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Home , Comorbidity, Conversion disorder, Depersonalization, Derealization, Dissociative disorder

disorders unclear? Think ‘rainbows from blows’

Visual metaphor answers the question, “What’s ‘dissociated’ in dissociative disorders?”

® Dowden Health Media r. D, age 45, presents to his primary care physi- cian with panic attacks, nausea, shortness of Mbreath, ,Copyright and dizzinessFor 6 months personal after use only being assaulted and robbed at an ATM. Following a rou- tine medical workup, the physician diagnoses posttrau- matic disorder (PTSD) and refers Mr. D for exposure

and response prevention therapy. During graded exposure sessions, Mr. D’s eyes some-

times glaze over and he seems to “fl oat away” from the CURRENT

discussion. When the therapist asks about these symp- FOR toms, Mr. D reports having had them as long as he can remember. In school, he says, teachers thought he was

a slow learner, a daydreamer, or had attention-defi cit/ MORGENSTERN hyperactivity disorder. From what he can recall of his MICHAEL childhood, he describes a history of trauma and neglect with a violent, drug-abusing father and absent mother. Kai MacDonald, MD Assistant clinical professor Neuropsychiatry and behavioral unit Patients with a history of early abuse or neglect are at risk Department of psychiatry for dissociative phenomena and other trauma-related University of California, San Diego psychiatric disorders.1 The heterogeneous dissociative disorders are often hidden and unrecognized2 —as in Mr. D’s case—or present with unfamiliar or atypical symptoms. Understanding and identifying dissociative symptoms is important because: • Dissociative symptoms worsen prognosis, wheth- er patients have conversion disorders1 or psychogenic seizures3 or are in .4 • Dissociative states may impair memory encoding5 and decrease patients’ ability to remember therapeutic Current Psychiatry information. Vol. 7, No. 5 73 continued

For mass reproduction, content licensing and permissions contact Dowden Health Media.

073_CPSY0508 073 4/17/08 11:50:11 AM Table 1 DSM-IV-TR classifi cation of dissociative disorders

Disorder Symptoms

Dissociative A reversible loss of memory, typically preceded by a stressor

Dissociative fugue Loss of memory and identity, along with travel away from home Dissociative Dissociative identity Presence of different identity states, often with lack of connection disorders disorder (formerly multiple between them; current models highlight the presence of recurrent ) dissociative intrusions into many aspects of executive function and self

Depersonalization Detachment from oneself as a present, feeling person disorder () and the world ()

Dissociative identity Functionally disturbing dissociative symptoms that do not fi t into any disorder NOS of the above

NOS: not otherwise specifi ed Source: Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000 Clinical Point Like colors in a beam of white • Symptoms (such as hearing voices in One paired component is a detached multiple personality disorder) can be con- “observer” and a more embodied, feeling light, dissociable fused with those of disorders with differ- “experiencer.” The observer is a perspective components ent treatment strategies (such as psychotic that begets metacognition (thinking about of experience disorders).6 one’s inner world) and self-observation; constitute normal • Peritraumatic dissociation may be a it resides in the same body as soma-based risk factor for PTSD.7 “feelings” that unconsciously contribute to consciousness This article presents a practical model the sense of “being present” with oneself for understanding dissociation, reviews and the world in the moment.9 clinical characteristics of this family of A second component is voluntary ac- symptoms, and offers suggestions for as- cess to one’s autobiographical memories sessing and treating patients with dissocia- (memories about the self in time), which tive disorders. are constantly “updated” and integrated with current experiences. This component allows one to distinguish between remem- Coming together, falling apart bered (past) experiences and “fi rsthand” Since ’s fi rst reports on disso- (present) experience. ciative disorders, a number of theories and Three other components of normal con- models of dissociation have been proposed,8 sciousness are: including empirically based, taxonomic • a sense of agency and voluntary con- models that address DSM-IV-TR categories trol over one’s mental contents, mental ac- (Table 1). The model I propose—which at- tivity, and bodily movements taches a visual metaphor to dissociative • an ongoing connection with one’s phenomena—answers the question, “What body and mind and an understanding of is ‘dissociated’ in dissociation disorders?” where sensations and images come from • a sense of sequential experience, with 5 components of consciousness. Just as relatively smooth transitions (from self at separable wavelengths compose a beam work to self at home, self a week ago to self of white light, dissociable “colors” or today, etc) that have a singular referent (an components of subjective experience con- identity). stitute a normal state of consciousness. Five implicit components of normal con- Pathologic dissociation occurs when a sciousness—present in various degrees, at prism of distress disperses one of these different times—are seamlessly integrated component “wavelengths” from the main Current Psychiatry 74 May 2008 and associated in real time. “beam” of consciousness. For example:

