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Psychiatric diagnoses in hospitalized adolescent and adult Ethiopian immigrants in Israel.
In 1984-85 Operation Moses brought a mass immigration of Jewish Ethiopians to Israel. Many of these immigrants were children and adolescents who came on their own having left their families behind. Since that time the adolescent department at the Geha Psychiatric Hospital has had the major responsibility of caring for those Ethiopian adolescents who required psychiatric hospitalization. The present study compares the diagnoses and reasons for admission of Ethiopian adolescents in Israel with those of Ethiopian adults and Israeli adolescents. The results of this comparison show that Ethiopian adolescents in hospital had significantly higher rates of dissociative disorders than the other two groups and significantly lower rates of the major functional psychoses than Ethiopian adults and Israeli adolescents. In addition the Ethiopian adolescents had relatively low levels of nonspecific depressive symptoms and anxiety symptoms and were hospitalized for significantly shorter periods of time than the other two groups.
Sadistic ritual abuse. An overview in detection and management.
Sadistic ritual abuse, including satanic cult abuse, is emerging as a syndrome among people with severe dissociative disorders, including multiple personality disorder. This article discusses the essential features that compose the clinical picture of sadistic ritual abuse in adults, adolescents, and children. Particular attention is paid to the differences between adolescents who may have been victimized by adults in sadistic and ritualized ways and disenfranchised "teenage dabblers" who may temporarily adopt a ritualized lifestyle as a way of expressing or acting out. The article also covers guidelines for appropriate medical, pharmacologic, and referral interventions. The controversy surrounding sadistic ritual abuse is discussed thoroughly, and primary care physicians are advised of the current status of understanding and validation in this area.
Nursing care of the self-mutilating patient.
Self-mutilative behavior is common among patients with multiple personality and other dissociative disorders. Nursing staff members face particular challenges in managing these patients because one act of self-mutilation can disrupt the entire inpatient milieu. The authors present an approach to nursing care that focuses on working with patients to understand and develop a specific plan to curtail the self-mutilative behavior.
Is the transference feared by the psychoanalyst?
The author considers whether the reason for the variety and multiplicity of theories about the transference might lie in analysts' fears of its dangers. He reviews Freud's development of the concept from its origins, when it was seen as resistance, to its use as a fundamental instrument of the treatment, and lays particular emphasis on its perception as a burden. Classical and later authors' conflicting views of the transference and its management are surveyed in the light of the common ground otherwise existing between schools. Views of the negative transference are also presented. Some clinical vignettes are given, showing the analyst responding to the patient's transference, grappling with his own countertransference feelings and using them to illuminate the clinical situation. The author emphasises the importance of the analyst's training and experience in enabling him to withstand the regressive onslaught of the patient's projections without resorting to theory-related or technical defensive measures. In his view, the transference is not in itself a resistance but may be used as such. The analyst must not interpret merely in order to get rid of the anxiety aroused in himself by the patient's regressive feelings. The paper ends with a consideration of the importance of intuition, the countertransference and sublimated projective counter-identification.
[Factors related to suicidal behavior among alcoholics].
Of 181 alcoholics who consecutively sought treatment as out- or inpatients, 68 (37.6%) had attempted suicide at least once. Compared with non-attempters, the suicide attempters were significantly more likely to be female, have had a chaotic upbringing and to have known suicide attempts in the family and social circle. Significantly more attempters suffered from depressive disorder, feelings of hopelessness, anxiety attacks, agoraphobia, substance abuse or cluster B personality disorders (dissocial, impulsive, borderline, and histrionic). Also significantly more suicide attempters had committed crimes and received early pension. Assessment of coping showed that suicide attempters had a significantly lower tendency to make plans or to make the best of a stressful situation by growing from it. They were significantly more likely to show mental disengagement, to resort to denial and drink alcohol or take drugs when faced with stressful events or difficulties. When evaluated on the Addiction Severity Index Scale, the suicide attempters were found to have a significantly greater need of treatment.
["Multiple personality disorder" in childhood and adolescence].
UNLABELLED: Multiple Personality Disorder (MPD) (ICD 10, DSM-III-R) or Dissociative Identity Disorder (DSM IV) is seen as a dissociative disorder. The diagnosis is mainly made only in adults. Descriptions of MPD in children or adolescents are rare in scientific literature. Both sexual and physical abuse are seen as the most important etiological factors. The diagnostic criteria include the presence of two or more identities within one person, the alternating control of the person's actions by the different personalities and amnesia with regard to episodes in one's life history which cannot be accounted for by forgetfulness. OBJECTIVES: Is MPD diagnosed in children and adolescents? Which criteria are relevant in this disorder? METHODS: All scientific publications found in an online search were individually analyzed. RESULTS: The literature survey yielded 120 published cases of MPD in children and adolescents. The main clinical presentations are affective and anxiety symptoms, auditory hallucinations, amnesia and behavioral disturbances. The sex ratio for children and adolescents is 5:4 f:m, resp. 9:1 for adults. Description of the social and familial backgrounds of children and adolescents with MPD is inadequate. The number of MPD cases among children, adolescents and adults has risen in recent years. CONCLUSION: MPD is diagnosed in children and adolescents. The diagnostic criteria are inconclusive.
