Dissociative Disorders: An Overview of Assessment, Phenomonology and Treatment.

Article · January 2010with1,943 Reads
Abstract
Dissociation is a process that provides protective psychological containment, detachment from, and even physical analgesia for, overwhelming experiences, usually of a traumatic or stressful nature. Dissociation is conceptualized as analogous to the “animal defensive reaction” of freezing in the face of predation, when fight/flight is impossible. Neurobiological studies have shown specific patterns of brain activation that differentiate dissociative posttraumatic reactions from “hyperaroused” forms of PTSD. This article provides a brief overview of the etiology, comorbidity, prevalence, clinical features, differential diagnosis, and treatment of dissociative disorders.
CATEGORY
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CREDITS: 1.5
RELEASE DATE: October 20, 2010
EXPIRATION DATE: Oct ober 20, 2011
FACU LTY
Bethany Brand, PhD, Department of Psychology,
Towson University,
Tow so n, M ar yl an d
Richard J. Loewenstein, MD, Department of Psychiatry,
University of Maryland School of Medicine,
Baltimore, Maryland
Sheppard Pratt Health System,
Tow so n, M ar yl an d
FACU LTY DIS CLOSU RES
Drs Brand and Loewenstein report no conflicts of interest
concerning the subject matter of this article.
This activity has been independently reviewed for balance.
TARG ET AU DIENCE
This continuing medical education activity is intended
for psychiatrists, psychologists, primary care physicians,
nurse practitioners, and other health care professionals
who seek to improve their care for patients with mental
health disorders.
GOAL STATEMENT
This activity will provide participants with education on the
etiology, comorbidity, prevalence, clinical features, differ-
ential diagnosis, and treatment of dissociative disorders.
ESTIMATED TIME TO COMPLETE
The activity in its entirety should take approximately 90
minutes to complete.
LEARNING OBJECTIVES
After completing this activity, participants should be able to:
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dissociative disorder and distinguish between
different types of the disorder
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their patients
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by Bethany Brand, PhD and
Richard J. Loewenstein, MD
Dr Brand is professor in the department of psychology
of Towson University in Towson, Md; Dr Loewenstein
is medical director of the Trauma Disorders Program at
Sheppard Pratt Health System in Towson, Md, and
associate clinical professor of psychiatry and behav-
ioral sciences at the University of Maryland School of
Medicine in Baltimore.
Dissociation is a process that provides
protective psychological containment
of, detachment from, and even physi-
cal analgesia for overwhelming expe-
riences, usually of a traumatic or stressful nature.
Dissociation is conceptualized as analogous to
the “animal defensive reaction” of freezing in the
face of predation, when fight/flight is impossi-
ble.1 Neurobiological studies have shown spe-
cific patterns of brain activation that differentiate
dissociative posttraumatic reactions from hyper-
aroused forms of posttraumatic stress disorder
(PTSD).
This article provides a brief overview of the
etiology, comorbidity, prevalence, clinical fea-
tures, differential diagnosis, and treatment of dis-
sociative disorders.
CAUSES AND COMORBIDITIES
Dissociation is defined in DSM-IV-TR2 as a dis-
ruption of the usually integrated functions of the
following:
 &RQVFLRXVQHVVHJWUDQFHVWDWHVQRQHSLOHSWLF
seizures, pseudodelirium)
 0HPRU\HJLPSDLUPHQWRIDXWRELRJUDSKLFDO
memory: dissociative amnesia)
 $ZDU H Q H V V RIERG\DQGRUVHOIGHSHUVRQDOL]D-
tion, eg, feeling numb, watching self from a
distance as if in a movie)
 $ZDU H Q H V V RIHQYLURQPHQWGHUHDOL]DWLRQHJ
world appears far away or “foggy”; familiar
places/people seem unfamiliar or strange; tun-
nel vision)
 ,GHQWLW\HJFRQIXVLRQDERXWRQH·VLGHQWLW\
experiencing discrete and discordant behav-
ioral states referred to as “identities”)2
One of the strongest predictors of dissociation
is antecedent trauma, particularly early childhood
trauma and difficulties with attachment and pa-
rental unavailability.3-6 The evidence for a rela-
tionship between dissociation and many types of
trauma is robust and has been validated across
cultures in clinical and nonclinical samples using
both cross-sectional and longitudinal methodolo-
gies as well as in large population studies and in
well-designed prospective, longitudinal studies.
C!4EGORY 1
63
PSYCHIATRIC TIMES
OCTOBER 2010
Exposure to multiple types of trauma over
multiple developmental epochs is associated
with a wide range of clinical problems that have
been organized into the construct of complex
PTSD.3,5,7-9 These include the following:
 $IIHFWLYHG\VUHJXODWLRQQXPEQHVVGLVVRFLD-
tion alternating with hyperarousal and emo-
tional flooding; problems with anger, anxiety,
shame)
 %HKDYLRUDOG\VUHJXODWLRQLPSXOVLYHVHOI
destructive, and aggressive behavior; sub-
stance abuse; high-risk behaviors)
 ,GHQWLW\SUREOHPVLQFOXGLQJFRPSDUWPHQ
talization of self and/or self-fragmentation,
difficulties with body image, and eating
disorders
 'LVUXSWLRQLQPHDQLQJHJVHHLQJWKHZRUOGDV
traumatizing and untrustworthy and the self as
damaged and blameworthy for trauma)
 ,QWHUSHUVRQDOSUREOHPVDYRLGDQFHRIUHODWLRQ-
ships; tumultuous attachments; violent, abu-
sive relationships)
 6RPDWL]DWLRQDQGVRPDWRIRUPGLVRUGHUVLQ-
cluding high-risk behaviors and multiple health
problems, such as heart disease, liver disease,
pulmonary diseases, autoimmune disorders,
chronic fatigue syndrome, gastroesophageal
reflux disease, irritable bowel syndrome, head-
aches, smoking, early and multiple pregnan-
cies, morbid obesity, and sexually transmitted
diseases, among others.10,11
Many patients with dissociative disorder also
fit the complex PTSD construct. Epidemiological
studies have found that mood, somatoform, and
non-PTSD anxiety disorders and substance abuse
are commonly associated with antecedent trau-
ma, as is PTSD.3,12$FFRUGLQJO\WKHVHDUHDOOFRP-
mon comorbidities of patients with dissociative
disorders.