074_CPSY0508 074 4/17/08 11:50:17 AM Box Dissociation’s neurobiology: Evidence of brain ‘disconnections’

rom a neurophysiologic perspective, fi ner temporal resolution than functional Fmental states may be viewed as arising imaging studies, Kirino et ale showed from synchronized integration of the activity reversible attenuation of a specifi c EEG of functionally specialized brain regions. signal within 300 msec during dissociative Functional of dissociation episodes. This ultra-rapid neural refl ex was supports an understanding of these correlated with allocation of attentional and symptoms as ‘disconnection .’ working memory resources, perhaps with Functional neuroimaging. Different the goal of minimizing memory activation ‘identities’—sometimes called a traumatic and resurgence of affect-laden memories.e personality state and neutral personality Hormonal. Stress-related disorders cause state—demonstrate different patterns of perturbations in neurohormonal function. cerebral blood fl ow, subjective reports, and Simeon et alf found a distinct pattern of peripheral physiologic parameters (blood stress-induced HPA axis dysregulation in a pressure, heart rate). dissociative patients compared with PTSD Clinical Point Functional imaging of traumatic patients and healthy controls. Similar dissociation shows active suppression of results were seen in patients with borderline Personality traits that limbic regions (amygdala) and increased personality disorder and dissociative may predispose to activity in dorsolateral prefrontal areas.b symptoms.g Similarly, neuroimaging of depersonalization Structural imaging. Stress-related dissociation include disorder show increased neural activity neurohormonal perturbations are known mental , in prefrontal regions associated with to affect critical neural structures, including suggestibility, affect regulation and decreased activity in the hippocampus. Using MRI, Vermetten et emotion-related areas.c,d alh found signifi cantly decreased amygdala and a tendency Speed. Dissociative responses occur and hippocampal volumes in patients with to fantasize extremely rapidly. Using EEG, which allows dissociative identity disorder.

EEG: ; HPA: hypothalamic-pituitary-adrenal; PTSD: posttraumatic stress disorder Source: For reference citations, see this article at CurrentPsychiatry.com

• separation of the “observer” and “ex- thought to include the individual pa- periencer” occurs in depersonalization tient’s temperamental or constitutional disorder predispositions11 as well as a strong con- • reversible loss of ability to access tribution of environmental trauma (early memories characterizes dissociative abuse, neglect).12 amnesia • disconnection between sequential ex- Constitutional predisposition for de- periences is a part of dissociative iden- veloping a may tity disorder. include personality traits such as being This modular perspective of dissocia- easily hypnotized, mental absorption, tive disorders parallels a neurophysiologic suggestibility, and a tendency to fanta- perspective of mental states as arising from size.13 These characteristics fueled con- the synchronized integration of the activ- cerns in the 1990s that therapists may ity of separate, functionally specialized contribute to dissociative identity disor- brain regions.10 Functional neuroimaging der by “digging” for repressed memo- of dissociation supports an understanding ries in susceptible patients and creating of these symptoms as “disconnection syn- “pseudomemories” of events that did not dromes” (Box). happen.14 The issue of repressed traumatic mem- ory and its role in therapy is extremely Causes of dissociative disorders controversial and contributes to the com- As with many psychiatric disorders, the plexity of psychotherapeutic treatment of Current Psychiatry etiology of dissociative phenomena is dissociation.15 Vol. 7, No. 5 75 continued

075_CPSY0508 075 4/17/08 11:50:22 AM Table 2 Identifying ‘hidden’ phenomena With these fi ndings, consider Dissociative disorders have been called screening for dissociation “ of hiddenness”18 because: • Many of their clinical characteristics— Posttraumatic stress disorder sense of identity, memory, connectedness, Certain personality disorders (especially somatosensory phenomena—are alterations borderline personality disorder) in subjective phenomena that lack clearly Dissociative Somatoform disorders (conversion disorders observable symptoms. disorders and nonepileptic ) • Patients are often reluctant to seek help Eating disorders or divulge their symptoms to clinicians. • When dissociative symptoms are ob- Substance use disorders vious—such as multiple personalities or Extensive history of trauma or neglect sudden loss of memories—they may be dis- Self-harm behavior missed or evoke skepticism because of their dramatic presentation.

