section. This decision was based on the observation that this section could effectively discriminate between patients with and without a DD (Ross & Ellason, 2005) and that local studies have also shown its high specificity (Fung, Choi, et al., 2018). This approach could help minimize false-positive diagnoses when the DDIS is administered by a research assistant rather than an experienced clinician.

Data analysis

SPSS 22.0 was used for statistical analyses. We report the descriptive analyses of all major variables, including demographic backgrounds, dissociative symptoms, trauma exposure, coping, and emotion regulation. We conducted independent sample t and chi-square tests to examine differences between participants with and without DD (this research-based diagnosis was based according to the DDIS results) for the major variables. We also conducted a hierarchical multiple regression analysis to examine the relationship of dissociative symptoms with trauma, emotion regulation strategies, and coping styles. A hierarchical multiple regression was conducted in order to reveal the unique effects of the included variables in each step. Before we ran the regression analysis, we checked that the required assumptions were met. For example, there was independence of residuals, as assessed by a Durbin-Watson statistic of 1.993; none of the independent variables had correlations greater than 0.7; there was also no evidence of multicollinearity, as all tolerance values were below 0.1. Although the distribution was not perfectly normally distributed, we continued to run the regression analysis because it is fairly robust to non-normality (Knief & Forstmeier, 2021; Staffa et al., 2019).

To examine whether the relationship between trauma and dissociative symptoms would be mediated by specific emotion regulation strategies or coping styles, the SPSS 22.0 PROCESS macro based on Model 4 with 10,000 bootstraps bias-corrected 95% confidence intervals (CI) was used (Hayes, 2018). If the bootstrapped 95% CI did not cross the “zero” point, the mediation effect was regarded as statistically significant (Baron & Kenny, 1986).

Results

Sample characteristics and differences between participants with and without a DD

All participants were Chinese-speaking Hong Kong residents with 18 to 64 years (mean age 35.16, SD 10.85). Most of them were female (80.2%) and full-time or part-time employed (68.3%). About half of them (47.5%) had visited a psychiatrist for psychiatric consultation in the past 12 months.

In this sample, 12 participants (11.9%) reported a clinical diagnosis of PTSD or complex PTSD, and only 3 participants (3.0%) reported a clinical diagnosis of a DD. The most commonly reported clinical diagnosis was depression (30.7%).

On the DDIS, 53 participants (52.5%) reported 5 or more dissociative symptoms (i.e., features associated with DID), and 66 (65.3%) met the DSM-5 criteria for a DD in the structured interview, who were considered to have probable DDs.

Independent sample t and chi-square test analyses showed that participants with and without a DD on the DDIS differed significantly on the number of both betrayal (p = .009) and non-betrayal (p = .017) traumatic events, dysfunctional coping (p < .001), the number of other clinical psychiatric diagnoses (p < .001), and recent use of psychiatric medication treatment (p = .038). However, the two groups did not differ in other demographic variables, coping styles, or emotion regulation strategies (see Table 1).

Table 1. Sample characteristics and differences between participants with and without a dissociative disorder (DD).