Recent research suggests that a predominantly
dissociative, hypoemotional subtype of PTSD is
distinguishable from a predominantly hyper-
aroused, hyperemotional subtype.12,13 This dis-
tinction has important implications because of
differences in etiology, clinical and neurobiolog-
ical features, and response to treatment (Tab le 1 ).
Many patients with the dissociative subtype of
PTSD will meet DSM-IV-TR criteria for a dis-
sociative disorder.
Specifically, neurobiological and neuroimag-
ing studies in clinical and nonclinical samples
that included patients with PTSD, depersonal-
ization disorder, and dissociative amnesia, as
well as healthy cohorts involved in memory sup-
pression/retrieval studies have shown a specific
pattern of findings.13 These findings include, in
clinical subjects, increased activation of brain
regions involved in arousal/emotional modula-
tion/regulation, such as the dorsal anterior cingu-
late cortex and medial prefrontal cortex in re-
sponse to specific personalized trauma scripts,
and/or in facial emotional recognition tasks. In
turn, these dissociative responses in PTSD popu-
lations, as well as in memory suppression in dis-
sociative amnesia patients and normal subjects,
are associated with decreased activation of the
amygdala, insular cortex, and hippocampus, re-
spectively. This contrasts with more typical hy-
peraroused PTSD patients who, in response to
traumatic reminders and/or masked fearful faces,
show decreased activation of medial anterior
brain regions involved in arousal/emotional
modulation/regulation (eg, the ventromedial pre-
frontal cortex and rostral anterior cingulate cor-
tex) and increased activation of the limbic sys-
tem, particularly the amygdala.
PREVALENCE OF
DISSOCIATIVE DISORDERS
DSM-IV-TR identifies 5 dissociative disorders:
dissociative amnesia, dissociative fugue, deper-
sonalization disorder, dissociative identity disor-
der, and dissociative disorder not otherwise spec-
ified (DDNOS). Epidemiological studies of
dissociative disorder have been conducted in the
8QLWHG6WDWHV&DQDGDWKH1HWKHUODQGV*HUPD-
Q\6ZLW]HUODQG)LQODQG&KLQDDQG7XUNH\
Dissociative amnesia is typically found to be
the most prevalent dissociative disorder in gen-
eral population studies, with a prevalence of up to
3%.14 The preva lence of de perso nalizati on disor-
der is estimated to be between 1% and 2%.
DDNOS tends to be the most prevalent dissocia-
tive disorder found in clinical studies, with a
prevalence of about 9.5% in both inpatient and
RXWSDWLHQWVDPSOHV$FURVVJHQHUDOSRSXODWLRQ
studies, the most severe dissociative disorder,
dissociative identity disorder (formerly multiple
personality disorder) has a prevalence of approx-
imately 1% and has been found in 1% to 20% of
psychiatric inpatients and outpatients, depending
on the sample.
CLINICAL FEATURES
Depersonalization disorder
Depersonalization can involve feeling robotic,
unreal and/or estranged, or detached or discon-
QHFWHGIURPRQH·VVHOI7KHV\PSWRPVRIGHSHU-
sonalization can be found in persons with a range
of disorders, and also in normal adolescents, and
they can be caused by substance abuse.2,15 The
typical age at onset of depersonalization disorder
is in adolescence or early adulthood, and it can be
acute or insidious.15$SSUR[LPDWHO\WZRWKLUGVRI
patients with depersonalization disorder have a
chronic course. In addition to feeling severely
depersonalized/derealized, many patients report
impairments in attention, memory, and occupa-
tional and interpersonal function.15,16
$OWKRXJKFRPRUELGPRRGDQGDQ[LHW\DUH
common, both of these disorders usually follow
the onset of depersonalization and do not predict
the severity of depersonalization disorder symp-
toms. Depersonalization disorder symptoms do
not respond to typical treatments for mood/anxi-
ety disorders. Patients with depersonalization
disorder report having experienced significantly
more childhood trauma, particularly emotional
abuse, than controls. Reports of emotional abuse
uniquely predict depersonalization severity.
Simeon and colleagues17 found that severe stress
or later-life traumatic stressors are associated
with the onset of depersonalization disorder in
25% of all cases.In placebo-controlled trials,
patients with depersonalization disorder did not
respond to fluoxetine and lamotrigine.15
Simeon15 hypothesized that there is a severity
(Please see Dissociative Disorders, page 64)
Typical differences between dissociative,
hypoemotional and hyperaroused,
hyperemotional PTSD12,41
Dissociative subtype Hyperaroused subtype
Etiology
Likely to be more severe, chronic, repeated, Likely to be later-occurring trauma and/or
usually childhood and adult trauma less cumulative trauma
Likely response when presented with traumatic narrative or triggers
Dissociation, numbing; decreased, blunted Terror; increased autonomic arousal: increased
autonomic arousal: decreased heart rate, heart rate, rapidly increased cortisol level,
delayed cortisol release, decreased skin increased skin conductance; brain areas
conductance; brain areas activated that activated that may undercontrol emotion
may overcontrol emotion and alter sense
of self (eg, MPFC)
Psychotherapy
Requires staged approach emphasizing Exposure therapy or cognitive processing
safety, stabilization, alliance-building, therapy after brief stabilization
and symptom management preceding
exploration of traumatic memories/modified
exposure therapy
Medication
None specifically targeting dissociation; FDA-approved for PTSD: sertraline, paroxetine
medication may be used to stabilize
PTSD and other comorbid conditions,
such as depression
PTSD, posttraumatic stress disorder; MPFC, medial prefrontal cortex.
Table 1
spectrum of dissociative symptoms (although not
necessarily of impairment). Depersonalization
disorder represents a “milder” end of the contin-
uum, and dissociative identity disorder, which is
associated with more extreme forms of early
trauma, represents the “more severe” end of the
continuum.
Dissociative amnesia
Patients with dissociative amnesia are unable to
recall important autobiographical information,
usually of a traumatic or stressful nature, that is
inconsistent with ordinary forgetfulness.2 This
memory impairment is caused by a reversible
psychological inhibition, rather than organic fac-
tors. Often the dissociated memories intrude in
disguised forms, such as nightmares, flashbacks,
or conversion symptoms.2 The ability to learn
new information remains intact, as does general
cognitive functioning.
There are 2 presentations of dissociative am-
nesia. The first is frequently portrayed in text-
books and media accounts: the patient experi-
ences sudden, dramatic amnesia involving
extensive aspects of personal information, often
with disorientation, confusion, alterations in con-
sciousness, and/or wandering.2 Such patients
often present in emergency departments or in in-
patient medical or neurology units.
