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Psychotherapy of the survivor of incest with a dissociative disorder.

The treatment of the survivor of incest who suffers from a dissociative disorder is probably somewhat more difficult than that of other survivors of incest because for these others the material is more readily available. Also the patient with DD was probably more severely abused or the dissociative defense would not have been needed. This too makes therapy difficult, especially in that most necessary step: the development of trust and rapport. Despite these problems, there is a very good chance for a successful therapy that will bring the dissociated material back into the main stream of consciousness with a "here and now" appropriate perspective. This can be accomplished through proper diagnosis, good theoretics grounding, and therapy including psychotherapy with appropriate limit setting and the judicious use of medication. This article presents a summary of the BASK model of dissociation and two other models and gives ideas on how these models may be applied to the understanding of the etiology of dissociative disorders and their treatment. Case examples are used to illustrate successful treatment. Although treatment of incest survivors with dissociative disorders is difficult, success can be anticipated, and the rewards to the patient and the satisfaction for the therapist are great.

Adolescent↗

Axis I dissociative disorder comorbidity in borderline personality disorder and reports of childhood trauma.

OBJECTIVE: The purpose of this study was to examine the dissociative disorder comorbidity of borderline personality disorder and its relation to childhood trauma reports in a nonclinical population. METHOD: In April 2003, 1301 college students were screened for borderline personality disorder using the Structured Clinical Interview for DSM-IV Personality Disorders. The Childhood Trauma Questionnaire and Steinberg's dissociation questionnaires were also administered. During May and June 2003, 80 students with a diagnosis of borderline personality disorder and 111 nonborderline students were evaluated using the Structured Clinical Interview for DSM-IV Dissociative Disorders by an interviewer blind to the diagnosis and scores obtained during the first phase. RESULTS: The prevalence of borderline personality disorder was 8.5%. A significant majority (72.5%; 58/80) of the borderline personality disorder group had a dissociative disorder, whereas this rate was only 18.0% (20/111) for the comparison group (p < .001). Childhood emotional and sexual abuse, physical neglect, and total childhood trauma scores had significant effect for borderline personality disorder (p < .001, p = .038, p = .044, and p = .003, respectively), whereas emotional neglect and diminished minimization of childhood trauma had significant effect for dissociative disorder (p = .020 and p = .007, respectively). CONCLUSION: A significant proportion of subjects with borderline personality disorder have a comorbid dissociative disorder. Lack of interaction between dissociative disorder and borderline personality disorder diagnoses for any type of childhood trauma contradicts the opinion that both disorders together might be a single disorder. Recognizing highly prevalent but usually neglected Axis I dissociative disorder comorbidity in patients with borderline personality disorder may contribute to conceptual clarification of this spectrum of psychopathology.

Adolescent↗

Prevalence of dissociative disorders in an acute care day hospital population.

To estimate the prevalence of dissociative disorders in a day hospital and examine their relation to traumatic experiences, trained clinicians evaluated 70 of 229 patients consecutively admitted to an acute care day hospital. They used the Mini-Structured Clinical Interview for DSM-III-R Dissociative Disorders and the Traumatic Experience Questionnaire. Six of the 70 patients (9 percent) received a definite diagnosis of a dissociative disorder. Five of the six patients reported a childhood history of sexual or physical abuse. The results show that dissociative disorders are not rare among general psychiatric patients in a day hospital setting and are associated with histories of childhood trauma.

Adult↗

Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity.

OBJECTIVE: To investigate the association of dissociative disorder (DD) with impaired functioning and co-occurring Axis I and personality disorders among adults in the community. METHOD: Psychiatric interviews were administered to a sample of 658 adult participants in the Children in the Community Study, a community-based longitudinal study. RESULTS: Depersonalization disorder (prevalence: 0.8%), dissociative amnesia (prevalence: 1.8%), dissociative identity disorder (prevalence: 1.5%), and dissociative disorder not otherwise specified (prevalence: 4.4%), evident within the past year, were each associated with impaired functioning, as assessed by the clinician-administered Global Assessment of Functioning Scale. These associations remained significant after controlling for age, sex, and co-occurring disorders. Individuals with anxiety, mood, and personality disorders were significantly more likely than individuals without these disorders were to have DD, after the covariates were controlled. Individuals with Cluster A (DD prevalence: 58%), B (DD prevalence: 68%), and C (DD prevalence: 37%) personality disorders were substantially more likely than those without personality disorders were to have DD. CONCLUSIONS: DD is associated with clinically significant impairment among adults in the community. DD may be particularly prevalent among individuals with personality disorders.