Clinical Point Early trauma. Factors that make it diffi cult Screening tools. To identify at-risk pa- To reduce shame to defi ne the specifi c role of early trauma tients, consider screening with a validated about not fi ghting in dissociative disorders include: questionnaire such as the Childhood Trau- • shame and secrecy of early sexual or ma Questionnaire (CTQ),19 particularly back, educate physical abuse and potential for vic- for patients with psychiatric comorbidity abused patients tims to repress traumatic memories (Table 2). Using the CTQ—which assesses that detachment • lability of memory, potential for physical, emotional, and sexual abuse and is a normal response suggestibility, and diffi culty with neglect—is a high-yield procedure, given verifi cation.14 the role of early trauma in brain develop- to threat Some experts—infl uenced by attach- ment and future .20 ment theory—view dissociative phenome- For more targeted screening, the self- na as manifestations of an innate, refl exive report Dissociative Experiences Scale relational pattern called disorganized at- (DES)21 is useful for clinical assessment in tachment.16 Attachment theory notes that: conjunction with the clinician-administered • early relationships are one of the pri- diagnostic Structured Clinical Interview for mary ways that humans learn to regu- DSM-IV Dissociative Disorder (SCID-D).22 late distress • early trauma frequently includes pa- Diff erential diagnosis. Diagnosing dis- thology in caregiving relationships, sociative disorders includes ruling out including overt role reversal, abuse, that can present with and neglect. “look-alike” symptoms (Table 3, page 81). Empathic treatment of dissociation, As in Mr. D’s case, dissociative phenome- therefore, is based on appreciating the dif- na may attenuate the benefi t of post-trauma fi culties that arose from an individual’s ex- therapeutic interventions, especially those perience of being alone with overwhelm- involving exposure. Therefore: ing distress. The relation of dissociation to • assess post-trauma patients for disso- attachment theory has specifi c therapeutic ciation before you start treatment implications, including a focus on con- • make specifi c alterations in psycho- structing a safe therapeutic relationship therapy for such patients, as described for patients. below. Finally, remember that transient dis- Educating trauma patients that detach- sociative symptoms can be considered ment is a normal response to threat17 can normal in high-stress situations. Inten- reduce shame about not fi ghting back. sive military training has been found to be associated with a very high incidence Medical causes. Because complex partial (96%) of dissociative symptoms in army seizures can cause dissociative symptoms,23 Current Psychiatry 76 May 2008 recruits.17 consider evaluating patients for seizures, continued on page 81

076_CPSY0508 076 4/17/08 11:50:27 AM continued from page 76 Table 3 Diff erential diagnosis: Dissociation ‘look-alikes’

Dissociation symptom Can be confused with:

Visual or auditory , other ‘fi rst-rank’ Psychotic disorder psychotic symptoms in dissociative identity disorder

‘Blanking out’ (cognitive disruption) ADHD, seizures

Somatoform (conversion) symptoms A variety of nonpsychiatric medical problems, including pelvic or abdominal pathology and headaches

Dissociative memory lapses Learning disability, not paying attention

‘Switching’ between states , rapid cycling

Lack of emotional reaction to traumatic stimuli Healthy coping (numbing response)