The second presentation is more common but
receives less attention because patients do not
VSRQWDQHRXVO\UHSRUWGLVVRFLDWLYHDPQHVLD$
careful history will show lack of recall for sig-
nificant aspects of the life history. This type of
dissociative amnesia usually has a clear onset
and offset, and the patient is aware of a gap in
memory. For example, a patient may not recall
being in junior high school despite memory for
the other years of school. Dissociative amnesia
has been documented for traumatic experiences,
LQFOXGLQJFRPEDWWKH1D]LDQG&DPERGLDQKR-
locausts; and sexual, physical, and emotional
abuse or assault.2,18 Many patients with dissocia-
tive amnesia have a history of depression and
suicidal ideation.
Predisposing factors may include a history of
personal or familial somatoform or dissociative
symptoms, and/or growing up with a rigid family
moral code enforced with harsh discipline. Dis-
sociative amnesia may be related to avoidance of
responsibility associated with sexual behavior or
legal or financial difficulties; fear of combat; or
avoidance of massively stressful situations or in-
tolerable conflicting emotions, including shame,
rage, desperation, despair, and intolerable urges
(eg, sexual, suicidal, violent).
Most cases of the classic dissociative amnesia
resolve within days or months, spontaneously or
through psychotherapy or hypnotherapy. The
second type of dissociative amnesia resolves
only in the course of overall psychotherapy for
complex PTSD.2%HFDXVHGLVVRFLDWLYHIXJXHLV
thought to occur only in the course of dissociative
amnesia or dissociative identity disorder, it is
likely to be removed from DSM-5 as a separate
disorder.
64 PSYCHIATRIC TIMES OCTOBER 2010
C!4EGORY 1
Dissociative Disorders
Continued from page 63
Office mental status interview for assessing dissociation
Blackout/time loss
s $O YOU ever have blackouts, blank spells, memory lapses?
s $O YOU LOSE TIME
Disremembered behavior
s $O You find evidence that you have said and done things that you do not recall?
s $O PEOPLE TELL YOU OF BEHAVIOR YOU HAVE ENGAGED IN THAT YOU DO NOT RECALL
Fugues
s $O YOU EVER FIND yourself in a place and not know how you got there?
Unexplained possessions
sDo you find objects in your possession (eg, clothes, groceries, books) that you do not remember acquiring?
Out-of-character items? Items a child might have?
s $O YOU FIND THAT OBJECTS DISAPPEAR FROM YOU IN WAYS FOR WHICH YOU CANNOT ACCOUNT
s $O YOU FIND WRITINGS DRAWINGS OR ARTISTIC PRODUCTIONS IN YOUR POSSESSION THAT YOU MUST HAVE CREATED BUT DO
not recall creating?
Changes in relationships
s $O YOU find that your relationships with people frequently change in ways that you cannot explain?
Fluctuations in skills/habits/knowledge
s $O YOU FIND THAT SOMETIMES YOU CAN DO THINGS WITH AMAZING EASE THAT SEEM MUCH MORE DIFFICULT OR
impossible at other times?
s $OES YOUR TASTE IN FOOD MUSIC OR PERSONAL HABITS SEEM TO FLUCTUATE
s $OES YOUR HANDWRITING CHANGE FREQUENTLY ! LITTLE ! LOT #HILDLIKE
s !RE YOU RIGHTHANDED OR LEFTHANDED $OES IT FLUCTUATE
Fragmentary recall of life history
s $O YOU HAVE Gaps in your memory of your life? Missing parts of your memory of your life history?
s $O YOU REMEMBER YOUR CHILDHOOD 7HEN DO THOSE MEMORIES START &IRST MEMORY .EXT .EXT
Intrusion/overlap/interference (passive influence)
s $O You have thoughts or feelings that come from inside or outside you that don’t feel like yours?
Are outside your control?
s $O YOU HAVE IMPULSES OR ENGAGE IN BEHAVIORS THAT DONT SEEM TO BE COMING FROM YOU
s $O YOU HEAR VOICES SOUNDS OR CONVERSATIONS IN YOUR MIND
Negative hallucinations
s $O YOU EVER not see/hear what’s going on around you? Can you block out people or things altogether?
Analgesia
s !RE YOU ABLE TO block OUT PHYSICAL PAIN 7HOLLY 0ARTLY !LWAYS 3OMETIMES
Depersonalization/derealization
s $O YOU FREQUENTLY HAVE THE EXPERIENCE OF FEELING AS IF YOU ARE OUTSIDE YOURSELF OR WATCHING YOURSELF AS IF YOU
were another person?
s $O YOU EVER FEEL DISCONNECTED FROM YOURSELF OR AS IF YOU WERE UNREAL
s $O YOU EXPERIENCE THE WORLD AS UNREAL !S IF YOU ARE IN A FOG OR DAZE
s $O YOU EVER LOOK IN THE MIRROR AND NOT RECOGNIZE YOURSELF
Trauma
s 7HO MADE THE RULES IN YOUR FAMILY AND HOW WERE THEY ENFORCED
s $ID YOU WITNESS VIOLENCE BETWEEN FAMILY MEMBERS
s (AVE YOU EVER HAD UNWANTED SEXUAL CONTACT WITH ANYONE !S A CHILD 4EENAGER !DULT
s !S A CHILD WHAT MADE YOU FEEL SAFE 7AS ANYONE KIND TO OR SUPPORTIVE OF YOU
s &LASHBACKS INTRUSIVE SYMPTOMS SIGHT SOUND TASTE SMELL TOUCH $O YOU EVER EXPERIENCE EVENTS
that happened to you before as if they are happening now?
s .IGHTMARES HOW OFTEN SINCE WHEN $O YOU AWAKEN DISORIENTED &IND YOURSELF SOMEWHERE ELSE
s !RE THERE SPECIFIC PEOPLE SITUATIONS OR OBJECTS THAT TRIGGER YOU !RE THESE ASSOCIATED WITH TIME LOSS
s !RE YOU A JUMPY PERSON %ASILY STARTLED
s $O YOU AVOID PEOPLE SITUATIONS OR THINGS THAT REMIND YOU OF TRAUMATIC OR OVERWHELMING EVENTS
Can you block out feelings?
Somatoform symptoms
s $O YOU EVER GET physical symptoms/pain that your doctors can’t medically explain?