Adult↗

Dissociative disorders: pathways to diagnosis, clinician attitudes and their impact.

OBJECTIVES: To study the attitudes and experiences of Australian clinicians with dissociative disorders and the paths to diagnosis and experiences of patients. METHOD: The attitudes of Australian clinicians to dissociative disorders and the experiences of patients were assessed by questionnaires. The clinicians were mental health specialists and a small number of general medical practitioners. The patients had all been diagnosed with a dissociative disorder. RESULTS: Of the 250 clinicians, 21% reported experience with more than six cases on average of any one of the dissociative disorders, 38% with less than six, 42% with none; 55% regarded them as valid diagnoses, 35% dubiously valid and 10% invalid. Of the 55 patients, 76% reported delays in diagnosis (57%, >3 years and 25%, >10 years) with adverse consequences in 64%; 80% had experienced sceptical or antagonistic attitudes from clinicians, rated as destructive by 48%. They were disabled (60% rated as >50% impaired) and were heavy consumers of health services (48% hospitalized, 68% >5 times). There was considerable comorbidity including moderate or severe depression (96%), self-harm (68%), suicide attempts (69%), panic disorder (53%), eating disorders (75%), substance abuse (25%), poor physical health (44%), major interpersonal (70%) and sexual problems (90%). Patients rated individual psychotherapy as the most helpful treatment (90%) but medications, such as antidepressants, were also valued (60%). CONCLUSIONS: Although over half of the responding Australian clinicians thought that dissociative disorders were valid, the rest were dubious about their validity with 10% believing them to be invalid. Only 21% had considerable experience with the disorders. These findings may relate to some of the difficulties perceived by patients, which included delays in diagnosis, suboptimal treatment and negative experiences with clinicians.

Adult↗

Self-destructive behavior in patients with dissociative disorders.

Highrates of self-injury have been reported in patients with dissociative disorders, yet no prior study has directly compared these patients with other psychiatric patients. The present study assesses self-destructive behavior in a group of inpatients who have dissociative disorders compared to those who report few dissociative symptoms. These patients more frequently engage in self-destructive behaviors, use more methods of self-injury, and begin to injure themselves at an earlier age then patients who do not dissociate. Results have important implications for understanding the relationship between dissociation, childhood trauma, and self-injury and for assessment and treatment of patients with dissociative disorders.

Adult↗

An epidemic of collective conversion and dissociation disorder in an indigenous group of Colombia: its relation to cultural change.

We describe a collective episode of psychogenic illness in an indigenous group (Embera) of Colombia, geographically isolated from its native homeland and surrounded by non-indigenous settlers. The condition, which affected three young adult men and six adolescent women, was attributed by them to a spell (maleficio). It was designated as ataques de locura (madness attacks) according to their traditional medical system; and as a conversive disorder with dissociative features by psychiatrists. Different therapeutic approaches, including antipsychotic medication, religious healers and traditional herbal remedies were unsuccessful. Contact with shamans of the same ethnic origin, on the other hand, proved to be an effective way of dealing with the symptoms. We interpret the situation as an expression of psychosocial stress secondary to cultural change. This medical problem bears close resemblance to other specific culture-bound syndromes such as ataques de nervios or possession syndromes and gives clues to ways of dealing with psychogenic expressions of cultural stress.

Adolescent↗

Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic.

The aim of the study was to determine the frequency of dissociative disorders among psychiatric inpatients in Germany and to investigate the relationship between childhood trauma and dissociation. The German version of the Dissociative Experiences Scale (DES), the Fragebogen für Dissoziative Symptome (FDS), was used to screen 115 consecutive inpatients admitted to the psychiatric clinic of a university hospital. Patients with FDS scores higher than 20 were interviewed by a trained clinician, using the German translation of the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R). The German version of the Childhood Trauma Questionnaire (CTQ) was administered to investigate prevalence of childhood trauma and relations between childhood trauma and dissociation in adult life. Twenty-five of the 115 patients (21.7%) had a score higher than 20 on the FDS. Of these, 15 patients were interviewed with the SCID-D-R. One patient was diagnosed with a dissociative identity disorder, three with dissociative disorders not otherwise specified, and one patient with depersonalization disorder. All diagnoses were confirmed clinically. A significant positive relationship was found between the severity of childhood trauma and dissociation. Dissociative disorders are common among German psychiatric inpatients. Clinicians who work in psychiatric inpatient units should be mindful of these disorders.

