Dissociative Disorders
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}Ê i`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 disorder Table 1 hypoemotional and hyperaroused, Depersonalization can involve feeling robotic, unreal and/or estranged, or detached or discon- hyperemotional PTSD12,41 - sonalization can be found in persons with a range Dissociative subtype Hyperaroused subtype of disorders, and also in normal adolescents, and they can be caused by substance abuse.2,15 The Etiology typical age at onset of depersonalization disorder Likely to be more severe, chronic, repeated, Likely to be later-occurring trauma and/or is in adolescence or early adulthood, and it can be usually childhood and adult trauma less cumulative trauma acute or insidious.15
Likely response when presented with traumatic narrative or triggers patients with depersonalization disorder have a chronic course. In addition to feeling severely Dissociation, numbing; decreased, blunted Terror; increased autonomic arousal: increased depersonalized/derealized, many patients report autonomic arousal: decreased heart rate, heart rate, rapidly increased cortisol level, impairments in attention, memory, and occupa- delayed cortisol release, decreased skin increased skin conductance; brain areas tional and interpersonal function.15,16 conductance; brain areas activated that activated that may undercontrol emotion may overcontrol emotion and alter sense common, both of these disorders usually follow of self (eg, MPFC) the onset of depersonalization and do not predict the severity of depersonalization disorder symp- Psychotherapy toms. Depersonalization disorder symptoms do Requires staged approach emphasizing Exposure therapy or cognitive processing not respond to typical treatments for mood/anxi- safety, stabilization, alliance-building, therapy after brief stabilization ety disorders. Patients with depersonalization and symptom management preceding disorder report having experienced significantly exploration of traumatic memories/modified more childhood trauma, particularly emotional exposure therapy abuse, than controls. Reports of emotional abuse uniquely predict depersonalization severity. Medication Simeon and colleagues17 found that severe stress None specifically targeting dissociation; FDA-approved for PTSD: sertraline, paroxetine or later-life traumatic stressors are associated medication may be used to stabilize with the onset of depersonalization disorder in PTSD and other comorbid conditions, 25% of all cases.In placebo-controlled trials, such as depression patients with depersonalization disorder did not respond to fluoxetine and lamotrigine.15 PTSD, posttraumatic stress disorder; MPFC, medial prefrontal cortex. Simeon15 hypothesized that there is a severity
(Please see Dissociative Disorders, page 64) 64 PSYCHIATRIC TIMES OCTOBER 2010 C!4EGORY1 Dissociative Disorders Table 1 Office mental status interview for assessing dissociation Continued from page 63
Blackout/time loss spectrum of dissociative symptoms (although not s $O YOU ever have blackouts, blank spells, memory lapses? necessarily of impairment). Depersonalization s $O YOU LOSE TIME disorder represents a “milder” end of the contin- uum, and dissociative identity disorder, which is Disremembered behavior associated with more extreme forms of early s $O You find evidence that you have said and done things that you do not recall? trauma, represents the “more severe” end of the s $O PEOPLE TELL YOU OF BEHAVIOR YOU HAVE ENGAGED IN THAT YOU DO NOT RECALL continuum.