ADHD: attention-defi cit/hyperactivity disorder Clinical Point Psychogenic of the therapist’s positive regard and commit- head trauma, and structural lesions. Psy- nonepileptic seizures chogenic nonepileptic seizures (PNES) often ment to help the patient and frequent pauses occur in conjunction with early trauma, dis- to “check in” that the patient feels present, safe, (PNES) often occur sociative symptoms, and PTSD.3 and understood. With this new focus, Mr. D’s in conjunction Recreational drugs such as , dissociative symptoms resolve and he feels with early trauma, methylenedioxymethamphetamine (“Ec- more ready to face and overcome his fear and dissociative stasy”), , marijuana, and dex- avoided memories. tromethorphan also can induce dissociative symptoms, and PTSD states. Consider evaluating for use of these substances, some of which may not be de- Psychotherapy: tected on a routine drug screen.24 Putting pieces together Psychotherapy is the primary treatment, CASE CONTINUED based on understanding dissociative dis- A tactical shift orders as manifestations of distress-related, Internal distress—such as when remember- traumatic fragmentation of the sense of self, ing painful events—clearly is linked with the interpersonal relatedness, and capacity for appearance of Mr. D’s symptoms. The thera- adaptive affect regulation (Table 4, page 82). pist—recognizing unacknowledged dissocia- tive phenomena—changes Mr. D’s therapeu- Depersonalization disorder. Cognitive- tic strategy from exposure therapy to aff ect behavioral integration has been proposed, and regulation, with an explicit focus based on the idea that detachment from on attachment security (safety). one’s self creates anxiety and reinforces ef- The therapist explains to Mr. D that dissocia- forts to avoid this internal state and events tion symptoms are a response to distress, and that trigger it. In an open study of 21 pa- he can learn more adaptive distress regulation tients with depersonalization disorder, in therapy. The in-session focus shifts to include individual cognitive-behavioral therapy more direct attention to components of the (CBT) reduced avoidance, safety behaviors, therapy relationship, including overt disclosure and symptom monitoring. Measures of dis- sociation, , anxiety, and general functioning also improved.25 For more on PNES See this article at CurrentPsychiatry.com Dissociative identity disorder (DID)—the Psychogenic nonepileptic seizures: quintessential dissociative disorder—is usu- ally treated by specialists. Treatment is com- Ways to win over skeptical patients Current Psychiatry JANUARY 2008 plex, but some components are appropriate Vol. 7, No. 5 81

081_CPSY0508 081 4/17/08 11:50:31 AM Table 4 Tips for conceptualizing dissociative disorders

Ground your understanding of this class of disorders as distress-related breakdowns in functional connection and integration among components of normal consciousness

Consider the overlap among dissociation, certain somatoform disorders (conversion symptoms, pseudoseizures), and PTSD

Dissociative Maintain a high index of suspicion for dissociative symptoms in patients with early trauma or neglect disorders (consider screening for this); do further evaluation with dissociative-specifi c tools

Avoid the tendency to assume that reversible, unfamiliar, or peculiar symptoms imply volition or lack of an organic basis

PTSD: posttraumatic stress disorder

for less severe forms of dissociation, includ- in enzymes such as catechol-O-methyl- ing dissociation as part of PTSD.26 transferase (COMT) may explain individ- Clinical Point Safety, stabilization, and symptom reduction. ual vulnerability to trauma.30 Reports of With psychotherapy, Providing a safe therapeutic relationship is dissociation related to ketamine31 and mari- 32 consider adding a primary and necessary part of DID treat- juana implicate other neurotransmitter ment. On that platform, a fi rst step in rein- systems in their etiology. medications to tegrating distressing material into the self treat , involves building the patient’s capacity for DID. Similar to guidelines for borderline aff ect instability, conscious, fl exible affect regulation. This personality disorder,33 guidelines for DID and posttraumatic keeps anxiety and distress within a thera- suggest using medications to treat the most peutic “window.” prominent symptom clusters such as in- intrusions Graded exposure. Exposure to feared somnia, affective instability, and posttrau- mental contents—typically traumatic matic intrusions. memories—is central to trauma-focused therapy. Dissociation is conceptualized as Depersonalization disorder. Trials of driven by distress greater than the system fl uoxetine and showed no can bear, loss of adaptive integration, and benefi t in depersonalization disorder.34,35 subsequent fear-based, refl exive avoid- In an open trial of 14 patients, ance.27 Re-experiencing trauma-related (mean 120 mg/d) reduced depersonaliza- memories in a safe relationship with a tion symptoms by 30%, as measured by 3 new regulatory capacity may work by an- validated scales.36 choring patients in an autobiographical memory base.28 PTSD-related dissociation. If dissocia- Integration of identity and person. Treat- tive symptoms are associated with PTSD, ment ends when formerly unintegrated or selective serotonin reuptake inhibitors are dissociated experiences or parts of the self considered fi rst-line pharmacologic treat- are integrated into a coherent whole, and ment.37 In a 10-week trial of 70 mostly the patient can deal adaptively with inter- minority adult outpatients with PTSD, par- personal relationships and distress with- oxetine, ≤60 mg/d, was more effective than out fragmentation. placebo in reducing dissociative symptoms, as shown by changes in DES scores.38