Dissociative experiences and disorders in forensic inpatients.
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Dissociation, childhood trauma, and ataque de nervios among Puerto Rican psychiatric outpatients.
OBJECTIVE: This study examined the relationships of dissociation and childhood trauma with ataque de nervios. METHOD: Forty Puerto Rican psychiatric outpatients were evaluated for frequency of ataque de nervios, dissociative symptoms, exposure to trauma, and mood and anxiety psychopathology. Blind conditions were maintained across assessments. Data for 29 female patients were analyzed. RESULTS: Among these 29 patients, clinician-rated dissociative symptoms increased with frequency of ataque de nervios. Dissociative Experiences Scale scores and diagnoses of panic disorder and dissociative disorders were also associated with ataque frequency, before corrections were made for multiple comparisons. The rate of childhood trauma was uniformly high among the patients and showed no relationship to dissociative symptoms and disorder or number of ataques. CONCLUSIONS: Frequent ataques de nervios may, in part, be a marker for psychiatric disorders characterized by dissociative symptoms. Childhood trauma per se did not account for ataque status in this group of female outpatients.
[Dissociation, hypnosis and multiple personality disorders].
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Depression, traumatic dissociation and epileptic-like phenomena.
OBJECTIVES: According to recent findings trauma and stress are important etiological factors in pathogenesis of depression. As characteristic features of depressive cognition have been reported intrusive thoughts and memory disturbances similar to posttraumatic symptoms known in patients with posttraumatic stress disorder or dissociative disorders. Hypothetically is also suggested a close relationship of traumatic dissociation and epileptic-like phenomena. SETTINGS AND DESIGN: In the clinical study were assessed 70 adult people with a diagnosis of depression and 50 healthy controls. In the assessment were used 6 measures for symptoms of dissociation, depression, traumatic stress and psychosenzoric symptoms of epileptic origin (the so-called complex partial seizure-like symptoms). RESULTS: Reported data show that a great number of depressive patients who met the cut-off score for dissociative disorders (34.2%, N=24) had significantly higher traumatization, depression, subjectively experienced stress and complex partial seizure-like symptoms than the whole group of patients and the controls. Most significant traumatization has been found in patients who met the cut-off score of psychosenzoric epileptic-like symptoms which is characteristic for the epilepsy spectrum disorder (5.7%, N=4). MAIN FINDINGS: Significant correlations of these assessed symptoms suggest close relationship between traumatic stress and dissociation in depression. This close relationship of dissociative symptomatology and traumatic stress also implicates an important role of dissociative processes in depression as a typical manifestation of depressive cognition. Assessed relationship between traumatic distress and complex partial seizure-like symptoms suggests a possible role of epileptic-like phenomena in dissociative states related to depression. CONCLUSIONS: Assessed relationship between traumatization, depression and epileptic-like phenomena in the patients who met cut-off score for epilepsy spectrum disorder can contribute to the problem of indication of several depressive patients to anticonvulsant therapy because of reported evidence that a clear majority of patients with epilepsy spectrum disorder respond well to anticonvulsant treatment. Careful assessment of this test battery thus may be useful also for anticonvulsant treatment strategy.
Multiple personality disorder.
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The characterological basis of multiple personality.
This review has focused on the characterological features of dissociative identity disorder (DID), extending the "state versus trait" debate to the realm of the dissociative disorders. A number of different theories are presented describing DID as a variant of, on a continuum with, or being comorbid with the narcissistic and the borderline personality disorders. It is then hypothesized that DID is best considered a distinct characterological entity. Two theories are put forth, which describe a personality disorder whose predominant defense is dissociation. The more developed model which possibly has more explanatory value is the "dissociative character." In this schema, DID would be considered a lower-level dissociative character, utilizing primitive forms of dissociation in which splitting is enhanced by an autohypnotic defensive altered state of consciousness. These altered states originate in response to the overstimulation of external trauma, but get reactivated in the service of here-and-now intrapsychic conflicts. Recognition of this dual quality of dissociation seems helpful in psychodynamic treatment, which allows for analysis of the defense and analysis of the content of these states. The nature of the content of what is "in dissociation" appears to have a dreamlike quality to it that may correspond to previous trauma but also be subject to some secondary revision. There is clinical evidence to suggest that "dream work" of the ego is operative in both the representation of a separate self in dreams and in alter personalities. Another organizing influence which contributes to seemingly separate identities is that of perverse sexuality. It appears that a number of dissociated sexual pathways may be followed in the same individual, which encapsulate aggression, childhood trauma, anxiety, and a sense of self. When this exceedingly complex psychic structure is successful, it may then free up some ego to proceed with aspects of healthy development.