Fugues Dissociative amnesia s $O YOU EVER FIND yourself in a place and not know how you got there? Patients with dissociative amnesia are unable to Unexplained possessions recall important autobiographical information, s Do you find objects in your possession (eg, clothes, groceries, books) that you do not remember acquiring? usually of a traumatic or stressful nature, that is Out-of-character items? Items a child might have? inconsistent with ordinary forgetfulness.2 This s $O YOU FIND THAT OBJECTS DISAPPEAR FROM YOU IN WAYS FOR WHICH YOU CANNOT ACCOUNT memory impairment is caused by a reversible psychological inhibition, rather than organic fac- s $O YOU FIND WRITINGS DRAWINGS OR ARTISTIC PRODUCTIONS IN YOUR POSSESSION THAT YOU MUST HAVE CREATED BUT DO tors. Often the dissociated memories intrude in not recall creating? disguised forms, such as nightmares, flashbacks, Changes in relationships or conversion symptoms.2 The ability to learn s $O YOU find that your relationships with people frequently change in ways that you cannot explain? new information remains intact, as does general cognitive functioning. Fluctuations in skills/habits/knowledge s $O YOU FIND THAT SOMETIMES YOU CAN DO THINGS WITH AMAZING EASE THAT SEEM MUCH MORE DIFFICULT OR There are 2 presentations of dissociative am- impossible at other times? nesia. The first is frequently portrayed in text- books and media accounts: the patient experi- s $OES YOUR TASTE IN FOOD MUSIC OR PERSONAL HABITS SEEM TO FLUCTUATE ences sudden, dramatic amnesia involving s $OES YOUR HANDWRITING CHANGE FREQUENTLY ! LITTLE ! LOT #HILDLIKE extensive aspects of personal information, often s !RE YOU RIGHT HANDED OR LEFT HANDED $OES IT FLUCTUATE with disorientation, confusion, alterations in con- sciousness, and/or wandering.2 Such patients Fragmentary recall of life history often present in emergency departments or in in- s $O YOU HAVE Gaps in your memory of your life? Missing parts of your memory of your life history? patient medical or neurology units. s $O YOU REMEMBER YOUR CHILDHOOD 7HEN DO THOSE MEMORIES START &IRST MEMORY .EXT .EXT The second presentation is more common but
Intrusion/overlap/interference (passive influence) receives less attention because patients do not s $O You have thoughts or feelings that come from inside or outside you that don’t feel like yours? Are outside your control? careful history will show lack of recall for sig- nificant aspects of the life history. This type of s $O YOU HAVE IMPULSES OR ENGAGE IN BEHAVIORS THAT DONT SEEM TO BE COMING FROM YOU dissociative amnesia usually has a clear onset s $O YOU HEAR VOICES SOUNDS OR CONVERSATIONS IN YOUR MIND and offset, and the patient is aware of a gap in
Negative hallucinations memory. For example, a patient may not recall s $O YOU EVER not see/hear what’s going on around you? Can you block out people or things altogether? being in junior high school despite memory for the other years of school. Dissociative amnesia Analgesia has been documented for traumatic experiences, s !RE YOU ABLE TO block OUT PHYSICAL PAIN 7HOLLY 0ARTLY !LWAYS 3OMETIMES - Depersonalization/derealization locausts; and sexual, physical, and emotional s $O YOU FREQUENTLY HAVE THE EXPERIENCE OF FEELING AS IF YOU ARE OUTSIDE YOURSELF OR WATCHING YOURSELF AS IF YOU abuse or assault.2,18 Many patients with dissocia- were another person? tive amnesia have a history of depression and s $O YOU EVER FEEL DISCONNECTED FROM YOURSELF OR AS IF YOU WERE UNREAL suicidal ideation. Predisposing factors may include a history of s $O YOU EXPERIENCE THE WORLD AS UNREAL !S IF YOU ARE IN A FOG OR DAZE personal or familial somatoform or dissociative s $O YOU EVER LOOK IN THE MIRROR AND NOT RECOGNIZE YOURSELF symptoms, and/or growing up with a rigid family
Trauma moral code enforced with harsh discipline. Dis- s 7HO MADE THE RULES IN YOUR FAMILY AND HOW WERE THEY ENFORCED sociative amnesia may be related to avoidance of responsibility associated with sexual behavior or s $ID YOU WITNESS VIOLENCE BETWEEN FAMILY MEMBERS legal or financial difficulties; fear of combat; or s (AVE YOU EVER HAD UNWANTED SEXUAL CONTACT WITH ANYONE !S A CHILD 4EENAGER !DULT avoidance of massively stressful situations or in- s !S A CHILD WHAT MADE YOU FEEL SAFE 7AS ANYONE KIND TO OR SUPPORTIVE OF YOU tolerable conflicting emotions, including shame, rage, desperation, despair, and intolerable urges s &LASHBACKS INTRUSIVE SYMPTOMS SIGHT SOUND TASTE SMELL TOUCH $O YOU EVER EXPERIENCE EVENTS (eg, sexual, suicidal, violent). that happened to you before as if they are happening now? Most cases of the classic dissociative amnesia s .IGHTMARES HOW OFTEN SINCE WHEN $O YOU AWAKEN DISORIENTED &IND YOURSELF SOMEWHERE ELSE resolve within days or months, spontaneously or s !RE THERE SPECIFIC PEOPLE SITUATIONS OR OBJECTS THAT TRIGGER YOU !RE THESE ASSOCIATED WITH TIME LOSS through psychotherapy or hypnotherapy. The s !RE YOU A JUMPY PERSON %ASILY STARTLED second type of dissociative amnesia resolves only in the course of overall psychotherapy for s $O YOU AVOID PEOPLE SITUATIONS OR THINGS THAT REMIND YOU OF TRAUMATIC OR OVERWHELMING EVENTS complex PTSD.2 Can you block out feelings? thought to occur only in the course of dissociative Somatoform symptoms amnesia or dissociative identity disorder, it is s $O YOU EVER GET physical symptoms/pain that your doctors can’t medically explain? likely to be removed from DSM-5 as a separate