Adjunctive medications References 1. Sar V, Akyuz G, Kundakci T, et al. Childhood trauma, Few studies have addressed using psycho- dissociation, and psychiatric comorbidity in patients with pharmacologic interventions in the hetero- . Am J Psychiatry 2004;161:2271-6. 2. Foote B, Smolin Y, Kaplan M, et al. Prevalence of dissociative geneous dissociative disorders. GABAA disorders in psychiatric outpatients. Am J Psychiatry 2006;163:623-9. antagonism and 5-HT2a/2c agonism have induced psychotic and dissociative-like 3. Reuber M, Pukrop R, Bauer J, et al. Outcome in psychogenic Current Psychiatry nonepileptic seizures: 1 to 10-year follow-up in 164 patients. 82 May 2008 symptoms in healthy men,29 and alterations Ann Neurol 2003;53:305-11. continued on page 85

082_CPSY0508 082 4/16/08 10:48:40 AM continued from page 82 4. Spitzer C, Barnow S, Freyberger HJ, Grabe HJ. Dissociation predicts symptom-related treatment outcome in short-term inpatient psychotherapy. Aust N Z J Psychiatry 2007;41:682-7. Related Resources 5. Allen JG, Console DA, Lewis L. Dissociative detachment and • International Society for the Study of Trauma and memory impairment: reversible amnesia or encoding failure? Dissociation. Site for professionals. www.isst-d.org. Compr Psychiatry 1999;40:160-71. • National Alliance on Mental Illness (NAMI). Patient 6. Dell PF. A new model of dissociative identity disorder. Psychiatr Clin North Am 2006;29:1-26. education on dissociative disorders. www.nami.org/Content/ 7. Shalev AY, Freedman S. PTSD following terrorist attacks: a ContentGroups/Helpline1/Dissociative_Disorders.htm. prospective evaluation. Am J Psychiatry 2005;162:1188-91. Drug Brand Names 8. Steinberg M, Rounsaville B, Cicchetti DV. The Structured Clinical Interview for DSM-III-R Dissociative Disorders: Fluoxetine • Prozac Naloxone • Narcan preliminary report on a new diagnostic instrument. Am J Lamotrigine • Lamictal Paroxetine • Paxil Psychiatry 1990;147:76-82. 9. Damasio A. The feeling of what happens: body and emotion in the Disclosure making of consciousness. New York, NY: Harcourt, Inc; 1999. Dr. MacDonald is a speaker for Eli Lilly and Company, Janssen, 10. Alkire MT, Miller J. General anesthesia and the neural L.P., and Pfi zer Inc. correlates of consciousness. Prog Brain Res 2005;150:229-44. 11. Simeon D, Guralnik O, Knutelska M, Schmeidler J. Personality factors associated with dissociation: temperament, defenses, 26. Guidelines for treating dissociative identity disorder in adults and cognitive schemata. Am J Psychiatry 2002;159(3):489-91. (2005). J Trauma Dissociation 2005;6(4):69-149. 12. Kihlstrom JF. Dissociative disorders. Annu Rev Clin Psychol 2005;1:227-53. 27. van der Hart O, Nijenhuis E. Generalized dissociative amnesia: episodic, semantic and procedural memories lost and found. 13. Isaac M, Chand PK. Dissociative and conversion disorders: Aust N Z J Psychiatry 2001;35:589-600. defi ning boundaries. Curr Opin Psychiatry 2006;19(1):61-6. 28. Holmes EA, Brown RJ, Mansell W, et al. Are there two Clinical Point 14. Laney C, Loftus EF. Traumatic memories are not necessarily qualitatively distinct forms of dissociation? A review and accurate memories. Can J Psychiatry 2005;50(13):823-8. some clinical implications. Clin Psychol Rev 2005;25(1):1-23. 15. Loftus EF, Davis D. Recovered memories. Annu Rev Clin Avoid the tendency Psychol 2006;2:469-98. 