Adapted with permission from Loewenstein RJ. Psychiatr Clin North Am. 1991.25
Table 1
65
PSYCHIATRIC TIMES
OCTOBER 2010
Dissociative identity
disorder and DDNOS
Extensive literature exists on the diagnosis, phe-
nomenology, etiology, epidemiology, and treat-
PHQWRIGLVVRFLDWLYHLGHQWLW\GLVRUGHU%HFDXVH
presenting symptoms, history, clinical course,
and treatment response are similar in patients
with DDNOS and dissociative identity disorder,
the two are combined here.2
Dissociative identity disorder is conceptual-
ized as a childhood onset, posttraumatic develop-
mental disorder in which the child is unable to
consolidate a unified sense of self. Detachment
from emotional and physical pain during trauma
can result in alterations in memory encoding and
storage. In turn, this leads to fragmentation and
compartmentalization of memory and impair-
ments in retrieving memory.2,4,19 Exposure to
early, usually repeated trauma results in the cre-
ation of discrete behavioral states that can persist
and, over later development, become elaborated,
ultimately developing into the alternate identities
of dissociative identity disorder.
%HFDXVHRIPHGLDSRUWUD\DOVFOLQLFLDQVPD\
believe that dissociative identity disorder pre-
sents with dramatic, florid alternate identities
with obvious state transitions (switching). These
florid presentations occur in only about 5% of
patients with dissociative identity disorder.20
How ever, the vast majority of these patients
have subtle presentations characterized by a
mixture of dissociative and PTSD symptoms
embedded with other symptoms, such as post-
traumatic depression, substance abuse, somato-
form symptoms, eating disorders, and self-
destructive and impulsive behaviors.2,10$KLVWRU\
of multiple treatment providers, hospitaliza-
tions, and good medication trials, many of which
result in only partial or no benefit, is often an
indicator of dissociative identity disorder or an-
other form of complex PTSD.10
Dissociative disorder experts focus less on
overt personality states than on the polysymp-
tomatic presentation of dissociative identity dis-
order.14 Some studies show that the phenomeno-
logical experience of overlap/interference/intru-
VLRQVEHWZHHQDOWHUQDWHLGHQWLWLHVLQWRSDWLHQWV·
consciousness—which can be misdiagnosed as
psychotic passive influence or Schneiderian first-
rank symptoms—is more common in dissocia-
tive identity disorder than overt switching.
$VVHVVPHQWRIWKHVHLQWUXVLRQVLQWKHFOLQLFDO
interview is useful in the differential diagnosis. In
several studies, patients with dissociative identity
disorder experienced more apparent first-rank
symptoms, although not thought broadcasting or
audible thoughts, than did patients who had
schizophrenia.21-23 These intrusions into con-
sciousness include those that are partially exclud-
ed from consciousness (eg, “hearing” voices of
identities, thought insertion/withdrawal, “made”
actions/impulses) and those that are fully exclud-
ed from consciousness (eg, time loss, fugues,
being told of disremembered behaviors).14,23
DIFFERENTIAL DIAGNOSIS
Making the diagnosis of a dissociative disorder
can be challenging because patients rarely volun-
teer information about dissociative symptoms or
their histories of trauma. Furthermore, most clini-
cians have not been trained to assess dissociation.
Unless a patient is asked about trauma history
and dissociation, the clinician will not be able to
accurately diagnose trauma-related disorders, in-
FOXGLQJGLVVRFLDWLYHGLVRUGHU$WWLPHVDVDIH
collaborative relationship must be developed be-
fore asking about these private and often sub-
MHFWLYHO\VKDPHIXOH[SHULHQFHV%UDQGDQGFRO-
leagues24 have reported that patients with dis -
sociative disorder are often reluctant to report
experiences that they are aware sound crazy and
that they tend to avoid confronting.
Loewenstein25 has detailed an office mental
status examination for assessing dissociative
symptoms (Table 2 presents an abridged ver-
sion). It reviews a wide variety of dissociative,
posttraumatic, affective, and somatic symptoms
as well as trauma exposure. Interviews sugges-
tive of dissociative disorders can be supplement-
ed with data from dissociative screening instru-
ments and structured interviews (Ta bl e 3 ).
There are several self-report screening mea-
sures for dissociation. The most widely used is
the Dissociative Experiences Scale (DES).26 The
DES has been used in more than 1000 studies and
translated into more than 40 languages. The DES
has 28 items that assess amnesia, absorption,
identity alteration, and depersonalization/dereal-
ization. Patients rate how much of the time they
experience symptoms, ranging from 0% to 100%,
DQGDQDYHUDJHVFRUHLVFDOFXODWHG$QDYHUDJH
score of 30 or higher has an 85% hit rate for se-
vere dissociative disorders, such as dissociative
identity disorder and related forms of DDNOS.
However, lower scores can also be found in pa-
tients with dissociative disorder.
Screening instruments must be interpreted in
the clinical context and are not a substitute for
clinical judgment in the diagnosis of dissociative
disorders or any other clinical diagnosis. The
Multidimentional Inventory of Dissociation
(MID) is a self-report, diagnostic assessment test
that measures partial and full pathological disso-
ciation.22$GGLWLRQDOLQIRUPDWLRQRQWKHDVVHVV-
ment of dissociation in adults and children is
C!4EGORY 1
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 WWWISSTDORG
s $%3 TAXON CALCULATOR AVAILABLE AT WWWISSTDORGEDUCATIONDESTAXONPORTALHTM
Multidimensional Inventory of Dissociation (MID)22 s !VAILABLE FREE FROM AUTHOR AT 0FDELL AOLCOM
s !VAILABLE FREE TO )334$ MEMBERS AT WWWISSTDORG
Somatoform Dissociation Questionnaire (SDQ)42 s !VAILABLE FREE TO )334$ MEMBERS AT WWWISSTDORG
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 WWWROSSINSTCOMSAMPLE?FORMSHTML
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 adults6s !VAILABLE FREE AT WWWISSTDORG
and for children and adolescents27
Table 3
(Please see Dissociative Disorders, page 66)
OCTOBER 2010
C!4EGORY 1
66 PSYCHIATRIC TIMES
Features that typically distinguish DID/DDNOS from borderline
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 persecutor y 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
Table 4
available.2,6,27 There are 2 DSM-IV-TR structured
interviews that can provide formal diagnoses of
GLVVRFLDWLYHGLVRUGHUWKH6WUXFWXUHG&OLQLFDO,Q-
terview for DSM-IV-TR Dissociative Disorders,
5HYLVHG6&,''5DQGWKH'LVVRFLDWLYH'LVRU-
ders Interview Schedule (DDIS).16,28
Dissociative identity disorder and severe
DDNOS are often confused with psychotic and
affective disorders as well as with borderline per-
sonality disorder. While they can be comorbid
with these disorders, they are not synonymous.