Adapted with permission from Loewenstein RJ. Psychiatr Clin North Am. 1991.25 disorder. OCTOBER 2010 PSYCHIATRIC TIMES 65 C!4EGORY1
Dissociative identity indicator of dissociative identity disorder or an- leagues24 have reported that patients with dis - disorder and DDNOS other form of complex PTSD.10 sociative disorder are often reluctant to report Extensive literature exists on the diagnosis, phe- Dissociative disorder experts focus less on experiences that they are aware sound crazy and nomenology, etiology, epidemiology, and treat- overt personality states than on the polysymp- that they tend to avoid confronting. tomatic presentation of dissociative identity dis- Loewenstein25 has detailed an office mental presenting symptoms, history, clinical course, order.14 Some studies show that the phenomeno- status examination for assessing dissociative and treatment response are similar in patients logical experience of overlap/interference/intru- symptoms (Table 2 presents an abridged ver- with DDNOS and dissociative identity disorder, sion). It reviews a wide variety of dissociative, the two are combined here.2 consciousness—which can be misdiagnosed as posttraumatic, affective, and somatic symptoms Dissociative identity disorder is conceptual- psychotic passive influence or Schneiderian first- as well as trauma exposure. Interviews sugges- ized as a childhood onset, posttraumatic develop- rank symptoms—is more common in dissocia- tive of dissociative disorders can be supplement- mental disorder in which the child is unable to tive identity disorder than overt switching. ed with data from dissociative screening instru- consolidate a unified sense of self. Detachment ments and structured interviews (Table 3). from emotional and physical pain during trauma interview is useful in the differential diagnosis. In There are several self-report screening mea- can result in alterations in memory encoding and several studies, patients with dissociative identity sures for dissociation. The most widely used is storage. In turn, this leads to fragmentation and disorder experienced more apparent first-rank the Dissociative Experiences Scale (DES).26 The compartmentalization of memory and impair- symptoms, although not thought broadcasting or DES has been used in more than 1000 studies and ments in retrieving memory.2,4,19 Exposure to audible thoughts, than did patients who had translated into more than 40 languages. The DES early, usually repeated trauma results in the cre- schizophrenia.21-23 These intrusions into con- has 28 items that assess amnesia, absorption, ation of discrete behavioral states that can persist sciousness include those that are partially exclud- identity alteration, and depersonalization/dereal- and, over later development, become elaborated, ed from consciousness (eg, “hearing” voices of ization. Patients rate how much of the time they ultimately developing into the alternate identities identities, thought insertion/withdrawal, “made” experience symptoms, ranging from 0% to 100%, of dissociative identity disorder. actions/impulses) and those that are fully exclud- ed from consciousness (eg, time loss, fugues, score of 30 or higher has an 85% hit rate for se- believe that dissociative identity disorder pre- being told of disremembered behaviors).14,23 vere dissociative disorders, such as dissociative sents with dramatic, florid alternate identities identity disorder and related forms of DDNOS. with obvious state transitions (switching). These DIFFERENTIAL DIAGNOSIS However, lower scores can also be found in pa- florid presentations occur in only about 5% of Making the diagnosis of a dissociative disorder tients with dissociative disorder. patients with dissociative identity disorder.20 can be challenging because patients rarely volun- Screening instruments must be interpreted in How ever, the vast majority of these patients teer information about dissociative symptoms or the clinical context and are not a substitute for have subtle presentations characterized by a their histories of trauma. Furthermore, most clini- clinical judgment in the diagnosis of dissociative mixture of dissociative and PTSD symptoms cians have not been trained to assess dissociation. disorders or any other clinical diagnosis. The embedded with other symptoms, such as post- Unless a patient is asked about trauma history Multidimentional Inventory of Dissociation traumatic depression, substance abuse, somato- and dissociation, the clinician will not be able to (MID) is a self-report, diagnostic assessment test form symptoms, eating disorders, and self- accurately diagnose trauma-related disorders, in- that measures partial and full pathological disso- destructive and impulsive behaviors.2,10 ciation.22 - of multiple treatment providers, hospitaliza- collaborative relationship must be developed be- ment of dissociation in adults and children is tions, and good medication trials, many of which fore asking about these private and often sub- result in only partial or no benefit, is often an - (Please see Dissociative Disorders, page 66)
