A time series evaluation of the treatment of histrionic personality disorder with cognitive analytic therapy

The central aim of this study was to assess the effectiveness of cognitive analytic therapy (CAT) with a patient presenting with Histrionic Personality Disorder (HPD). The methodology employed an A/B single case time‐series experimental design, with additionally 6 months of continuous follow‐up in the experimental measures. Five HPD experimental variables were collected on a daily basis, creating 357 days of continual data for analysis, across various phases of assessment baseline (A), treatment (B) and follow‐up. The therapy contract was 24 sessions of CAT, with 4 additional follow‐up sessions, spread over the 6‐month's post‐therapy period. Three out of the five HPD experimental variables (focus on physical appearance, emptiness and child inside) displayed statistically significant phase of treatment effects. Graphing of such data indicated that a ‘sudden deterioration’ occurred at the point of termination, with eventual recovery and maintenance of the progress made during the intervention. A battery of validated clinical measures were also completed at assessment, termination and final follow‐up sessions; analysis of the general measures illustrated clinically significant change, indexing personality integration and reductions to depression. The study is discussed in terms of methodological and clinical limitations, the central importance of process issues and effective termination in HPD, plus the potential utility of CAT in the treatment of HPD presentations.     

Dissociation as a Mediator of the Relationship Between Childhood Trauma and Nonsuicidal Self-Injury in Females: A Path Analytic Approach

New theoretical models of nonsuicidal self-injury (NSSI) postulate that symptoms subsequent to childhood maltreatment rather than childhood maltreatment itself may lead to engagement in NSSI. However, little is known concerning which specific syndromes serve as underlying mechanisms. In this study we sought to examine the mediating effects of dissociative, posttraumatic, and depressive symptoms, 3 often comorbid syndromes following childhood trauma. In addition, we aimed to assess differences between women with and without NSSI. A sample of 87 female inpatients with a history of childhood abuse and neglect was divided into 2 subgroups (NSSI: n = 42, no NSSI: n = 45). The assessment included measures of NSSI characteristics; adverse childhood experiences; and posttraumatic, dissociative, and depressive symptoms. The NSSI group reported significantly more cases of childhood maltreatment and higher levels of current dissociative, posttraumatic, and depressive symptoms than patients without NSSI. The results of a path analysis showed that only dissociation mediated the relationship between a history of child maltreatment and NSSI when all 3 psychopathological variables were included in the model. The findings point toward a strong and rather specific association between dissociative experiences and NSSI and therefore have important implications for clinical practice.     

Measuring Dissociative Experiences in a College Population

Abstract

Because the phenomenon of dissociation has been difficult to define and disentangle from other constructs, further study of the nature of dissociative experiences and the validity of instruments measuring dissociation was conducted. In this study, multiple measures of dissociative experiences were compared with instruments measuring a variety of theoretically related constructs in a sample of 225 college students. The results supported the convergent validity of the measures of dissociative experiences, but they demonstrated relatively poor discriminant validity. However, poor discriminant validity was not specific to dissociation measures and was found for almost all of the constructs studied. This suggests that dissociation can be seen as a distinct, valid, and reliable phenomenon, and that available instruments measure the phenomenon with similar precision as instruments measuring depression, anxiety, borderline, antisocial, and posttraumatic symptoms.     

Dissociation and Schizophrenia

Abstract

Comorbidity of psychotic and dissociative disorders often is not reported. This 38 year-old female with a history of schizophrenic symptoms displayed evidence of dissociative identity disorder (DID) during admission to an inpatient psychiatric unit. The case illustrates how the presence of a dissociative disorder may influence the presentation of a co-morbid psychosis. The historical association and differential diagnosis between DID and schizophrenia is described. Implications of various treatment approaches for patients exhibiting dissociation in the context of psychosis are discussed.     

Childhood Psychological and Physical Abuse: Psychopathology,Dissociation, and Axis I Diagnosis

ABSTRACT

The present study compared (1) college students who reported childhood physical and psychological abuse (combined; N = 35) with (2) students who reported psychological abuse alone (psychological; N = 30), and with (3) students who reported no history of childhood abuse (no abuse; N = 35). Combined abuse and psychological abuse participants were more likely to receive an Axis I diagnosis on a structured interview and to report more dissociative experiences than were no abuse participants. In addition, a structured interview for dissociative disorders was the single measure that differentiated psychologically abused participants from participants reporting combined abuse and no abuse. However, the most psychological impairment was evident in the combined abuse group. Relative to participants who reported no abuse history, combined abuse participants reported more dissociative symptoms on a structured interview and more symptoms of general psycho-pathology, depression, and state and trait anger on self-report measures.     