Distinguishing characteristics are presented in
Tab l e 4 to clar ify the differential diagno sis.
TREATMENT
Psychological treatment
The current standard of care is that treatment of
severe dissociative disorders involves a phasic,
multimodal, trauma-focused psychotherapy that
addresses the manifold dimensions of symp-
toms.6,29 There are no randomized clinical trials of
dissociative disorder to date and only 1 controlled
FDVHVWXG\%UDQGDQGFROOHDJXHV29 recently re-
viewed 16 dissociative disorder treatment out-
come studies and 4 case studies that used stan-
dardized measures. Data from these noncon-
trolled, observational trials showed that treatment
based on the above model was associated with
reductions in symptoms of dissociation, depres-
sion, general distress, anxiety, and PTSD. Some
studies found that treatment was associated with
decreased use of medications and improved work
and social functioning. Eight open inpatient and
outpatient studies provided sufficient data to be
included in a small meta-analysis. Effect sizes,
based on before and after within-patient mea-
sures, ranged from medium to large (Tab l e 5).
Treatment studies have primarily focused on
dissociative identity disorder; case series studies
suggest that one group was successfully treated to
full fusion or integration so that they no longer
PHWFULWHULDIRUGLVVRFLDWLYHLGHQWLW\GLVRUGHU$Q-
other group gradually showed a reduction in
symptoms, while a third group showed some im-
provement yet continued to be chronically ill.30
Nonrandomized open dissociative identity disor-
der treatment studies have found that hospitaliza-
tions that focus on trauma and/or dissociation are
associated with reductions in a range of symp-
C!4EGORY 1
67
PSYCHIATRIC TIMES
OCTOBER 2010
(Please see Dissociative Disorders, page 68)
Features that typically distinguish DID/DDNOS from borderline
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.
Table 4, cont'd
OCTOBER 2010
C!4EGORY 1
68 PSYCHIATRIC TIMES
toms, including depression, anxiety, a number of
$[LV,DQG$[LV,,GLDJQRVHVDQGGLVVRFLDWLRQ29,31
The first international, naturalistic, prospec-
tive study of dissociative identity disorder and
DDNOS treated by community therapists shows
LQLWLDOSURPLVLQJUHVXOWV&URVVVHFWLRQDOUHVXOWV
indicate that treatment is associated with a wide
range of improvements.32 Therapists (N = 292)
from around the world and one of their patients
with dissociative identity disorder or DDNOS
(N = 280) reported on a variety of variables, in-
cluding stage of therapy, symptoms, and level of
adaptive functioning. Patient and therapist re-
ports showed that the patients in the later stages
of treatment had fewer symptoms of dissociation,
PTSD, and general distress; fewer recent hospi-
talizations; and better adaptive functioning than
patients in the early stages of treatment.32 Pre-
liminary follow-up data extend these findings.33
Dissociative disorders are heterogenous disor-
ders with somewhat different treatment ap-
proaches. Detailed descriptions of treatment are
available and inform the brief overview that
follows.2,6,7,34-37
Phase-oriented treatment is the standard of
care for treating dissociative disorder and com-
plex trauma disorders. Three phases typify the
course of treatment, although aspects of each
phase may repeat throughout treatment.
Phase 1. The early exposure to trauma and
disruptions in attachment reported by many pa-
tients with dissociative disorder are frequently
reenacted in adulthood through self-injurious be-
haviors, suicide attempts, alcohol and drug abuse,
aggression toward others, and current abusive
relationships. Thus, the first phase of treatment
emphasizes the stabilization of safety issues. The
focus is on enhancing symptom control, contain-
ing affect and impulses, educating about trauma
treatment, and establishing a collaborative work-
ing relationship. This phase is often the longest
and is considered the most important. Some pa-
tients may remain in the first phase for years be-
cause of ongoing enmeshment in destructive re-
lationships, overinvestment in the dissociative
disorder, and/or debilitating psychiatric or medi-
cal comorbidity.
Phase 2. If the patient becomes sufficiently
stabilized, he or she may choose to move into the
second phase. It involves processing of traumatic
memories by exploring the meanings and impact
of traumatic experiences; identifying and resolv-
ing trauma-related cognitive distortions and re-
enactments; and expressing previously avoided
emotions, including grief, betrayal, terror, help-
lessness, rage, and shame. This process enables
patients to develop a coherent narrative of their
nontraumatic as well as traumatic experiences
and a sense of mastery over their memories. The
goal is to gain a sense of self-efficacy and an
identity that includes growth and strength.
Phase 3. In patients with dissociative identity
disorder, integration of personality states occurs
throughout the second and third phases. Phase 3
entails reintegration into life, in which the patient
integrates disowned aspects of self and focuses
increasingly on current and future life issues and
goals.38 Patients often develop deeper recognition
that earlier trauma and attachment difficulties
may have altered their development and health in
ways that cannot be fully overcome. Thus, the
SDWLHQW·VLQFUHDVLQJVHQVHRIIUHHGRPDQGFDOPLV
tempered by a fuller recognition of the conse-
quences of early trauma and related dysfunction.
Pharmacotherapy
Medication is not the primary treatment for dis-
sociative disorder or complex PTSD, although it
is commonly used to assist with stabilization and
to treat comorbid conditions.38 Medications typi-
cally result in partial improvement, so they are
best thought of as “shock absorbers” rather than
as curative.
Psychiatric medications should target the hy-
perarousal and intrusive symptoms of PTSD and
comorbid conditions such as affective disorders
and obsessive-compulsive symptoms (a surpris-
ingly common comorbidity to dissociative disor-
ders and complex PTSD).2,6,38 Patients with dis-
sociative disorder may have frequent symptom
and mood fluctuations; thus, experts recommend
DGMXVWLQJPHGLFDWLRQVWRDWWHQGWRWKHSDWLHQW·V
overall emotional climate rather than trying to
medicate the day-to-day psychological changes.
$SRRUPHGLFDWLRQUHVSRQVHGHVSLWHDGHTXDWH
trials of many different medications may provide
a clue that dissociative disorder should be as-
VHVVHG$IIHFWLYHV\PSWRPVDUHDPRQJWKHPRVW
responsive to medication in dissociative disorder,
although less robustly than in primary affective
disorders.2 Intrusions and hyperarousal symp-
toms of PTSD are often partially responsive to
medication.