Table 3 Additional resources for screening for dissociative disorders
Resource Source and additional details
Self-report dissociation measures Dissociative Experiences Scale (DES)26 s !VAILABLE FREE TO )334$ MEMBERS AT WWWISST DORG s $%3 TAXON CALCULATOR AVAILABLE AT WWWISST DORGEDUCATIONDES TAXON PORTALHTM
Multidimensional Inventory of Dissociation (MID)22 s !VAILABLE FREE FROM AUTHOR AT 0FDELL AOLCOM s !VAILABLE FREE TO )334$ MEMBERS AT WWWISST DORG
Somatoform Dissociation Questionnaire (SDQ)42 s !VAILABLE FREE TO )334$ MEMBERS AT WWWISST DORG
Multiscale Dissociation Inventory (MDI)43 s !VAILABLE FROM 0!2 )NC Structured clinical interviews of dissociation
Structured Clinical Interview for Dissociative Disorders-Revised (SCID-D-R)16 s !VAILABLE FROM !MERICAN 0SYCHIATRIC 0RESS
Dissociative Disorders Interview Schedule (DDIS)28 s !VAILABLE FREE AT WWWROSSINSTCOMSAMPLE?FORMSHTML Training )NTERNATIONAL 3OCIETY FOR THE 3TUDY OF 4RAUMA AND $ISSOCIATION )334$ s &!1S CONFERENCES ONLINE AND IN PERSON THERAPIST TRAINING COURSES ONLINE webinars, study groups, DES taxon calculator, assessment measures available at www.isst-d.org Readings for therapists
Treatment and assessment detailed in guidelines for adults6 s !VAILABLE FREE AT WWWISST DORG and for children and adolescents27 66 PSYCHIATRIC TIMES OCTOBER 2010 C!4EGORY1
Features that typically distinguish DID/DDNOS from borderline Table 4 personality disorder, bipolar disorder, and schizophrenia
Schizophrenia and Borderline personality DID/DDNOS1 psychotic disorders Bipolar disorder disorder
Trauma Typically report early-onset, severe, Less likely to have severe, chronic Less likely to have severe, Although may report a history of chronic childhood trauma44; high number childhood trauma; fewer traumatic chronic childhood trauma childhood trauma, less severe than of traumatic intrusions on Rorschach44 intrusions on Rorschach compared for DID45; do not differ from DID with DID44 on traumatic intrusions on Rorschach44
Dissociative symptoms Typically endorse high levels (eg, DES Endorse mildly high symptoms Lower dissociation scores Endorse moderate symptoms average score 44.646) with intact reality (eg, DES average score 17.646) expected (eg, DES average score 21.646) testing; often prefer to feel numb than with poor reality testing but significantly lower than DID45 to have strong feelings with intact reality testing; not significantly different from DID on May self-harm to induce a state of Low hypnotizability derealization and depersonalization, dissociation; when dissociating, may be but significantly lower on involved in elaborate inner world involving amnesia, identity confusion, identities, some of whom may be identity alteration45 related to past traumatic experiences (IGHEST HYPNOTIZABILITY OF ANY CLINICAL /FTEN FIND IT DISTRESSING TO FEEL NUMB group on standard scales2 and may self-harm to end an episode of dissociation; when dissociating, are merely “trancing” or depersonalized; do not have an inner world of identities Moderate to high hypnotizability on standard scales2
Transformations in identity May admit to transformations in identity May admit to transformations in None May experience identity changes (eg, “there’s a part of me that is a scared identity but with magical or related to polarized mood changes child and another part is critical and yells delusional beliefs (eg, “I had to (eg, “I was the loving, happy me when like my abuser did”); endorse past and become the prophet David and I was dating my boyfriend, but when current amnesia for many types of behaviors then had to fight myself when I he left me, the depressed, angry me became the devil”); no current took over”); little if any significant amnesia (except when recalling current amnesia outside of drug and periods of florid psychosis) alcohol use Time loss mostly when patient is “trancing”; may have less detailed recall for behavior in mood states dif- ferent from the current one