	Total (N = 101)		With DD (N = 66)		Without DD (N = 35)
Variables	M	SD	M	SD	M	SD	t (df)	p
Age	35.16	10.85	34.79	10.35	35.86	11.87	−0.469 (99)	.640
Betrayal trauma	1.97	1.66	2.26	1.75	1.43	1.33	2.659 (87)	.009
Non-betrayal trauma	1.07	1.19	1.27	1.18	0.69	1.11	2.425 (99)	.017
Dissociative symptoms (Features associated with DID)	5.11	3.15	6.29	3.00	2.89	2.03	6.754 (93)	<.001
Emotion regulation: Cognitive reappraisal	15.67	3.54	15.89	3.37	15.26	3.84	0.860 (99)	.392
Emotion regulation: Expressive suppression	11.31	2.52	11.14	2.55	11.63	2.45	−0.935 (99)	.352
Coping: Active coping	37.85	6.97	38.35	7.10	36.91	6.73	0.983 (99)	.328
Coping: Dysfunctional coping	27.20	5.57	28.67	5.30	24.43	5.05	3.886 (99)	<.001
Coping: Distraction, comprises humor and self-distraction	10.22	2.30	10.42	2.23	9.83	2.41	1.242 (99)	.217
Number of other clinical diagnoses	0.87	1.10	1.14	1.20	0.37	0.65	4.163 (99)	<.001
Variables	Frequency		Frequency		Frequency		χ2 (df)	p
Gender (Female)	80.2%		81.8%		77.1%		0.315 (1)	.575
Marriage status (married or common-law)	27.7%		30.3%		22.9%		0.633 (1)	.426
Employment status (unemployed)	31.7%		30.3%		34.3%		0.436 (2)	.804
Recent psychiatric medication treatments (past 3 months)	39.6%		47.0%		25.7%		4.320 (1)	.038
Recent counseling and psychotherapy (past 3 months)	35.6%		40.9%		25.7%		2.302 (1)	.129

The relationship between trauma, coping, emotion regulation, and dissociative features

We conducted a hierarchical multiple regression analysis to examine whether trauma, emotion regulation strategies, and coping styles would be associated with dissociative symptoms. As shown in Table 2, we found that, compared with non-betrayal trauma (β = .206, p = .05), betrayal trauma (β = .248, p = .019) had a stronger relationship with dissociative symptoms (Step 1). Emotion regulation strategies were not associated with dissociative symptoms (Step 2). When coping styles were added to the model, dysfunctional coping (β = .309, p = .003) had the strongest relationship with dissociative symptoms (Step 3) (see Table 2). Also, it is important to note that the results remained the same even if we only included female participants (n = 81) in the regression analysis – i.e., betrayal trauma (β = .226, p = .053) had a stronger relationship with dissociative symptoms than non-betrayal trauma (β = .170, p = .143) in Step 1 and dysfunctional coping (β = .380, p = .002) remained to be the strongest factor associated with dissociative symptoms in Step 3.

Table 2. Hierarchical multiple regression predicting dissociative symptoms (N = 101).

	Step 1		Step 2		Step 3
	β	p	β	p	β	p
Constant		.000		.010		.505
Betrayal trauma	.248	.019	.243	.025	.168	.107
Non-betrayal trauma	.206	.050	.221	.044	.259	.015
Emotion regulation: Cognitive Reappraisal			−.054	.591	−.024	.805
Emotion regulation: Expressive Suppression			−.021	.829	−.104	.290
Coping: Active coping					−.146	.149
Coping: Dysfunctional coping					.309	.003
Coping: Distraction, comprises humor and self-distraction					.121	.233
R2	.148		.152		.272
Adjust R2	.131		.117		.217
F	8.540***		4.302***		4.959***
ΔR2	.148		.004		.120
ΔF	8.540***		0.202		5.100**

*p < .05 **p < .01 ***p < .001.

Potential mediating effects of dysfunctional coping style

As dysfunctional coping was the only coping style that was significantly associated with dissociative symptoms, we further examined its potential mediating effect. A mediation analysis using the SPSS PROCESS macro was conducted to examine whether dysfunctional coping would mediate the relationship between betrayal trauma and dissociative symptoms. First, betrayal trauma was significantly associated with dysfunctional coping (β = 0.2572, p = .0094 (path a); F(1, 99) = 7.01, p = .0094. Second, betrayal trauma was significantly associated with dissociative symptoms (β = 0.3380, p = .0005 (path c); F(1, 99) = 12.77, p = .0005). Third, when betrayal trauma and dysfunctional coping were put in the model, this model was statistically significant, F(2, 98) = 11.92, p < .0001. In this model, both dysfunctional coping (β = 0.2953, p = .0022) (path b) and betrayal trauma (β = 0.2621, p = .0062)(path c’) were significantly associated with dissociative symptoms. The indirect effect of betrayal trauma on dissociative symptoms through dysfunctional coping was significant (indirect effect = 0.1441; 95% CI: 0.0263–0.2925) (see Figure 1). Also, even among female participants, dysfunctional coping was a statistically significant mediator in the relationship between betrayal trauma and dissociative symptoms (indirect effect = 0.1848; 95% CI: 0.0330–0.3733).