&OLQLFLDQVUHSRUWVRPHVXFFHVVLQUHGXFLQJ
anxiety with the medications found useful for
PTSD; these include SSRI, tricyclic, and mono-
DPLQHR[LGDVHLQKLELWRU0$2,DQWLGHSUHVVDQWV
!-blockers; clonidine; prazosin; anticonvulsants;
and benzodiazepines.27ULF\FOLF0$2,DOO
SSRI/serotonin-norepinephrine reuptake inhibi-
tor antidepressants except paroxetine and sertra-
line; !-blockers; clonidine; prazosin; anticonvul-
sants; and neuroleptics may be used off-label for
WKHWUHDWPHQWRI376'$OWKRXJKQHXUROHSWLFV
are typically ineffective for apparent or pseudo-
psychotic symptoms, such as hearing voices, in
dissociative disorder, low doses—particularly of
the atypical neuroleptics—can be beneficial in
patients with severe anxiety, intrusive symptoms
of PTSD, and/or entrenched illogical thinking.2
THE COSTS OF
DISSOCIATIVE DISORDER
$QDWLRQZLGHVWXG\RIWKHXVHRIPHQWDOKHDOWK
services among wives of active-duty servicemen
found that those with dissociative disorders had a
higher number of mental health visits per person
than any other psychiatric disorder.39 Ke ssl er, 9 cit -
LQJGDWDIURPWKH1DWLRQDO&RPRUELGLW\6WXG\
estimated that the cost of PTSD is $40 to $50 bil-
lion per year and that the average duration of ac-
tive PTSD symptoms is more than 2 decades.
*LYHQWKDWGLVVRFLDWLYHGLVRUGHUVDUHW\SLFDOO\DV-
sociated with not only PTSD but also a variety of
other medical and psychiatric conditions, it is
likely that the cost of dissociative disorders and
the duration of symptoms are significantly higher
WKDQIRU376'DORQH&RVWHIIHFWLYHQHVVVWXGLHV
have shown a substantial reduction in costs over
time with the treatment model described above.40
In summary, dissociative disorders exact a
high social, psychological, and occupational cost
to patients, as well as a high economic cost to our
VRFLHW\$FFXUDWHGLDJQRVLVDQGWUHDWPHQWKDYH
been shown to reduce morbidity, cost, and mor-
tality in this severely ill patient population.
References
1. Nijenhuis ER, Vanderlinden J, Spinhoven P. Animal defensive reac-Nijenhuis ER, Vanderlinden J, Spinhoven P. Animal defensive reac-
tions as a model for trauma-induced dissociative reactions. J Trauma
Stress. 1998;11:243-260.
2. Simeon D, Loewenstein RJ. Dissociative disorders. In: Sadock BJ,
Sadock VA, Ruiz P, eds. Comprehensive Textbook of Psychiatry. Vol 1.
TH ED 0HILADELPHIA 7OLTERS +LUWER,IPPINCOTT 7ILLIAMS 7ILKENS
2009:1965-2026.
3. Gershuny BS, Thayer JF. Relations among psychological trauma,
dissociative phenomena, and trauma-related distress: a review and
integration. Clin Psychol Rev. 1999;1 9:631 -657.
4. 0UTNAM &7 Dissociation in Children and Adolescents: A Develop-
mental Perspective. New York : Guilf ord Pr ess; 1 997.
5. Schore AN. Attachment trauma and the developing right brain: ori-Schore AN. Attachment trauma and the developing right brain: ori-
gins of pathological dissociation. In: Dell PF, O’Neil JA, eds. Dissocia-
tion and the Dissociative Disorders: DSM-V and Beyond. New Yor k:
Routledge; 2009:107-141.
6. International Society for the Study of Dissociation. Guidelines for
Dissociative Disorders
Continued from page 67
Effect sizes for improvements associated
with treatment of dissociative disorders29
Effect size comparing pretreatment
Outcome and posttreatment data
Overall outcomes .71
Anxiety .94
Borderline personality disorder symptoms .95
Depression 1.12
Dissociation .70
General distress 1.09
Somatoform symptoms .83
Substance abuse symptoms .78
Table 5
69
PSYCHIATRIC TIMES
OCTOBER 2010
C!4EGORY 1
treating dissociative identity disorder in adults (2005). J Trauma Dis-
sociation. 200 5;6:69 -149.
7. Courtois CA, Ford JD, eds. Tr ea ti ng Co mp le x Tr au ma ti c Str es s Di s-
orders: An Evidence-Based Guide. Ne w York: Gui lford Press ; 2009 .
8. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood
abuse and household dysfunction to many of the leading causes of
death in adults. The Adverse Childhood Experiences (ACE) Study. Am J
Prev Med. 1998 ;14:24 5-258 .
9. +ESSLER 2# 0OSTTRAUMATIC STRESS DISORDER THE BURDEN TO THE INDI+ESSLER 2# 0OSTTRAUMATIC STRESS DISORDER THE BURDEN TO THE INDI-
vidual and to society. J Clin Psychiatry. 2000;61(suppl 5):4-14.
10. Dell PF, O’Neil JA, eds. Dissociation and the Dissociative Disorders:
DSM-V and Beyond. New York : Routl edge; 2009.
11. $UBE 32 &AIRWEA THER $ 0EARSON 73 ET AL #UMULATIVE CHILDHOOD
stress and autoimmune diseases in adults. Psychosom Med. 2009;
71:243-250.
12. Lanius RA, Vermetten E, Loewenstein RJ, et al. Emotion modulation
in PTSD: clinical and neurobiological evidence for a dissociative sub-
type. Am J Psychiatry. 2010;1 67:64 0-647 .
13. 'INZBURG+ +O OPMAN # "UTLER ,$ ET AL %VIDENCE FOR ADISSOCIATIVE
subtype of post-traumatic stress disorder among help-seeking child-
hood sexual abuse survivors. J Trauma Dissociation. 2006; 7:7-2 7.
14. Dell PF. The long struggle to diagnose multiple personality disorder
(MPD): MPD. In: Dell PF, O’Neil JA, eds. Dissociation and the Dissocia-
tive Disorders: DSM-V and Beyond. New Yor k: Rou tledge ; 200 9:383 -
402.
15. Simeon D. Depersonalization disorder. In: Dell PF, O’Neil JA, eds.
Dissociation and the Dissociative Disorders: DSM-V and Beyond. New
Yor k: Ro ut led ge ; 20 09 :43 5- 44 4.