The Multidimensional Inventory of Dissociation (MID): A Comprehensive Measure of Pathological Dissociation

ABSTRACT

This article describes the development and validation of the Multidimensional Inventory of Dissociation (MID). The MID is a 218-item, self-administered, multiscale instrument that comprehensively assesses the phenomenological domain of pathological dissociation and diagnoses the dissociative disorders. The MID measures 14 major facets of pathological dissociation; it has 23 dissociation diagnostic scales that simultaneously operationalize (1) the subjective/ phenomenological domain of pathological dissociation and (2) the hypothesized dissociative symptoms of dissociative identity disorder (Dell, 2001a). The MID was designed for clinical research and for diagnostic assessment of patients who present with a mixture of dissociative, posttraumatic, and borderline symptoms. The MID demonstrated internal reliability, temporal stability, convergent validity, discriminant validity, and construct validity. The MID also exhibited incremental validity over the Dissociative Experiences Scale (DES) by predicting an additional 18% of the variance in weighted abuse scores on the Traumatic Experiences Questionnaire (TEQ). Confirmatory factor analysis (CFA) did not support a one-factor model of the MID's clinical scales (i.e., the 14 facets and the 23 diagnostic symptoms). In contrast, however, CFA of the MID's factor scales (Dell & Lawson, 2005) has strongly supported a one-factor model. It was concluded that both the MID's 168 dissociation items and the construct of pathological dissociation have a second-order, unifactorial structure.     

Discriminating Dissociative Identity Disorder from Schizophrenia and Feigned Dissociation on Psychological Tests and Structured Interview

ABSTRACT

Objective: The purpose of this study was to evaluate the relative efficacy of a number of psychological tests and interviews in discriminating dissociative identity disorder (DID) from feigned dissociation and schizophrenia.

Method: Three measures of dissociation (SCID-D, DES, SDQ-5) two personality measures (MMPI-2, Millon-III) and a brief measure of hypnotic susceptibility (Spiegel & Spiegel's Eye-Roll Sign) were assessed for their ability to differentiate these diagnostic groups.

Results: Results indicate that the SCID-D was clearly the most efficacious instrument in discriminating DID from schizophrenia and from feigned dissociation. The DES-Taxon and the SDQ-5 were adequate in screening pathological dissociation from schizophrenia but were less discriminative of feigned dissociation. The commonly used personality inventories were unable to detect feigned dissociation and the DID group tended to have higher elevations on scales measuring psychotic symptoms than did the schizophrenic group. The Eye-Roll Sign discriminated feigned dissociation from those with dissociative disorders.

Conclusions: Structured interviews such as the SCID-D, although resource consuming, are essential in comprehensive assessment of dissociative disorders. Comprehensive assessment of psychotic disorders should include some measure of dissociation.     

SCL-90-R Norms for Dissociative Identity Disorder

ABSTRACT

Norms for dissociative identity disorder (DID) have been provided for a variety of structured interviews, self-report measures and computer-scored instruments. The SCL-90-R is a widely used self-report measure of general psychopathology, but prior to this report norms for DID were not available. The authors provide scores on the SCL-90-R for 101 participants with DID at baseline, and for 36 of the participants on two-year follow-up.     

Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: a feasibility study in Sri Lanka

