Dissociation,Depression and Trauma in Psychiatric Inpatients in Puerto Rico

ABSTRACT

This study investigated the frequency of self-reported childhood abuse experiences of psychiatric inpatients, and the presence of dissociative and depressive symptoms. A total of 100 Puerto Rican in-patients who were hospitalized during a two month period were included in the study. The participants' dissociative and depressive symptoms were assessed using the Dissociative Experiences Scale and a subset of its items (DES-Taxon), the Questionnaire of Experiences in Dissociation and the Beck Depression Inventory. We also used a self-report instrument to assess the frequency and severity of a variety of abusive experiences. Seventy-eight percent (78%) of the participants reported some type of abusive experiences, 38% reported extreme and frequent abuse, and 40% reported being sexually abused during childhood. The findings showed a correlation between greater frequency of the abusive experiences and higher levels of dissociative and depressive symptoms. When the variable of child sexual abuse was used, only the Dissociative Experiences Scale was able to detect differences between those patients who reported such abusive experiences and those who reported none. We conclude that the level of abusive experiences reported by psychiatric in-patients in Puerto Rico is very similar to the rate in other investigations in the international literature. The data demonstrate that the participants who report frequent and intense abuse endorse a wide variety of dissociative experiences, and, to a lesser extent, depressive symptoms. As more than 95% of our inpatients had never been screened or assessed for the possibility of a dissociative disorder, we suggest that clinicians in psychiatric units in Latin America should be more sensitive and attentive to the presence of such disorders.     

Surviving the Bad Object

ABSTRACT

A case study of a pivotal crisis in the treatment of a woman with Dissociative Identity Disorder illustrates attachment dilemmas and strategies as they are re-enacted within the treatment. Attachment theory has been applied to the development of dissociative disorders by Barach (1991) and Blizard (1997). The case crisis under study demonstrates how the resolution of an attachment conflict, expressed by two alters in regard to the transference, facilitated significant integration.     

Psychophysiological and Psychological Correlates of Dissociation in a Case of Dissociative Identity Disorder

ABSTRACT

The aim of this study was to examine the psychological and psychophysiological mechanisms that underlie dissociative experiences in dissociative disorders. A four-stage, personalized guided imagery methodology was used to recreate the psychological and psychophysiological responses associated with two dissociative episodes experienced by a 25 year old, single female diagnosed with Dissociative Identity Disorder. The responses to these two dissociative episodes were compared with a stressful experience and an emotionally neutral event. The results demonstrated a reduction in psychophysiological arousal associated with the experience of dissociation during times of intense distress accompanied by relevant alterations in psychological response. It was concluded that the experience of dissociation served to protect this individual from extreme distress and, therefore, functioned as a protective mechanism.     

Dissociation in sexually abused Puerto Rican children: a replication utilizing social workers as informers

This study explores dissociative symptoms in 3 different groups of Puerto Rican children. Data were collected on 40 children with documented sexual abuse history, 39 children with psychiatric disorders but without a history of sexual abuse, and 40 community control children. Dissociative symptoms were assessed with the child using the Trauma Symptom Checklist for Children (TSCC); a social worker answered the Child Dissociative Checklist (CDC). Results indicated that children with sexual abuse obtained significantly different scores on both the TSCC and the CDC. Further analysis indicated that child and social worker reports of dissociative symptoms were highly correlated (r = .73). Furthermore, 30% of the children in the sexual abuse group scored at or above the cutoff point of 12 on the CDC, which is indicative of a dissociative disorder. None of the children in the other 2 groups obtained such a score. The results suggest that children with documented sexual abuse victimization demonstrate a significant number of dissociative phenomena that not only are subjectively experienced but also can be observed by a non-family member. Finally, as nearly a third of the abused children obtained a score of 12 or higher on the CDC, the next step is to prepare clinicians to conduct a proper and formal diagnosis assessment of dissociative disorders.     

Hypnosis and Traumatic Dissociation: Therapeutic Opportunities

ABSTRACT

Hypnosis and the related phenomenon of dissociation have long been linked to trauma. Evidence is reviewed regarding the relationship between trauma and dissociation, the prevalence of these dissociative symptoms in the acute aftermath of trauma, and their salience in predicting the development of later PTSD symptoms. The evidence reviewed regarding the prevalence of dissociative and other symptoms in the immediate aftermath of trauma formed the basis for including Acute Stress Disorder (ASD) as a new diagnosis in the DSM-IV. Dissociative amnesia is described as the key commonality between formally induced hypnosis and dissociative symptomatology, and controversy regarding traumatic amnesia is discussed. Finally principles of psychotherapy involving hypnosis and related techniques for dissociative and other post-traumatic symptoms are reviewed.     