16. Steinberg M. Interviewer’s Guide to the Structured Clinical Inter-
view for DSM-IV Dissociative Disorders—Revised (SCID-D-R). 2nd e d.
7ASHINGTO N $#!MERICAN 0SYCHIATRIC 0RESS 
17. 3IMEON $ +NUTELSKA - .ELSON $ 'URALNIK / &EELING UNREAL A
depersonalization update of 117 cases. J Clin Psychia try. 2003;64:
990-997.
18. Loewenstein RJ. Dissociative amnesia and dissociative fugue. In:
-ICHELSON ,+ 2AY 7* EDS Handbook of Dissociation: Theoretical,
Empirical, and Clinical PerspectivesND ED .EW 9ORK (ARPER AND
Row; 1996:307-336.
19. Spiegel D, Cardeña E. Disintegrated experience: the dissociative
disorders revisited. J Abnorm Psychol. 199 1;100 :366- 378.
20. +LUFT 20 4HE NATURAL HISTORY OF MULTIPLE PERSONALITY DISORDER)N
+LUFT 20ED Childhood Antecedents of Multiple Personality7ASHI NG-
ton, DC: American Psychiatric Association; 1985:197-238.
21. +LUFT 20&IRST RANK SYMPTOMS AS ADIAGNOSTIC CLUE TO MULTIPLE PER+LUFT 20&IRST RANK SYMPTOMS AS ADIAGNOSTIC CLUE TO MULTIPLE PER-
sonality disorder. Am J Psychiatry. 1987;144:293-298.
22. Dell PF. The Multidimensional Inventor y of Dissociation (MID): a
comprehensive measure of pathological dissociation. J Trauma Dis-
sociation. 2006;7:77-106.
23. Ross CA, Miller SD, Reagor P, et al. Schneiderian symptoms in
multiple personality disorder and schizophrenia. Compr Psychiatr y.
1990;31:111-118.
24. Brand BL, Armstrong JG, Loewenstein RJ. Psychological assess-Brand BL, Armstrong JG, Loewenstein RJ. Psychological assess-
ment of patients with dissociative identity disorder. Psychiatr Clin
North Am. 2006;29:145-168, x.
25. Loewenstein RJ. An office mental status examination for complex
chronic dissociative symptoms and multiple personality disorder. Psy-
chiatr Clin North Am. 1991;14:567-604.
26. "ERNSTEIN %- 0UTNAM &7 Development, reliability, and validity of
a dissociation scale. J Nerv Ment Dis. 1986;174:727-735.
27. 3ILBERG * 7ATERS & .EMZER % ET AL 'UIDELINES FOR THE ASSESSMENT
and treatment of dissociative symptoms in children and adolescents.
J Trauma Dissociation. 20 04;5: 119-15 0.
28. Ross CA. Dissociative Identity Disorder: Diagnosis, Clinical Fea-
tures, and Treatment of Multiple Personality.EW 9OR K *OHN 7ILEY
Sons; 1997.
29. "RAND ", #LASSEN ## -C.ARY 37 :AVERI 0 !REVIEW OF DISSOCIA"RAND ", #LASSEN ## -C.ARY 37 :AVERI 0 !REVIEW OF DISSOCIA-
tive disorders treatment studies. J Nerv Ment Dis. 2009;197:646-654.
30. +LUFT 20 4REATMENT TRAJECTORIES IN MULTIPLE PERSONALITY DISORDER
Dissociation. 199 4;7:63 -76.
31. %LLASON *7 2OSS #! 4W OYE AR FOLLOWUP OF INPATIENTS WITH DISSO%LLASON *7 2OSS #! 4W OYE AR FOLLOWUP OF INPATIENTS WITH DISSO-
ciative identity disorder. Am J Psychiatry. 1997;154:832-839.
32. Brand BL, Classen CC, Lanius R, et al. A naturalistic study of dis-Brand BL, Classen CC, Lanius R, et al. A naturalistic study of dis-
sociative identity disorder and dissociative disorder not otherwise
specified patients treated by community clinicians. Psychol Trauma.
2009;1:153-171.
33. Brand BL, Classen CC, Lanius R, et al. Treatment outcome of dis-Brand BL, Classen CC, Lanius R, et al. Treatment outcome of dis-
sociative disorders patients: cross sectional and longitudinal results of
the TOP DD Study. Presented at: the Annual International Society for
the Study of Trauma and Dissociation Conference; November 2008;
Chicago.
34. Chu JA. Rebuilding Shattered Lives: The Responsible Treatment of
Complex Post-Traumatic and Dissociative Disorders. New York: John
7ILEY 3ONS )NC 
35. +LUFT 20 !N OVERVIEW OF THE PSYCHOTHERAPY OF DISSOCIATIVE IDENTITY
disorder. Am J Psychother. 1999;53:289-319.
36. +LUFT 20 ,OEWENSTEIN 2* $ISSOCIATIVE DISORDERS AND DEPERSONAL+LUFT 20 ,OEWENSTEIN 2* $ISSOCIATIVE DISORDERS AND DEPERSONAL-
ization. In: Gabbard GO, ed. Gabbard’s Treatment of Psychiatric Disor-
ders. TH ED 7ASH INGTON $# !MERICAN 0SYCHIA TRIC 0RESS 
572.
37. (ERMAN *, Trauma and Recovery: The Aftermath of Violence—
From Domest ic Abuse to Political Terror. Ne w York: Basi c Books ; 1992.
38. Loewenstein RJ. Psychopharmacologic treatments for dissociative
identity disorder. Psychiatr Ann. 2005;35:666-673.
39. -ANSFIELD!* +AUFMAN *3 -ARSHALL 37ET AL $EPLOYMENT AND THE
use of mental health services among U.S. Army wives. N Engl J Med.
2010;362:101-109.
40. Loewenstein RJ. Diagnosis, epidemiology, clinical course, treat-Loewenstein RJ. Diagnosis, epidemiology, clinical course, treat-
ment, and cost effectiveness of treatment for dissociative disorders
and MPD: report submitted to the Clinton administration task force on
health care financing reform. Dissociation. 1994;7:3-11.
41. Vermetten E, Dorahy MJ, Spiegel D. Tra um at ic D iss oc ia ti on : N eu -
robiology and Treatment. Arlingt on, VA: American Psychiatric Publish-
ing, Inc; 2007.
42. Nijenhuis ER, Spinhoven P, Van Dyck R, et al. The development and
psychometric characteristics of the Somatoform Dissociation Ques-
tionnaire (SDQ-20). J Nerv Men Dis. 199 6;184:688 -694.