Figure 1. Dysfunctional coping as a mediator in the relationship between betrayal trauma and dissociative symptoms (N = 101).

^apath c, without the mediator, ^bpath c,’ with the mediator

When the independent variable was changed to non-betrayal trauma (instead of betrayal trauma), dysfunctional coping was not a significant mediator in the relationship between trauma and dissociative symptoms (indirect effect = 0.0589; 95% CI: −0.1109–0.2343), no matter if we only included female participants or not.

However, there could be other possible mediation paths. For example, we found that dissociative symptoms also mediated the relationship between betrayal trauma and dysfunctional coping in our sample (indirect effect = 0.3537; 95% CI: 0.1138–0.6550) (see Figure 2).

Figure 2. Dissociative symptoms as a mediator in the relationship between betrayal trauma and dysfunctional coping (N = 101).

^apath c, without the mediator, ^bpath c,’ with the mediator

Discussion

The findings of this study further our understanding of the potential roles of emotion regulation and coping in dissociative pathology. Participants with probable DDs reported more traumatic events (p = .009 to .017) and exhibited higher levels of dysfunctional coping (p < .001) when compared to those participants who reported dissociative symptoms (i.e., DES-T ≥ 20) but did not meet the criteria for a DD on the DDIS. Among different emotion regulation and coping strategies, dysfunctional coping was the only significant factor associated with dissociative symptoms (β = .309, p = .003). Dysfunctional coping also statistically mediated the relationship between betrayal trauma and dissociative symptoms, highlighting the potential importance of coping skills training when managing dissociative symptoms after trauma. Additionally, the present study replicated the betrayal trauma theory by showing that dissociative symptoms were more strongly associated with betrayal trauma than with non-betrayal trauma – it points to the importance of preventing betrayal trauma.

This is the first study which reveals an association between dissociative symptoms and dysfunctional coping in the Chinese context. This is also one of the few studies that has replicated the betrayal trauma theory in Asian cultures (e.g., Allard, 2009; Wu et al., 2022). The findings contribute to the ongoing debate regarding whether dissociation can be explained by maladaptive coping mechanisms in the face of trauma and stress.

The major findings suggested that dysfunctional coping was significantly associated with dissociative symptoms and that it might also mediate the relationship between betrayal trauma and dissociative symptoms. The results highlighted the potential importance of improving coping skills in betrayal trauma survivors in order to prevent or manage dissociative symptoms. This is also in line with the clinical research emphasizing coping skills training in the treatment of dissociation (Boon et al., 2011; Brand et al., 2019; Fung, Chan, et al., 2022). Our findings also support the idea that dissociative symptoms might be explained by the cognitive behavioral model (Vancappel & El-Hage, 2023). Especially in the early stages of recovery, trauma survivors need to learn healthy coping strategies to replace their maladaptive behaviors (Fisher, 1999; Van der Hart et al., 2017). Considering the potentially important role of dysfunctional coping, future research should evaluate whether skills-focused interventions, such as dialectical behavior therapy (DBT) (Foote & Van Orden, 2016) and psychoeducation (Brand et al., 2019; Shabb, 2016), could be effective in preventing and treating dissociative symptoms because these interventions focus on improving coping strategies and symptom management skills. Moreover, we found that the mediating effect of dysfunctional coping was specific to betrayal trauma, highlighting the particular importance of coping skills training in betrayal trauma survivors.