Adolescent↗

The use of electroconvulsive therapy in patients with dissociative disorders.

The psychiatric literature generally discourages the use of electroconvulsive therapy (ECT) to treat depression in dissociative disorder patients, but contains little data on outcome. This prospective study of ECT in three dissociative disorder patients demonstrates that ECT is indicated for severe treatment-resistant depression in such patients. Their Hamilton Depression Scale scores fell by 50%, they were remarkably clinically improved, and they maintained their gains for at least 4 months. The ECT proved helpful when depression was felt by most of the active alters rather than just by one depressed personality. Mini-Mental State Examination scores and clinical observation revealed no unusual confusion or side effects from ECT. These patients' dissociated condition was not altered by ECT, which indicates that ECT neither treats nor impairs treatment of dissociation. Electroconvulsive therapy can be helpful in the overall treatment of dissociative disorders by alleviating severe depressions which block utilization of psychotherapy.

Adult↗

The Structured Clinical Interview for DSM-III-R Dissociative Disorders: preliminary report on a new diagnostic instrument.

The authors describe the Structured Clinical Interview for DSM-III-R Dissociative Disorders (SCID-D), which investigates five groups of dissociative symptoms (amnesia, depersonalization, derealization, identity confusion, and identity alteration) and systematically rates both the severity of individual symptoms and the evaluation of overall diagnosis of dissociative disorder. Preliminary findings from a study of 48 subjects with and without psychiatric diagnoses indicate good to excellent reliability and discriminant validity for the SCID-D as a diagnostic instrument for the five dissociative disorders and as a tool for the evaluation of dissociative symptoms encountered within nondissociative syndromes.

Adult↗

The parenting experiences of mothers with dissociative disorders.

This article presents a qualitative analysis of the experience of parenting of mothers with dissociative disorders. This analysis was performed to complement the quantitative analysis of problems of mothers with dissociative disorders that Benjamin, Benjamin, and Rind (1996) presented previously. They found that the functioning of these mothers, as well as their subjective experience of mothering, was poorer than that of either clinical or nonclinical control mothers. Our goal was to provide a clearer, richer picture of their problems in parenting. Using the mothers' own words, we describe how the five symptom areas of dissociation (amnesia, depersonalization, derealization, identity confusion, and identity alteration) impeded their parenting efforts. We conclude with a discussion of the necessity of addressing parenting in the treatment of client-mothers with dissociative disorders.

Adaptation, Psychological↗

Enhancing the hospital treatment of dissociative disorder patients by developing nursing expertise in the application of hypnotic techniques without formal trance induction.

Many symptoms suffered by dissociative disorder patients are unresponsive or incompletely responsive to medications. This poses a unique challenge to the staff of specialized dissociative disorder units, in which many such patients who require hospital care suffer serious distress that may not respond predictably to the pharmacological interventions that are available. However, the majority of their symptoms are dissociative in nature, and dissociative disorder patients generally are quite hypnotizable. Anticipating the need for nonpsychopharmacological interventions that we could use in the absence of the treating psychiatrist, we taught the unit's nursing and social work staff to rely on the inherent trance-proneness of these patients to utilize hypnotic techniques without the formal induction of hypnosis. Their implementation facilitated crisis resolution, led to a greater sense of safety on the part of the patients, enhanced the staff's sense of mastery, and minimized the need for emergency sedation and restraints.

Dissociative Disorders↗

Sociodemographic and clinical characteristics of patients with dissociative disorders in an Arabian society.