BACKGROUND: Research on the management and the outcome of treatment of medically unexplained symptoms is very limited. Development of simple but effective techniques for treatment and demonstration of their effectiveness when applied in primary health care are needed. METHODS: A randomized controlled trial was carried out with follow-up assessments at 3 months after baseline assessments using the Short Explanatory Model Interview (SEMI), General Health Questionnaire (GHQ-30), Bradford Somatic Inventory (BSI) and patient satisfaction on a visual analogue scale. The study was carried out in a general out-patient clinic in Sri Lanka. The intervention group received six, 30 min sessions based on the principles of cognitive behavioural therapy over a period of 3 months. The control group received standard clinical care. RESULTS: Eighty patients out of the 110 patients referred, were eligible. Sixty-eight were randomly allocated equally to the control and treatment groups. All 34 in the treatment group accepted the treatment offer and 22 completed between three and six sessions. At 3 months, 24 in the treatment and 21 in the control group completed follow-up assessments. Intention-to-treat analysis revealed significant differences in mean scores of outcome measures (adjusted for baseline scores) between control and intervention groups respectively--complaints 6.1 and 3.8 (P = 0.001), GHQ 10.4 and 6.3 (P = 0.04), BSI score 15.6 and 132 (P < 0-01), visits 7.9 and 3.1 (P = 0.004). CONCLUSIONS: Intervention based on cognitive behavioural therapy is feasible and acceptable to patients with medically unexplained symptoms from a general out-patients clinic in Sri Lanka. It had a significant effective in reducing symptoms, visits and distress, and in increasing patient satisfaction.     

Dissociation and Compulsive Eating

ABSTRACT

Numerous investigators have noted a correlation between compulsive eating patterns and dissociative symptoms, but there is no systematic explanation for how these two phenomena interact. It is not uncommon for patients with compulsive eating patterns to experience previously dissociated memories of abuse and trauma, but there are no generally accepted interventions that address both the eating disorder and the traumatic experience. Furthermore, there are no commonly accepted guidelines for assessing trauma and dissociative symptoms in the many patients with intractable compulsive eating symptoms who may initially present with no traumatic history. This article presents theoretical formulations, a review of relevant research, and a model that suggests a causal relationship between dissociation and compulsive eating. Guidelines for assessment and intervention are proposed. The theoretical constructs in this paper are based on hunger-based symptom assessment and a feminist interpretation of object relations theory as it applies to compulsive eating and body shame.     

Early Traumatized Inpatients High in Psychoform and Somatoform Dissociation: Characteristics and Treatment Response

This study examined the clinical relevance of differences in psychoform and somatoform dissociative symptoms in 55 early traumatized inpatients. The high psychoform and somatoform dissociative group (n = 18), somatoform dissociative group (n = 22), and nondissociative group (n = 15) did not differ on abuse severity, depressive symptoms, interpersonal problems, Axis I or II comorbidity, or deterioration rates. Compared to the other 2 groups, the highly dissociative group was characterized by younger age, living alone, higher levels of posttraumatic and general distress, more frequent reports of suicidality, self-mutilation, eating problems, and less favorable treatment response. The results highlight the clinical relevance of using dissociation measures for identifying subgroups of patients with severe psychopathology who may be more treatment resistant.     

Telephone-based behavioral activation intervention for dementia family caregivers: Outcomes and mediation effect of a randomized controlled trial

ObjectivesThe study examined the effects of a telephone-administered psycho-education with behavioral activation intervention (TBA) for family caregivers of person’s with Alzheimer’s dementia to reduce levels of depressive symptoms and burden and to enhance relationship satisfaction with the care-recipientMethodsA double-blinded randomized trial compared TBA with telephone-based psycho-education with general monitoring (TGM). Ninety-six dementia caregivers were randomized. Both conditions received four weekly psycho-education sessions led by a social worker. TBA participants then received eight bi-weekly behavioral activation practice sessions delivered by paraprofessionals. TGM participants received eight bi-weekly monitoring sessions by paraprofessionals.ResultsAs compared to TGM, TBA participants reported significantly larger reductions in depressive symptoms and burden and larger improvement in relationship satisfaction. Self-efficacy for controlling upsetting thoughts was found to have a partial meditation effect between TBA and the reduction of depressive symptoms. Qualitative feedback suggested that TBA participants expressed unique gains in awareness and developing new ways of reappraising the caregiving situation.ConclusionTBA was an effective intervention to reduce depressive symptoms and burden as well as to enhance relationship satisfaction in dementia caregivers.Practice implicationsThe use of telephone and trained paraprofessionals can enhance the accessibility and sustainability of behavioral activation intervention for dementia family caregivers.     

A systematic review of social support interventions for caregivers of people with dementia: Are they doing what they promise?