Hallucinatory experiences Often endorse hearing voice(s) but aware May endorse voices without awareness Experience hallucinations only during If experience hallucinations, they of the “as if” quality (“I know they’re not real of the hallucinatory quality; typically episodes of psychotic mania or are brief, distressing and occur during but I hear a child crying as she gets yelled at voices are not involved in elaborate, depression; in psychotic depression, stress; if endorse voices, they express by a man who sounds like the person who ongoing, interrelated discussions the voices are typically solely persecutory patient’s polarized thoughts, not abused me.”); voices express conflicting and arguments; voices are not typically (do not have child voices or different values and opinions44 opinions and values44; hearing “thoughts that related to past abusers and/or hurt encouraging voices); voices are aren’t mine” or “arguing thoughts”; most often, children; may have visual hallucinations not in conflict with one another voices are experienced inside the head; may without observing ego; hallucinations have elaborate conversations with voices, are due to psychotic process multiple conversations at the same time, or written conversations; may experience brief periods of “seeing” past traumatic events in flashback or “seeing” identities; reality testing otherwise intact; auditory and visual hallucinations relate to high dissociativity/hypnotizability OCTOBER 2010 PSYCHIATRIC TIMES 67 C!4EGORY1 available.2,6,27 There are 2 DSM-IV-TR structured severe dissociative disorders involves a phasic, included in a small meta-analysis. Effect sizes, interviews that can provide formal diagnoses of multimodal, trauma-focused psychotherapy that based on before and after within-patient mea- - addresses the manifold dimensions of symp- sures, ranged from medium to large (Table 5). terview for DSM-IV-TR Dissociative Disorders, toms.6,29 There are no randomized clinical trials of Treatment studies have primarily focused on - dissociative disorder to date and only 1 controlled dissociative identity disorder; case series studies ders Interview Schedule (DDIS).16,28 29 recently re- suggest that one group was successfully treated to Dissociative identity disorder and severe viewed 16 dissociative disorder treatment out- full fusion or integration so that they no longer DDNOS are often confused with psychotic and come studies and 4 case studies that used stan- - affective disorders as well as with borderline per- dardized measures. Data from these noncon- other group gradually showed a reduction in sonality disorder. While they can be comorbid trolled, observational trials showed that treatment symptoms, while a third group showed some im- with these disorders, they are not synonymous. based on the above model was associated with provement yet continued to be chronically ill.30 Distinguishing characteristics are presented in reductions in symptoms of dissociation, depres- Nonrandomized open dissociative identity disor- Table 4 to clarify the differential diagnosis. sion, general distress, anxiety, and PTSD. Some der treatment studies have found that hospitaliza- studies found that treatment was associated with tions that focus on trauma and/or dissociation are TREATMENT decreased use of medications and improved work associated with reductions in a range of symp- Psychological treatment and social functioning. Eight open inpatient and The current standard of care is that treatment of outpatient studies provided sufficient data to be (Please see Dissociative Disorders, page 68)
Features that typically distinguish DID/DDNOS from borderline Table 4, cont'd personality disorder, bipolar disorder, and schizophrenia
Schizophrenia and Borderline personality DID/DDNOS1 psychotic disorders Bipolar disorder disorder
Affect Typically experience a range of sometimes Flat and/or inappropriate affect; Shifts in mood state occur more Affect is significantly less modulated inexplicable, rapid mood changes that may be affect less modulated than in DID44 slowly (take at least 12 hours to shift than in DID46 and shifts according to triggered by internal or external precipitants mood state and usually much longer external precipitants; often the most (eg, sad to angry to helpless and afraid); many than that) frequent affects are emptiness and mood shifts can occur per day; rarely complain intense anger of “emptiness”; instead, the inner world is complex, “full” of conflict, identities, and inner struggles; typically avoid affect and are obsessive, intellectualized24
Ability to perceive accurately and think logically
Perceptions are generally accurate44; Perception is not significantly Disturbed only during Perception is significantly less accurate thinking is usually logical and organized less accurate than in DID44; thinking mood episodes than in DID44; thinking is significantly despite traumatic intrusions44 is significantly less logical and less logical and organized than in organized than in DID44 DID44
