JOURNAL OF INSURANCE MEDICINE Copyright ᮊ 2000 Journal of Insurance Medicine J Insur Med 2000;32:71–78 ORIGINAL ARTICLE Underwriting Considerations for Dissociative Disorders Polly M. Galbraith, MD; Patricia J. Neubauer, PhD Objective.—Dissociative identity disorder (DID) has been diag- Address: Fortis Benefits Insurance nosed more frequently and is under greater scrutiny. Because of the Company, 2323 Grand Blvd, 7th number of comorbid conditions, the underwriting risks must be floor, Kansas City, MO 64108-2670. evaluated to determine morbidity and mortality implications. Correspondent: Polly M. Galbraith, Background.—The number of diagnosed cases of DID has in- MD, Medical Director; e-mail creased in recent years. The diagnosis often coexists with other di- [email protected]. agnoses such as bipolar disorder, major depression, post-traumatic stress disorder, anxiety disorder, somatization, personality disor- Key words: Underwriting, dissocia- ders, and psychotic disorder. A high incidence of substance abuse tive disorder, multiple personality and eating disorders is found in the population diagnosed with DID. disorder, psychiatric disorders, mor- Methods and Results.—A query of disability claim experience bidity, mortality, disability. with DID indicated that these claims tended to reach the maximum Received: December 1, 1999. duration for mental/nervous benefits despite case management and return to work activities. Accepted: January 16, 2000. Conclusions.—The DID psychiatric population is a complex group with mental disorders that place them in a group likely to use maximum disability benefits and who would pose increased life underwriting risk. In addition, the literature indicates a high excess risk for early mortality and excess health care expenses compared to the normal population. psychiatric diagnosis that has been un- Most recent estimates suggest that more than Ader serious scrutiny for more than 10 6000 diagnosed cases of DID or dissociative years is dissociative identity disorder (DID), disorder, not otherwise specified (DDNOS, a formerly known as multiple personality dis- dissociative disorder with many similar fea- order (MPD) until the publication of the Di- tures but lacking in key elements that consti- agnostic and Statistical Manual of Mental Dis- tute a diagnosis of DID) have been identified orders, Fourth Edition (DSM-IV) in 1994.1 The since 1980.3 name was changed to address both the con- Clinical studies have identified that 12–30% cerns about the misconceptions regarding the of psychiatric inpatients have a dissociative nature of the disorder and the clinical tran- disorder and approximately 3–5% would be sition from a rare to a more commonplace diagnosed with DID.2,4–7 Using semistruc- diagnosis. Dissociation has been described in tured interviews of randomly selected psy- psychiatric literature as early as 1815, but chiatric inpatients, Rifkin et al8 found an in- only 200 cases were estimated prior to 1980.2 cidence rate of 1% for DID. In groups of non- 71 JOURNAL OF INSURANCE MEDICINE clinical subjects, prevalence rates of 3.5–11% ality disorder, 44% anxiety disorder, 40% were found for dissociative disorders and schizophrenia, and 31% substance abuse. 0.5–1.3% were diagnosed with DID.7,9 Given All studies of DID have found evidence of the increased assignment of this diagnosis, comorbidity with other mental and physical there is a real need to determine associated disorders. It was found that the average num- morbidity and mortality risks. ber of lifetime comorbid Axis I disorders was The essential features of the dissociative 7.3 (SD ϭ 2.5) while the average number of disorders are a disruption in the usually in- Axis II diagnoses was 3.6 (SD ϭ 2.5). This did tegrated functions of consciousness, memory, not include DID, post-traumatic stress disor- identity, or perception of the environment. der (PTSD), sleep disorders, or psychosexual The disturbance may be sudden, gradual, disorders. It was concluded the average DID transient, or chronic. DID is characterized by patient meets the lifetime criteria for about 15 the presence of two or more distinct identi- different DSM-IV disorders.11 Associated fea- ties, or personality states, that recurrently tures include post-traumatic symptoms such take control over an individual’s behavior ac- as nightmares, flashbacks, and startle reac- companied by an inability to recall important tions; thus, an additional diagnosis of post- personal information that is too extensive to traumatic stress disorder is warranted.1 Her- be explained by ordinary forgetfulness. This man and van der Kolk et al12,13 suggest that disturbance cannot be attributed to the direct DID should be diagnosed as complicated physiological effects of a substance or general PTSD, as the diagnosis is clearly related to medical condition. Amnesia or memory gaps early trauma. The Sidran Foundation14 (a DID are frequent in the personal history. Transi- advocacy group) estimates that 80–100% of tions between identities are often triggered people with DID also have secondary PTSD. by psychosocial stress.1 