However, it is important to note that the study had a cross-sectional design, which precludes drawing causal conclusions about the relationships among the variables. Additionally, we found that dissociative symptoms also mediated the relationship between betrayal trauma and dysfunctional coping, as shown in Figure 2. Whether one or both of these mediation paths are valid can only be confirmed through future longitudinal studies. Nonetheless, our current findings highlight the vital link between dysfunctional coping and dissociative symptoms and suggest that interventions for betrayal trauma survivors with dissociative symptoms should incorporate coping skills training.

Although recent studies found that dissociation was moderately associated with maladaptive emotion regulation (Cavicchioli et al., 2021), dissociative symptoms were not significantly associated with any type of emotion regulation strategies in our sample. One possible explanation of this inconsistent finding could be cultural factors/differences, which played an important role in emotion regulation (Qu & Telzer, 2017). For example, expressive suppression might be more normative and not necessarily lead to dissociation in Chinese culture. However, further research should be done to confirm the absence or presence of the relationship between emotion regulation and dissociation in the Chinese populations/contexts.

Additionally, it is worth noting that there was a considerable difference between self-reported clinical diagnoses (3%) and research diagnoses (65.3%) of DDs in our sample. While this difference is noteworthy, it is not unexpected. Previous local studies have consistently found that DDs are rarely diagnosed clinically in Chinese contexts, and many participants with DDs identified in research studies did not have a prior DD diagnosis (e.g., Chiu et al., 2017; Wu et al., 2022; Xiao et al., 2006). As observed in the local field, in some cases, clinicians may avoid or hesitate to make a DD diagnosis, while in other cases, dissociative symptoms may be misinterpreted as psychotic symptoms (Fung, 2016a, 2016b). It highlights the possibility that DD is commonly undiagnosed, even in clinical settings.

This study has the strengths of using reliable and valid measures and conducting structured interviews after self-report assessments. The use of structured interviews is regarded as the “gold standard” to assess mental health problems in psychiatric research because structured interviews could provide less biased and more reliable data (Drill et al., 2015; Mueller & Segal, 2014). However, there are also some limitations in this study. First, we analyzed baseline data from an intervention study in one city (i.e., Hong Kong), and the sample was unlikely representative of Chinese people with dissociative symptoms. Second, most participants were female in this study, who were often more active in seeking mental health support and service. The findings, therefore, might not be generalizable to a diverse Chinese population with dissociative symptoms. Third, although the DDIS is a fully standardized measure validated in previous studies, inter-rater agreement was not assessed in our study. Fourth, although the BBTS is a reliable measure of trauma exposure, adding up the types of trauma experienced to generate a total score for betrayal and non-betrayal trauma, respectively, may fail to account for different degrees of the traumatic impact of the different trauma items. Fifth, although we assessed dissociative symptoms using the DDIS after collecting self-report data on trauma exposure, emotion regulation and coping, the cross-sectional design of this study could not allow us to confirm the causal relationship between the study variables. Consistent with previous cross-sectional mediation studies (e.g., Carruthers et al., 2022; Geng et al., 2021), the present study treated “mediators as clues that point to possible mechanisms of change” (p. 2) based on conceptual analyses and rationales (David & Sava, 2015). Our cross-sectional mediation analysis, however, can help identify the potential mediating effect of coping to facilitate further research using more representative samples and a prospective design.

Concluding remarks

The present study provides evidence for the cross-cultural validity of the betrayal trauma theory and reveals the potentially important role of dysfunctional coping in association with dissociative symptoms. Individuals with DDs are characterized by higher levels of dysfunctional coping compared to those without a DD. Coping skills training might be a promising strategy for preventing and managing dissociative symptoms in trauma survivors. Future longitudinal research and evaluation studies are required to investigate the effectiveness of improving coping skills in preventing and treating dissociative symptoms.

Acknowledgments

The last author received The RGC Postdoctoral Fellowship Scheme 2022/2023 from the Research Grants Council (RGC), Hong Kong.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data that support the findings of this study are available from the corresponding authors upon reasonable request.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This study was supported by the 2022 Sigma Theta Tau International Small grant.