ObjectiveSocial support interventions for caregivers of persons with dementia (PwD) are important because informal carers often rely on their social networks for support. This systematic review synthesises findings from research on social support interventions, and examines their methodological quality and effectiveness on caregiver social support and well-being variables.MethodsA systematic literature search utilised five databases. Papers were selected when the primary aim of the intervention was to improve social support. Quality of papers was assessed by the Level of Evidence grade and the criteria list from the Cochrane Back Review Group.Results39 papers were identified and classified into 4 social support intervention categories: befriending and peer support, family support and social network interventions, support groups, and remote interventions using the internet or telephone. Content, intensity, uptake, effectiveness and quality of interventions varied widely. In general, the level of evidence was low. Most studies measured effect on well-being variables, while few examined social support outcomes. Multi-component social support interventions were most effective. Evidence suggested, also a caregiver benefit from remote interventions. Generally, results were inconsistent; some papers demonstrated beneficial results, while others demonstrated no improvement on social support and well-being variables. Social support outcomes were more positively evaluated when qualitative outcome measures rather than quantitative measures were used.ConclusionsAlthough multi-component social support interventionsmay improve caregiver well-being, there is insufficient evidence to conclude whether a change in social support is the underlying mediating factor. The inclusion, validation and operationalization of caregiver social support measures deserve more attention.     

Predictors of Continued Suicidal Behavior in Adolescents Following a Suicide Attempt

Describes adolescents who attempt suicide and their risk for ongoing suicidal behavior. Fifty-eight adolescents (53 female) who attempted suicide received a baseline evaluation that was analyzed to identify factors that were associated with continued suicidal ideation and reattempt. At a 3-month follow-up assessment, 45% reported continued suicidal ideation and 12% reported a repeat attempt. Baseline measures of family functioning, feelings of hopelessness, and abilities to regulate affect were associated with suicidal ideation at follow-up but not as strongly as depressed mood. After controlling for depressive symptoms, the association between family functioning and continued suicidal behavior was no longer significant. Depressed mood at baseline was most strongly associated with both continued suicidal ideation and reattempt.     

The Language of Dissociation

ABSTRACT

Three case studies of inner-city elementary school children illustrate the connection between speech-language disorders and dissociative disorders in children who have known or suspected trauma histories. The role of speech language pathologists in identifying and responding to dissociative symptoms in children is explored. Lack of adequate training concerning the impact of trauma and scarce literature on the communication profiles of dissociative children contributes and greatly impacts the diagnosis, referral, and treatment of these children. The case studies demonstrate how unusual speech and language symptoms and awareness of dissociative features may aid in identifying trauma-related problems and instituting effective treatment. Grounding techniques and specific language interventions can assist children in acquiring the vocabulary needed for communicating both their daily experiences and traumatic histories. The nature of the relationship between dissociation and communication disorders is explored, and the importance of future research, interdisciplinary collaboration, and trauma training in the speech-language curriculum is emphasized.     

Intradialytic hypotension: Is intradialytic acupuncture a complementary option? A case report

BackgroundIntradialytic hypotension (IDH) is a common complication during hemodialysis (HD) and is positively associated with either poor quality of life or mortality. The present case report described the effect of intradialytic acupuncture (IA) in decreasing the occurrence of IDH.MethodsA 70-year-old female with diabetic nephropathy had been receiving regular dialysis twice weekly since end-stage renal disease was diagnosed. She had several episodes of intradialytic systolic blood pressure (iSBP) drop accompanied with severe complications within one month. In the 10 dialysis sessions prior to IA intervention, the case patient experienced two episodes of nadir iSBP < 90 mmHg, seven episodes of iSBP drop ≥ 20 mmHg, among which two episodes occurred with symptoms; and three episodes of iSBP drop required nursing intervention.InterventionsDialysis sessions proceeded as usual with the patient receiving five sessions of 30-min IA as an add-on therapy starting from the second hour of dialysis.ResultsIn the 10 sessions with IA administered alternately, she experienced one episode of nadir iSBP < 90 mmHg and three episodes of iSBP drop ≥ 20 mmHg, among which two episodes occurred with symptoms. Occurrence of IDH reduced and no IDH necessitating nursing intervention occurred during IA-HD sessions.ConclusionsThe administration of IA showed potential effect in decreasing the occurrence of IDH.     

