CA30/.3/2%$T"9 #-%E,,# s 039#()!42)#G4)-%3Os /#4/"%2 RY $ISSOCIATIVE $ISORDERS !N /VERVIEW OF !SSESSMENT 0HENOMeNOLOGY AND 4REATMENT by Bethany Brand, PhD and ble.1 Neurobiological studies have shown spe- tion, eg, feeling numb, watching self from a Richard J. Loewenstein, MD cific patterns of brain activation that differentiate distance as if in a movie) dissociative posttraumatic reactions from hyper- Dr Brand is professor in the department of psychology aroused forms of posttraumatic stress disorder world appears far away or “foggy”; familiar of Towson University in Towson, Md; Dr Loewenstein (PTSD). places/people seem unfamiliar or strange; tun- is medical director of the Trauma Disorders Program at This article provides a brief overview of the nel vision) Sheppard Pratt Health System in Towson, Md, and etiology, comorbidity, prevalence, clinical fea- associate clinical professor of psychiatry and behav- tures, differential diagnosis, and treatment of dis- experiencing discrete and discordant behav- ioral sciences at the University of Maryland School of sociative disorders. ioral states referred to as “identities”)2 Medicine in Baltimore. One of the strongest predictors of dissociation CAUSES AND COMORBIDITIES is antecedent trauma, particularly early childhood issociation is a process that provides Dissociation is defined in DSM-IV-TR2 as a dis- trauma and difficulties with attachment and pa- protective psychological containment ruption of the usually integrated functions of the rental unavailability.3-6 The evidence for a rela- of, detachment from, and even physi- following: tionship between dissociation and many types of cal analgesia for overwhelming expe- trauma is robust and has been validated across Driences, usually of a traumatic or stressful nature. seizures, pseudodelirium) cultures in clinical and nonclinical samples using Dissociation is conceptualized as analogous to both cross-sectional and longitudinal methodolo- the “animal defensive reaction” of freezing in the memory: dissociative amnesia) gies as well as in large population studies and in face of predation, when fight/flight is impossi- - well-designed prospective, longitudinal studies. CREDITS: 1.5 ESTIMATED TIME TO COMPLETE CREDIT DESIGNATION RELEASE DATE: October 20, 2010 The activity in its entirety should take approximately 90 Ê Ê`iÃ}>ÌiÃÊÌ ÃÊi`ÕV>Ì>Ê>VÌÛÌÞÊvÀÊ>Ê EXPIRATION DATE: October 20, 2011 minutes to complete. maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with LEARNING OBJECTIVES FACULTY the extent of their participation in the activity. Bethany Brand, PhD, Department of Psychology, After completing this activity, participants should be able to: DISCLAIMER Towson University, UÊ `ÕVÌÊ`vviÀiÌ>Ê`>}ÃÃÊÊÌ iÀÊ«>ÌiÌà The opinions and recommendations expressed by faculty Towson, Mar yland UÊ `iÌvÞÊ«>ÌiÌÃÊÜÌ Ê`ÃÃV>ÌÛiÊ`ÃÀ`iÀ and other experts whose input is included in this activity UÊ Ê,iV}âiÊVV>Êvi>ÌÕÀiÃÊ>ÃÃV>Ìi`ÊÜÌ Ê are their own and do not necessarily reflect the views of Richard J. Loewenstein, MD, Department of Psychiatry, dissociative disorder and distinguish between the sponsors or supporter. Discussions concerning drugs, University of Maryland School of Medicine, different types of the disorder dosages, and procedures may reflect the clinical Baltimore, Maryland UÊ Ê iÛi«Ê>««À«À>ÌiÊÌÀi>ÌiÌÊÃÌÀ>Ìi}iÃÊvÀÊ experience of the faculty or may be derived from the Sheppard Pratt Health System, their patients Towson, Mar yland professional literature or other sources and may suggest COMPLIANCE STATEMENT uses that are investigational in nature and not approved FACULTY DISCLOSURES This activity is an independent educational activity under labeling or indications. Activity participants are Drs Brand and Loewenstein report no conflicts of interest Ì iÊ`ÀiVÌÊvÊ Ê °Ê/ iÊ>VÌÛÌÞÊÜ>ÃÊ«>i`Ê>`Ê encouraged to refer to primary references or full concerning the subject matter of this article. «iiÌi`ÊÊ>VVÀ`>ViÊÜÌ ÊÌ iÊ ÃÃiÌ>ÊÀi>ÃÊ>`Ê prescribing information resources. This activity has been independently reviewed for balance. «ViÃÊvÊÌ iÊ ]ÊÌ iÊ Ì V>Ê"«ÃÉÕ`iiÃÊvÊ METHOD OF PARTICIPATION Ì iÊ]ÊÌ iÊ ]ÊÌ iÊ"]Ê>`ÊÌ iÊ* ,Ê `iÊÊ Participants are required to read the entire article and to TARGET AUDIENCE ÌiÀ>VÌÃÊÜÌ Êi>Ì V>ÀiÊ*ÀviÃÃ>Ã]ÊÌ ÕÃÊ>ÃÃÕÀ}Ê complete the posttest and evaluation to earn a certificate of This continuing medical education activity is intended the highest degree of independence, fair balance, completion. A passing score of 80% or better earns the for psychiatrists, psychologists, primary care physicians, scientific rigor, and objectivity. nurse practitioners, and other health care professionals participant 1.5 AMA PRA Category 1 Credits™. A fee of who seek to improve their care for patients with mental ACCREDITATION STATEMENT $15 will be charged. Participants are allowed 2 attempts health disorders. This activity has been planned and implemented in to successfully complete the activity. >VVÀ`>ViÊÜÌ ÊÌ iÊ ÃÃiÌ>ÊÀi>ÃÊ>`Ê*ViÃÊvÊÌ iÊ GOAL STATEMENT VVÀi`Ì>ÌÊ ÕVÊvÀÊ ÌÕ}Êi`V>Ê `ÕV>ÌÊ This activity will provide participants with education on the Ì ÀÕ} ÊÌ iÊÌÊëÃÀà «ÊvÊ Ê Ê>`ÊPsychiatric etiology, comorbidity, prevalence, clinical features, differ- Times°Ê Ê ÊÃÊ>VVÀi`Ìi`ÊLÞÊÌ iÊ ÊÌÊ«ÀÛ`iÊ ential diagnosis, and treatment of dissociative disorders. continuing medical education for physicians. 