Saxe et al2 found that all of the psychiatric Controversy exists concerning the differ- inpatients with DID had comorbidity with ential diagnosis, which may include many another psychiatric diagnosis. Most met the other mental disorders such as bipolar dis- criteria for PTSD and major depression, either order with rapid cycling, anxiety disorders, currently or during their lifetime. Approxi- somatization disorders, personality disorders, mately two thirds met the criteria for border- and psychotic disorders.1 Self mutilation, ag- line personality disorder and substance gressiveness, and suicidal and conversion abuse. symptoms such as pseudoseizures may occur. Ross interpreted these findings to suggest The condition appears to have a fluctuating that DID is part of a normal human response clinical course that is chronic and recurring. to severe chronic childhood trauma. He fur- People with DID may also meet the psychi- ther opined that trauma is a major etiologic atric criteria for mood, substance, sexual, eat- factor in all psychiatric disorders.11 Pribor and ing, and sleep disorders.1 Some meet the cri- Dinwiddie found that abused subjects show teria for borderline personality disorder as more PTSD, panic disorder, social and simple well. Thus, there is a strong association of phobia, agoraphobia, major depression, and multiple comorbid psychiatric disorders with substance abuse when compared to general DID. The diagnosis may be difficult to make population and nonabused psychiatric sub- and confused with a number of other better- jects.15 A review of the literature found that known psychiatric disorders. Estimates sug- DID was notable for auditory hallucinations gest that persons will be treated in the mental (positive Schneiderian symptoms), depres- health system for up to 7 years before an ap- sion and suicidality, phobic anxiety, somati- propriate diagnosis is made. Ross et al10 zation, substance abuse, and borderline fea- found that prior to the MPD (or DID) diag- tures.16 In a study of 2-year outcomes for in- nosis, patients averaged 2.74 other diagnoses, patients, Ellason and Ross17 found that people including 64% affective disorder, 57% person- with DID endorse a mean of 7.3 Axis I di- 72 GALBRAITH ET AL—UNDERWRITING CONSIDERATIONS FOR DISSOCIATIVE DISORDERS agnoses at the onset of diagnosis. Ross and In a study of 51 sexual abuse survivors, Norton18 suggest that DID might be a supe- 94% had depression, 65% had substance rordinate diagnosis in that other Axis I di- abuse history, and 55% had DID diagnosed.24 agnoses tend to remit with successful treat- Von Braunsberg7 reviewed the literature and ment and integration. Ross and Dua19 deter- concluded that having a dissociative experi- mined the lifetime health costs of treatment ence at the moment of trauma is the most sig- for 15 people with DID. The total cost spent nificant long-term predictor for development by the Canadian health system was $4.1 mil- of PTSD. Increased dissociative experiences lion. The average time in the health care sys- were found in 100% of people with trauma tem before diagnosis was 98 months. The av- history. McCauley et al25 found that subjects erage time in care after diagnosis was 32 abused in childhood were four times as likely months. to attempt suicide, three times more likely to be hospitalized, and twice as likely to have DEPRESSION AND ANXIETY suicidal thoughts as nonabused controls. The single most common presenting symp- SUBSTANCE ABUSE AND EATING tom in MPD patients is depression. A Nation- DISORDERS al Institute of Mental Health (NIMH) survey found depression in 88% of the cases, and Substance abuse is another frequent prob- about 75% of patients reported mood lem and polysubstance abuse was noted in swings.20 Symptoms suggestive of phobic, one third of the NIMH study group. Anal- anxiety, or panic disorder are common in dis- gesic overuse often accompanies the treat- sociative patients. These often accompany ment for headaches, which are common to triggers, or reminders of traumatic experienc- this group. In one study group in Canada, es, and lead to much avoidance behavior. El- Ross and Norton found 43% of a group of 100 lason et al16 found that depression was the subjects with substance abuse met criteria for most common comorbid disorder with DID. a dissociative disorder, and of those, 14 met In a study of subjects presenting for treat- the criteria for DID. In an American group of ment for obsessive-compulsive disorder, 20% subjects, Ross11 found 60% of substance abus- presented with significant dissociative symp- ers met criteria for dissociative disorders, in- toms. These persons were more likely to have cluding 18% with DID. Felker et al26 deter- personality disorders and had a greater num- mined that substance abuse alone or in con- ber and severity of obsessive-compulsive junction with other psychiatric disorders has symptoms.21 Goff et al21 did not find an over- repeatedly led to increased mortality rates. lap with a diagnosis of DID, but 3 of the sub- Dunn et al27 provided the opinion that per- jects met the criteria for DDNOS.