A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder

A randomized trial was performed in which imaginal exposure (IE) and cognitive therapy (CT) were compared in the treatment of chronic posttraumatic stress disorder (PTSD). Patients who continued to meet PTSD caseness at the end of a 4-week symptom-monitoring baseline period (n = 72) were randomly allocated to either IE or CT. There was a significant improvement in all measures over treatment and at follow-up, although there were no significant differences between the 2 treatments at any assessment. A significantly greater number of patients who showed worsening over treatment received IE, although this effect was not found at follow-up. Patients who worsened showed a greater tendency to miss treatment sessions, rated therapy as less credible, and were rated as less motivated by the therapist. It was concluded that either exposure or a challenge to cognition can result in symptom reduction, although neither resulted in complete improvement.     

Using ePROMs for follow-up after palliative radiotherapy: An exploratory study with patients and health care providers

ObjectivesPatients treated with palliative radiotherapy may experience symptoms decreasing their quality of life. Electronic patient-reported outcome measures (ePROMs) could provide an opportunity to follow-up patients after treatment.MethodsA mixed-method study was performed using self-constructed questionnaires, focus groups and interviews with patients and health care professionals (HCP). A qualitative approach was used to code the data.ResultsForty-two patients, 21 radiation-oncologists, 15 general practitioners (GPs) and 24 home-care nurses completed a questionnaire. Ten patients, 6 radiation-oncologists, 14 GPs and 5 nurses were interviewed or participated in a focus group. Although patients and HCP are satisfied with current care, they believe ePROMs could improve follow-up, communication, continuity of care and self-management of symptoms. An easy to use, versatile ePROM platform seems to be important for successful implementation. Self-care tips and contact information should be added to relevant ePROM-questions, on both physical and psychological symptoms.ConclusionPatients and HCP agree that ePROMs could improve systematical clinical follow-up after palliative radiotherapy, with self-management support being the primary objective of such a system. Practice implications ePROMs after palliative radiotherapy seem feasible, the exact patient population that could benefit the most will need to be explored further; as the palliative population is very diverse.     

Shared decision-making and patient engagement program during acute exacerbation of COPD hospitalization: A randomized control trial

ObjectiveTo evaluate the effectiveness of a shared decision-making and patient engagement (SDM-PE) program concerning in-hospital stay during acute exacerbation of COPD and determine its impact on patients’ perceived health status.MethodsPatients were randomly allocated to a control group that received standard treatment or an intervention group that received an individualized SDM-PE program in addition to standard treatment. The SDM-PE program included personalized health care focused on information about the disease, healthcare management, and reinforcement of behaviors regarding nutrition and exercise taking into account patients’ preferences.ResultsA comparative analysis between groups showed a significant improvement in perceived health status at discharge in patients included in the experimental group compared to those in the control group (60.28 ± 21.65 vs. 54.13 ± 22.69, p = 0.036). In addition, perceived health status, COPD knowledge, adherence to pharmacological treatment, general functionality, and healthy lifestyle measures were significantly better at 3-month follow-up in the intervention group.ConclusionAn SDM-PE program significantly enhanced all the clinical measures assessed during hospitalization at 3-month follow-up.Practice implicationsCOPD patients and professionals need to work together to select the best care and treatment model for patients, taking into account individual values and preferences.     

Longer booking intervals in general practice: effects on doctors'' stress and arousal.

A controlled trial was carried out to determine whether longer booking intervals at surgeries affected general practitioners' self-assessed levels of stress and arousal. Sixteen general practitioners from 10 practices took part. Surgery sessions with patients booked at 10 minute intervals (experimental sessions) were compared with the doctors' usual booking intervals of between 7.5 and 5.0 minutes (control sessions). Stress and arousal were assessed by the general practitioner before and after each surgery session using a mood adjective check list. The study included 109 experimental and 184 control sessions. The median consultation length increased from six minutes in the control sessions to seven minutes in the experimental sessions. At the end of the experimental sessions, stress scores were lower, and arousal scores higher than at the end of the control sessions (P less than 0.001). There were no significant differences between experimental and control sessions in stress or arousal at the start of the sessions. Favourable mood changes were seen more consistently in the experimental sessions than control sessions, with less than a quarter of doctors showing increased stress or decreased arousal after sessions relative to before. It is concluded that longer booking intervals are of psychological advantage to general practitioners.