29. D’Souza DC, Gil RB, Zuzarte E, et al. gamma-Aminobutyric acid-serotonin interactions in healthy men: implications for to assume that 16. Lyons-Ruth K, Dutra L, Schuder MR, Bianchi I. From infant network models of and dissociation. Biol Psychiatry attachment disorganization to adult dissociation: relational 2006;59(2):128-37. adaptations or traumatic experiences? Psychiatr Clin North Am reversible or peculiar 2006;29(1):63-86. 30. Savitz JB, van der Merwe L, Newman TK, et al. The symptoms imply 17. Morgan CA 3rd, Hazlett G, Wang S, et al. Symptoms of relationship between childhood abuse and dissociation. Is it dissociation in humans experiencing acute, uncontrollable infl uenced by catechol-O-methyltransferase (COMT) activity? volition or lack of an stress: a prospective investigation. Am J Psychiatry Int J Neuropsychopharmacol 2008;11:149-61. 2001;158(8):1239-47. 31. Curran HV, Morgan C. Cognitive, dissociative and organic basis 18. Spiegel D. Recognizing traumatic dissociation. Am J Psychiatry psychotogenic effects of ketamine in recreational users on the 2006;163(4):566-8. night of drug use and 3 days later. 2000;95:575-90. 19. Scher CD, Stein MB, Asmundson GJ, et al. The childhood 32. Mathew RJ, Wilson WH, Humphreys D, et al. Depersonalization trauma questionnaire in a community sample: psychometric after marijuana smoking. Biol Psychiatry 1993;33:431-41. properties and normative data. J Trauma Stress 2001;14:843-57. 33. American Psychiatric Association. Practice guideline for the 20. Teicher MH, Andersen SL, Polcari A, et al. The neurobiological treatment of patients with borderline personality disorder. Am consequences of early stress and childhood maltreatment. J Psychiatry 2001;158(10 suppl):1-52. Neurosci Biobehav Rev 2003;27:33-44. 34. Sierra M, Phillips ML, Ivin G, et al. A placebo-controlled, 21. Bernstein EM, Putnam FW. Development, reliability, and cross-over trial of lamotrigine in depersonalization disorder. validity of a dissociation scale. J Nerv Ment Dis 1986;174(12):727- J Psychopharmacol 2003;17:103-5. 35. 35. Simeon D, Guralnik O, Schmeidler J, Knutelska M. Fluoxetine 22. Steinberg M, Rounsaville B, Cicchetti D. Detection of therapy in depersonalisation disorder: randomised controlled dissociative disorders in psychiatric patients by a screening trial. Br J Psychiatry 2004;185:31-6. instrument and a structured diagnostic interview. Am J Psychiatry 1991;148(8):1050-4. 36. Simeon D, Knutelska M. An open trial of in the 23. Devinsky O, Putnam F, Grafman J, et al. Dissociative states treatment of depersonalization disorder. J Clin Psychopharmacol and . 1989;39:835-40. 2005;25:267-70. 24. Schonenberg M, Reichwald U, Domes G, et al. Effects of 37. Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post peritraumatic ketamine medication on early and sustained traumatic stress disorder (PTSD). Cochrane Database Syst Rev posttraumatic stress symptoms in moderately injured accident 2006(1):CD002795. victims. Psychopharmacology (Berl) 2005;182(3):420-5. 38. Marshall RD, Lewis-Fernandez R, Blanco C, et al. A controlled 25. Hunter EC, Phillips ML, Chalder T, et al. 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Bottom Line Think of dissociative disorders as distress-related breakdowns in the functional connection and integration of components of normal consciousness. Neurobiologic changes underlie these disorders’ often-unique symptoms. Screen at-risk patients with the Dissociative Experiences Scale, and consider dissociation when assessing patients with signifi cant early trauma, somatoform disorders, or posttraumatic Current Psychiatry stress disorders, in particular. Vol. 7, No. 5 85

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