OBJECTIVE: The aim of the study was to determine the sociodemographic and clinical characteristics of patients with dissociative disorders among psychiatric patients in the population of the United Arab Emirates. SUBJECTS AND METHODS: Six hundred inpatients with dissociative disorders were approached during the period 1997-2003, and 468 agreed to participate in the study. These patients were recruited from Al-Ain and Tawam Teaching Hospitals and Al-Jahili Primary Health Care Centers in Al-Ain, United Arab Emirates. The study is based on a questionnaire that included sociodemographic and clinical variables. Dissociative disorders were diagnosed according to the classification set forth in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the International Classification of Diseases (ICD-10) of the World Health Organization. RESULTS: Of the 468 patients studied, the majority (67.9%) were young, under the age of 25 years; 55% were UAE nationals, 59.4% female and 40.6% male. Disorganized movement was significantly lower among females (34.2%) than males (44.2%, p < 0.03). Disapproving of the key relative behaviour was higher in females (24.1%) compared to males (13.2%); comorbid anxiety was higher in females (37.4%) vs. males (25.3%). Disturbed relationships were more common in females (40.3%) while precipitating factors, such as intolerable stressful events, were significantly higher in males (42.6%, p < 0.01). Furthermore, males (20.5%) had a significantly higher history of similar episodes and other psychiatric illnesses (7.5%) than females. Finally, females (41%) showed more statistically significant improvements compared to males (29.5%, p < 0.001). CONCLUSION: Patients under 25 years of age suffered more from dissociative disorders with no correlation to educational level as a predisposing factor. The most common symptoms were fits or unorganized movements.

Chi-Square Distribution↗

Characteristics of patients with multiple personality and dissociative disorders on psychological testing.

We describe a new psychological testing procedure used on a consecutive series of 14 patients with multiple personality and dissociative disorders who met DSM-III-R and research criteria for dissociative disorders. Once dissociative phenomena were accounted for in testing, most patients displayed response patterns markedly different from those of schizophrenic and borderline patients. Patients showed striking variability on cognitive and projective tests, often related to posttraumatic intrusions. Rorschach protocols showed unusual thinking accompanied by psychological complexity and highly developed self-observing capacity. In contrast to classical conceptualizations about these patients, most subjects had personality profiles that were intellectualized, obsessive, and introversive, not histrionic or labile.

Adaptation, Psychological↗

Group psychotherapy for persons with multiple personality and dissociative disorders.

Group psychotherapy is a valuable part of the treatment of patients with multiple personality and dissociative disorders. After reviewing the sparse literature on the subject, the author describes the use of group psychotherapy with these patients alone, as well as with two types of groups in which these patients may participate: incest survivors and general group therapy patients. She concludes by emphasizing the need for expert training for therapists who conduct group psychotherapy with multiple personality and dissociative disorder patients.

Dissociative Disorders↗

Screening for dissociative disorders in children and adolescents.

This paper describes the concept of dissociation as it might be assessed in children. It compares the measurement of adult symptoms of dissociative disorders in an effort to propose an appropriate, age-specific evaluation tool for children. The authors review several psychometric instruments that are utilized to screen for the effects of abuse in children. A thorough evaluation of children exhibiting early signs of a dissociative disorder provides the opportunity for prompt diagnosis and proper treatment. The primary impact of expeditious assessment is the significant reduction of the potential for the development of full-blown chronic trauma symptomatology in adulthood such as multiple personality disorder.

Adolescent↗

Degree of somatoform and psychological dissociation in dissociative disorder is correlated with reported trauma.

In this study, the prevalence and severity of traumatic experiences as reported by patients with dissociative disorders and with other DSM-IV psychiatric diagnoses were compared. Furthermore, the predictive value of emotional, physical, and sexual trauma with respect to somatoform and psychological dissociation was analyzed. In contrast with comparison patients, dissociative disorder patients reported severe and multifaceted traumatization. Physical and sexual trauma predicted somatoform dissociation, sexual trauma predicted psychological dissociation as well. According to the memories of the dissociative disorder patients, this abuse occurred in an emotionally neglectful and abusive social context. Pathological dissociation was best predicted by early onset of reported intense, chronic and multiple traumatization. Methodological limitations restricting causal inferences between reported trauma and dissociation are discussed.

Adolescent↗

Dissociative disorders among psychiatric patients.

The aim was to determine the rate of dissociative disorders among psychiatric in- (n = 34) and out-patients (n = 37) and to compare the rate to that of nonclinical subjects (n = 297). Dissociative disorders (17% of patients) could be grouped according to the severity of the symptoms and their relation to affective disorders.

Adult↗