Working alliance Capable of developing a working alliance Less capable of developing a working Capable of developing a Less capable of developing a working with therapist as a result of capacity to alliance because expect others to be less working alliance alliance because expect others to be experience others as cooperative44; interest cooperative than in DID46; significantly less cooperative than in DID44; about in others despite fear of being hurt44; capacity less interest in others than in DID44; less the same level of interest in others as for emotional distancing and self-reflection44; capacity for emotional distancing and in DID44; less capacity for emotional may have long-standing relationships and/or self-reflection than in DID44 distancing and self-reflection than be avoidant and prefer to be alone because it in DID44; tumultuous, chaotic feels “safer” relationships; difficulty in tolerating being alone
Comorbidity Usually meet criteria for multiple Typically meet criteria for fewer Typically meet criteria for fewer Often have a variety of comorbid comorbid disorders, including mood comorbid conditions, although comorbid conditions disorders, but less prevalence of PTSD disorder, PTSD and other anxiety disorders, substance abuse disorders and somatoform disorders substance abuse disorders, mixed personality are common disorders, and somatoform disorder, as well as multiple medical illnesses, such as headaches, fibromyalgia, and GI and gynecological problems; usually meet BPD criteria when severely decompensated or having overwhelming PTSD/dissociative disorder symptoms; most do not meet BPD criteria once stabilized
DID, dissociative identity disorder; DDNOS, dissociative disorder not otherwise specified; DES, Dissociative Experiences Scale; PTSD, posttraumatic stress disorder; BPD, borderline personality disorder. 68 PSYCHIATRIC TIMES OCTOBER 2010 C!4EGORY1 Dissociative Disorders cause of ongoing enmeshment in destructive re- sociative disorder may have frequent symptom Continued from page 67 lationships, overinvestment in the dissociative and mood fluctuations; thus, experts recommend disorder, and/or debilitating psychiatric or medi- toms, including depression, anxiety, a number of cal comorbidity. overall emotional climate rather than trying to 29,31 Phase 2. If the patient becomes sufficiently medicate the day-to-day psychological changes. The first international, naturalistic, prospec- stabilized, he or she may choose to move into the tive study of dissociative identity disorder and second phase. It involves processing of traumatic trials of many different medications may provide DDNOS treated by community therapists shows memories by exploring the meanings and impact a clue that dissociative disorder should be as- of traumatic experiences; identifying and resolv- indicate that treatment is associated with a wide ing trauma-related cognitive distortions and re- responsive to medication in dissociative disorder, range of improvements.32 Therapists (N = 292) enactments; and expressing previously avoided although less robustly than in primary affective from around the world and one of their patients emotions, including grief, betrayal, terror, help- disorders.2 Intrusions and hyperarousal symp- with dissociative identity disorder or DDNOS lessness, rage, and shame. This process enables toms of PTSD are often partially responsive to (N = 280) reported on a variety of variables, in- patients to develop a coherent narrative of their medication. cluding stage of therapy, symptoms, and level of nontraumatic as well as traumatic experiences adaptive functioning. Patient and therapist re- and a sense of mastery over their memories. The anxiety with the medications found useful for ports showed that the patients in the later stages goal is to gain a sense of self-efficacy and an PTSD; these include SSRI, tricyclic, and mono- of treatment had fewer symptoms of dissociation, identity that includes growth and strength. PTSD, and general distress; fewer recent hospi- Phase 3. In patients with dissociative identity -blockers; clonidine; prazosin; anticonvulsants; talizations; and better adaptive functioning than disorder, integration of personality states occurs and benzodiazepines.2 patients in the early stages of treatment.32 Pre- throughout the second and third phases. Phase 3 SSRI/serotonin-norepinephrine reuptake inhibi- liminary follow-up data extend these findings.33 entails reintegration into life, in which the patient tor antidepressants except paroxetine and sertra- Dissociative disorders are heterogenous disor- integrates disowned aspects of self and focuses line; -blockers; clonidine; prazosin; anticonvul- ders with somewhat different treatment ap- increasingly on current and future life issues and sants; and neuroleptics may be used off-label for proaches. Detailed descriptions of treatment are goals.38 Patients often develop deeper recognition available and inform the brief overview that that earlier trauma and attachment difficulties are typically ineffective for apparent or pseudo- follows.2,6,7,34-37 may have altered their development and health in psychotic symptoms, such as hearing voices, in Phase-oriented treatment is the standard of ways that