4O EARN CREDIT ONLINE GO TO WWW0SYCHIATRIC4IMESCOMCME OCTOBER 2010 PSYCHIATRIC TIMES 63 C!4EGORY1 Exposure to multiple types of trauma over non-PTSD anxiety disorders and substance abuse peraroused PTSD patients who, in response to multiple developmental epochs is associated are commonly associated with antecedent trau- traumatic reminders and/or masked fearful faces, with a wide range of clinical problems that have ma, as is PTSD.3,12- show decreased activation of medial anterior been organized into the construct of complex mon comorbidities of patients with dissociative brain regions involved in arousal/emotional PTSD.3,5,7-9 These include the following: disorders. modulation/regulation (eg, the ventromedial pre- - Recent research suggests that a predominantly frontal cortex and rostral anterior cingulate cor- tion alternating with hyperarousal and emo- dissociative, hypoemotional subtype of PTSD is tex) and increased activation of the limbic sys- tional flooding; problems with anger, anxiety, distinguishable from a predominantly hyper- tem, particularly the amygdala. shame) aroused, hyperemotional subtype.12,13 This dis- tinction has important implications because of PREVALENCE OF destructive, and aggressive behavior; sub- differences in etiology, clinical and neurobiolog- DISSOCIATIVE DISORDERS stance abuse; high-risk behaviors) ical features, and response to treatment (Table 1). DSM-IV-TR identifies 5 dissociative disorders: Many patients with the dissociative subtype of dissociative amnesia, dissociative fugue, deper- talization of self and/or self-fragmentation, PTSD will meet DSM-IV-TR criteria for a dis- sonalization disorder, dissociative identity disor- difficulties with body image, and eating sociative disorder. der, and dissociative disorder not otherwise spec- disorders Specifically, neurobiological and neuroimag- ified (DDNOS). Epidemiological studies of ing studies in clinical and nonclinical samples dissociative disorder have been conducted in the traumatizing and untrustworthy and the self as that included patients with PTSD, depersonal- - damaged and blameworthy for trauma) ization disorder, and dissociative amnesia, as - well as healthy cohorts involved in memory sup- Dissociative amnesia is typically found to be ships; tumultuous attachments; violent, abu- pression/retrieval studies have shown a specific the most prevalent dissociative disorder in gen- sive relationships) pattern of findings.13 These findings include, in eral population studies, with a prevalence of up to - clinical subjects, increased activation of brain 3%.14 The prevalence of depersonalization disor- cluding high-risk behaviors and multiple health regions involved in arousal/emotional modula- der is estimated to be between 1% and 2%. problems, such as heart disease, liver disease, tion/regulation, such as the dorsal anterior cingu- DDNOS tends to be the most prevalent dissocia- pulmonary diseases, autoimmune disorders, late cortex and medial prefrontal cortex in re- tive disorder found in clinical studies, with a chronic fatigue syndrome, gastroesophageal sponse to specific personalized trauma scripts, prevalence of about 9.5% in both inpatient and reflux disease, irritable bowel syndrome, head- and/or in facial emotional recognition tasks. In aches, smoking, early and multiple pregnan- turn, these dissociative responses in PTSD popu- studies, the most severe dissociative disorder, cies, morbid obesity, and sexually transmitted lations, as well as in memory suppression in dis- dissociative identity disorder (formerly multiple diseases, among others.10,11 sociative amnesia patients and normal subjects, personality disorder) has a prevalence of approx- Many patients with dissociative disorder also are associated with decreased activation of the imately 1% and has been found in 1% to 20% of fit the complex PTSD construct. Epidemiological amygdala, insular cortex, and hippocampus, re- psychiatric inpatients and outpatients, depending studies have found that mood, somatoform, and spectively. This contrasts with more typical hy- on the sample. CLINICAL FEATURES Typical differences between dissociative, Depersonalization