Dissociative experiences and posttraumatic stress disorder among female victims of criminal assault and rape.
This study examines the relationship between posttraumatic stress disorder (PTSD) and dissociative experiences in a sample of 158 recent female assault victims (74 rape, 84 nonsexual assault) and 46 comparison subjects who had not been assaulted within the last year. Results indicated that victims had elevated scores on Dissociative Experiences Scale (DES) as compared to the comparison subjects, but that this elevation was not as high as for other traumatized samples. The level of dissociation reported by assault victims declined significantly over the three month course of the study. DES scores were related to PTSD diagnosis and symptom severity, but only among nonsexual assault victims. In rape victims, there was no correlation between dissociation and PTSD. Recent victims with a history of childhood sexual abuse were significantly more dissociative than those who did not report such a history. These results are discussed with regard to vulnerability factors for developing PTSD subsequent to a criminal assault.
The utility of dimensional and categorical approaches to understanding dissociation in the eating disorders.
OBJECTIVE: The present study compared levels of dissociation across groups of eating-disordered women, investigating the utility of dimensional and categorical measures of dissociation in understanding diagnoses and behaviours in the eating disorders. METHODS: The Dissociative Experiences Scale (DES-II) was completed by 170 eating-disordered women (drawn from out-patient assessment clinics) and 203 nonclinical women. The clinical group also supplied information regarding eating behaviours and related features (alcohol abuse, reported history of sexual abuse). The DES-II and a subset of its items (DES-Taxon) were used as dimensional and categorical discriminators of the groups and of the presence/absence of specific features and symptoms. RESULTS: When treated as dimensional measures, the DES-II and DES-Taxon had similar levels of clinical utility (particularly discriminating the binge-purge anorexics from the other clinical groups). However, the DES-Taxon was a superior categorical measure, discriminating groups more clearly and predicting the presence of many symptoms and features much more powerfully. CONCLUSIONS: The DES-Taxon is a potentially valuable self-report measure for indicating the level and presence of dissociative psychopathology in the eating disorders. As well as being convenient to administer and score, it has the clinical and research value of indicating those patients in whom treatment might need to include addressing pathological dissociation.
Utilizing hypnosis and ego-state therapy to facilitate healthy adaptive differentiation in the treatment of sexual disorders.
Much of the literature focuses on the pathology that falls to the far right of the Watkins (1997) differentiation-dissociation continuum, such as Dissociative Identity Disorder and Dissociative Disorder NOS. Adding a "far left" to this continuum, as well as a construct of what the "far left" looks like, makes apparent the value of healthy adaptive differentiation for those individuals that fall to the "far left" of the spectrum; those who don't differentiate enough. A discussion of sexual dysfunction at this end of the continuum and cases of Hypoactive Sexual Desire Disorder and Vaginismus demonstrate the clinical effectiveness of an approach combining hypnosis and ego-state therapy to facilitate healthy adaptive differentiation.
Multiple personality in eating disorder patients.
Although the overlap between childhood sexual and physical abuse and eating disorders is well known, little work has been done on the sequelae of childhood trauma in eating disorder patients. Dissociative phenomena are common in adult survivors of childhood abuse, with multiple personality disorder (MPD) being the most extreme form of dissociative disorder. We describe two women who presented for inpatient treatment of eating disorders who were subsequently found to have MPD. Because the eating pathology in these patients contained atypical features related to the MPD process, uncovering MPD was critical in the treatment of their eating behavior. MPD should be considered in any atypical or treatment-resistant eating disorder patient.
[A case of incest with dissociative amnesia and post traumatic stress disorder].
Incest is a kind of sexual abuse that causes serious disorders during childhood and adulthood. In order to overcome the trauma, abuse victims frequently use dissociative defence mechanisms. Post traumatic stress disorder, dissociative disorders, major depression and borderline personality disorder can be seen in the victims of childhood sexual abuse. In this article we present an adolescent who was found and brought to our clinic by the Children's Police Department while she was wandering around aimlessly. She could not remember anything about her identity or personal history. She had no apparent physical disturbances, marks of beating or wounds which could be seen externally. Her physical and neurological examinations were both normal. In her laboratory tests, there was nothing abnormal. No sign of intoxication or infection was detected. EEG and CT were also normal. After the family was found, we learned about the sexual and physical abuse and the patient was diagnosed with dissociative amnesia. The psychometric evaluations also supported our diagnosis. When the dissociation began to disappear, post traumatic stress disorder symptoms became more apparent. After she described her traumatic memories, PTSD symptoms began to recede. Through this case presentation we would like to emphasize the relationship between childhood physical and sexual abuse and dissociative disorders.