43. "RIERE * 7EAT HERS &72UNTZ - )S DISSOCIATION AMULTIDIMENSION"RIERE * 7EA THERS &72UNTZ - )S DISSOCIATION AMULTIDIMENSION-
al construct? Data from the Multiscale Dissociation Inventory. J Trau-
ma Stress. 2005;18:221-231.
44. "RAND ", !RMSTRONG *' ,OEWENSTEIN 2* -C.ARY 370E RSONALI TY
differences on the Rorschach of dissociative identity disorder, border-
line personality disorder and psychotic inpatients. Psychol Trauma.
2009;1:188-205.
45. Boon S, Draijer N. The differentiation of patients with MPD or
DDNOS from patients with a cluster B personality disorder. Dissocia-
tion. 1993;6:126-135.
46. 0UTNAM &7 #ARLSON %" 2OSS #! ET AL 0ATTERNS OF DISSOCIATION
in clinical and nonclinical samples. J Nerv Men Dis. 1996;184:
673-679.
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1. In DSM-IV-TR, dissociation is defined as a disruption of the
usually integrated functions of which of the following:
A. Consciousness
B. Memory
C. Identity
D. All of the above
E. None of the above
 7HICH OF THE FOLLOWING IS ASTRONG PREDICTOR OF DISSOCIA TION
A. Early childhood trauma
B. Chronic depression
C. A first-degree biological relative with a psychotic disorder
E. All of the above
F. N o n e o f t he a b o v e
 7HICH OF THESE ARE FREQUENTLY COMORBID WITH DISSOCIATIVE
disorder?
A. Depression
B. Somatoform disorders
C. Substance abuse
D. All of the above
E. None of the above
 (OW MANY DISSOCIATIVE DISORDERS ARE IDENTIFIED IN
DSM-IV-TR?
A. 2
B. 5
C. 7
D. 10
5. Feeling detached or disconnected from one’s self describes
which of the following dissociative disorders?
A. Depersonalization disorder
B. Dissociative amnesia
C. Dissociative identity disorder
D. None of the above
6. Presenting symptoms, clinical course, and treatment
response are similar in dissociative identity disorder and
depersonalization disorder.
A. True
B. False
7. Dissociative identity disorder almost always presents
with dramatic, florid alternate identities with obvious state
transitions.
A. True
B. False
 7HAT IS OF FOREMOST IMPORTANCE IN BEING ABLE TO DIAGNOSE A
dissociative disorder in a patient?
A. An office mental state examination for assessing
dissociative symptoms
B. Self-report screening measures
C. A safe, collaborative relationship between patient
and clinician
D. All of the above
E. None of the above
9. A phasic, multimodal, trauma-focused psychotherapy is the
standard of care for severe dissociative disorders.
A. True
B. False
10. Although neuroleptics are typically ineffective for apparent
or pseudopsychotic symptoms, in dissociative disorder low
doses can be beneficial in which of the following cases:
A. Severe anxiety
" (EARING VOICES
C. Entrenched illogical thinking
D. B and C
E. A and C
10001101
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    • Had one of the vignettes depicted adultonset trauma, greater variation in treatment approach (exposure vs. phased) may have been evident. Given that dissociation is more likely after earlyonset than adult-onset trauma (Brand & Loewenstein, 2010), therapists may be more likely to prefer exposure therapy for adult-onset trauma and phased treatment for childhood relational trauma, notwithstanding the presence of dissociative symptoms. Such preferences, and their relationship to clinical outcome studies, require further investigation.
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    [Show abstract] [Hide abstract] ABSTRACT: Dissociative experiences are common among children and adults, ranging from normative to pathological frequency and severity. This chapter details important aspects of dissociation following traumatic experiences , including empirical support for the trauma model of dissociation, psychobiological processes involved in dissociative experiences, and the presence of both dissociative symptomatology and dissociative disorders in patients diagnosed with post-traumatic stress disorder. Additionally, the authors discuss the complexities of conducting trauma treatment with dissociative individuals, including differential diagnosis and treatment approaches grounded in current treatment outcome research. Finally, key points to further inform readers about assessment and treatment of dissociative disorders are included at the conclusion of the chapter.
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    • Emptiness, a hallmark symptom of BPD, is less typical in DID. Finally, compared to schizophrenia, DD patients recognize that voices they hear are not heard by others; their voices often sound like abusers or hurt children (Brand and Loewenstein 2010).
    [Show abstract] [Hide abstract] ABSTRACT: Dissociative experiences are common among children and adults, ranging from normative to pathological frequency and severity. This chapter details important aspects of dissociation following traumatic experiences , including empirical support for the trauma model of dissociation, psychobiological processes involved in dissociative experiences, and the presence of both dissociative symptomatology and dissociative disorders in patients diagnosed with post-traumatic stress disorder. Additionally, the authors discuss the complexities of conducting trauma treatment with dissociative individuals, including differential diagnosis and treatment approaches grounded in current treatment outcome research. Finally, key points to further inform readers about assessment and treatment of dissociative disorders are included at the conclusion of the chapter.
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  • [Show abstract] [Hide abstract] ABSTRACT: Dissociative symptoms may be the by-products of a labile sleep-wake cycle (Koffel and Watson, 2009a). This may help to explain why dissociation overlaps with fantasy proneness and cognitive failures. Using path analysis, we tested to what extent data gathered in a nonclinical, predominantly female sample (N=139) supported two conceptual models. The first model assumes that unusual sleep experiences increase fantasy proneness and cognitive failures, which in turn encourage trait dissociation and reports of trauma. The second model assumes that trauma leads to dissociative experiences both directly and through its influence on sleep. In this cross-sectional design, the data were reasonably well described by both models. Importantly, in both models, unusual sleep experiences serve as antecedents of trait dissociation. Our analysis underlines the importance of unusual sleep experiences and may inspire treatment intervention focusing on sleep normalization.
    Article · May 2014
  • [Show abstract] [Hide abstract] ABSTRACT: n a lively and wide-ranging roundtable discussion, five seasoned clinicians versed in the treatment of dissociative disorders discuss the importance of recognizing dissociative phenomena: why they happen, how to recognize them, how to work with dissociation and Dissociative Identity Disorder. The panel emphasizes the point that dissociative processes are not exclusive to those suffering from an extreme dissociative disorder and can germinate from other experiences such as attachment trauma, for exam- ple. The case is made that dissociation has important implications for work with all patients, as it conveys a more experientially near conceptualization for a model of the mind.
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