cannot be fully overcome. Thus, the dissociative disorder, low doses—particularly of care for treating dissociative disorder and com- the atypical neuroleptics—can be beneficial in plex trauma disorders. Three phases typify the tempered by a fuller recognition of the conse- patients with severe anxiety, intrusive symptoms course of treatment, although aspects of each quences of early trauma and related dysfunction. of PTSD, and/or entrenched illogical thinking.2 phase may repeat throughout treatment. Phase 1. The early exposure to trauma and Pharmacotherapy THE COSTS OF disruptions in attachment reported by many pa- Medication is not the primary treatment for dis- DISSOCIATIVE DISORDER tients with dissociative disorder are frequently sociative disorder or complex PTSD, although it reenacted in adulthood through self-injurious be- is commonly used to assist with stabilization and services among wives of active-duty servicemen haviors, suicide attempts, alcohol and drug abuse, to treat comorbid conditions.38 Medications typi- found that those with dissociative disorders had a aggression toward others, and current abusive cally result in partial improvement, so they are higher number of mental health visits per person relationships. Thus, the first phase of treatment best thought of as “shock absorbers” rather than than any other psychiatric disorder.39 Kessler,9 cit- emphasizes the stabilization of safety issues. The as curative. focus is on enhancing symptom control, contain- Psychiatric medications should target the hy- estimated that the cost of PTSD is $40 to $50 bil- ing affect and impulses, educating about trauma perarousal and intrusive symptoms of PTSD and lion per year and that the average duration of ac- treatment, and establishing a collaborative work- comorbid conditions such as affective disorders tive PTSD symptoms is more than 2 decades. ing relationship. This phase is often the longest and obsessive-compulsive symptoms (a surpris- - and is considered the most important. Some pa- ingly common comorbidity to dissociative disor- sociated with not only PTSD but also a variety of tients may remain in the first phase for years be- ders and complex PTSD).2,6,38 Patients with dis- other medical and psychiatric conditions, it is likely that the cost of dissociative disorders and the duration of symptoms are significantly higher Effect sizes for improvements associated Table 5 with treatment of dissociative disorders29 have shown a substantial reduction in costs over time with the treatment model described above.40 In summary, dissociative disorders exact a Effect size comparing pretreatment high social, psychological, and occupational cost Outcome and posttreatment data to patients, as well as a high economic cost to our Overall outcomes .71 been shown to reduce morbidity, cost, and mor- tality in this severely ill patient population. Anxiety .94 References Borderline personality disorder symptoms .95 1. Nijenhuis ER, Vanderlinden J, Spinhoven P. 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1. In DSM-IV-TR, dissociation is defined as a disruption of the (OW MANY DISSOCIATIVE DISORDERS ARE IDENTIFIED IN 7HAT IS OF FOREMOST IMPORTANCE IN BEING ABLE TO DIAGNOSE A usually integrated functions of which of the following: DSM-IV-TR? dissociative disorder in a patient? A. Consciousness A. 2 A. An office mental state examination for assessing B. Memory B. 5 dissociative symptoms C. Identity C. 7 B. Self-report screening measures D. All of the above D. 10 C. A safe, collaborative relationship between patient E. None of the above 5. Feeling detached or disconnected from one’s self describes and clinician 7HICH OF THE FOLLOWING IS A STRONG PREDICTOR OF DISSOCIATION which of the following dissociative disorders? D. All of the above A. Early childhood trauma A. Depersonalization disorder E. None of the above B. Chronic depression B. Dissociative amnesia 9. A phasic, multimodal, trauma-focused psychotherapy is the C. A first-degree biological relative with a psychotic disorder C. Dissociative identity disorder standard of care for severe dissociative disorders. E. All of the above D. None of the above A. True F. None of the above 6. Presenting symptoms, clinical course, and treatment B. False 7HICH OF THESE ARE FREQUENTLY COMORBID WITH DISSOCIATIVE response are similar in dissociative identity disorder and 10. Although neuroleptics are typically ineffective for apparent disorder? depersonalization disorder. or pseudopsychotic symptoms, in dissociative disorder low A. Depression A. True doses can be beneficial in which of the following cases: B. Somatoform disorders B. False A. Severe anxiety C. Substance abuse 7. Dissociative identity disorder almost always presents " (EARING VOICES D. All of the above with dramatic, florid alternate identities with obvious state C. Entrenched illogical thinking E. None of the above transitions. D. B and C A. True E. A and C B. False 10001101