Masochistic and Sadistic Ego States

Abstract

A theory describing the development of alternating, dissociated, victim/masochistic and perpetrator/sadistic ego states in persons who grew up with abusive primary caretakers will be proposed and a paradigm for treatment will be derived from the theory. Alternating ego states can be observed throughout the spectrum of dissociative disorders, from Borderline Personality to Dissociative Identity Disorder. Dependence on an abusive caretaker creates a series of relational dilemmas for the child. To maintain attachment, abuse must be dissociated, but to protect the self from abuse, need for attachment must be disavowed. Disorganized attachment may result. Incompatible internal working models, using parallel masochistic and sadistic defensive strategies, may be developed and elaborated into ego states. Masochistic and sadistic defenses are ultimately maladaptive, because they require dissociation of need for either self-protection or attachment. Each defensive attempt at resolving a relational dilemma leads to another impasse, a change in defensive strategy, and perhaps a shift in ego state. When alternating ego states are understood as evolving from defensive schemas developed to negotiate the dilemmas of attachment to an abuser, the following therapeutic techniques can be derived: (1) identifying adaptive needs and maladaptive defenses, (2) interpreting ego state switches as attempts to resolve relational dilemmas, (3) gradually bridging dissociation between states, (4) using transference and countertransference to understand relational patterns, and (5) cultivating more adaptive interpersonal skills within the therapeutic relationship.     

Three controversies about dissociative identity disorder

Three controversies about Dissociative Identity Disorder are discussed. First, is DID an artefact due to iatrogenic influences? The empirical evidence does not support such a conclusion, although iatrogenic influences may play a considerable part in the presentation of this disorder. Second, how adequate are the present diagnostic criteria? It is argued that the DSM-IV may elicit overdiagnosis and that the use of structured clinical interviews is mandatory. The third controversy concerns memory processes of DID patients. Does psychogenic amnesia for sexual abuse exist, or are the so-called repressed memories of sexual abuse false memories (unintentionally) induced by overzealous therapists? Clinical data and experimental laboratory findings do not converge in this. The massive amnesia for traumatic events that is clinically reported in dissociative disorders, has not been replicated in laboratory studies, whereas memory research has shown that some false memories can be created in the laboratory. © 1998 John Wiley & Sons, Ltd.     

Evaluation of the Swedish Version of Dissociation Questionnaire (DIS-Q), Dis-Q-Sweden,Among Adolescents

ABSTRACT

The aim of this study was to investigate the psychometric properties of the Swedish version of the Dissociation Questionnaire in a normative adolescent population and also to investigate dissociative symptoms associated with trauma including sexual and physical abuse. A normative sample of 449 adolescents between the ages of 12 and 19 and a clinical group of 74 adolescents with known experiences of trauma, sexual and/or physical abuse was given Dis-Q-Sweden. A mixed group of 22 abused and non-abused adolescents who answered Dis-Q-Sweden was also interviewed by using the Structural Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). A test-retest procedure was conducted with 90 subjects from the normative group. The results showed good reliability concerning both internal consistency and test-retest stability. Validity was tested in several ways (criterion, predictive, construct and concurrent) and found to be satisfactory. Significant differences for the total sum scores of Dis-Q-Sweden were found between the normative group and the clinical group with known sexual abuse (p < 0.001). The prevalence of dissociative symptoms (cut-off score > 2.5) was 2.3% in the normative group and 50% in the clinical group. Dis-Q-Sweden has proven to be a screening instrument with good psychometric properties and has proven to be able to capture dissociative symptoms in adolescents with self-reported trauma and known trauma (sexual abuse).     

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.     

Why the Diagnostic Criteria for Dissociative Identity Disorder Should Be Changed

Abstract

This paper examines the psy chi at ricdiagnosis of dissociative identity disorder (DID)inlightofthedevelopmentsinpsychi at ricclassification that have guided the last four re vi sions of the Diagnostic and Sta tis ti calMan ualforMen talDis or ders (DSM) (Amer i can Psychiatric Association, 1980, 1987, 1994, 2000). The author argues that multiple per son al ity 's pas sage from DSM-III, through DSM-III-R, to its current form as DID in DSM-IV-TR has left the di ag no sis out of step with the state of the art of psy chi atric classification. Ten dis advantages of the Diagnostic and Sta tis ti calMan ual of Men talDis or ders, Fourth Edi tion- Text Revision (DSM-IV-TR) cri te riafor DID are iden ti fied. The DSM-IV-TR cri te ria for DID: (1) are out of step with the state of the art of psy chi at ric clas si fi cation; (2) are not based on taxometric anal y sis of the symp toms of DID; (3) in correctly im ply that DID is a closed con cept; (4) have poor con tent valid ity; (5) throw away im portantinformation; (6) dis courage taxonomic research; (7) have poor reliability and cause frequent misdiagnoses; (8) are not “user-friendly”; (9) are un nee es sar ily con tro versial; and (10) along with pre vi ous ver sions of the DSM, have pro duced an artifactually low base-rate of DID for the past 20 years. In an effort to remedy these disadvantages, a re liable, user-friendly, polythetic set of diagnostic criteria for “Major Dissociative Disorder” is proposed for DSM-V. Using these polythetic cri te ria, the dissociative dis or ders (presently con cep tu al ized as Dissociative Am ne sia, Dissociative Fugue, DID, Depersonalization Disorder, and Dissociative Disorder Not Otherwise Spec ified) can be re struc tured into an eas ily un der stood and more re liable set of di ag nos tic en ti ties. This al ter nate nosology of the dissociative disorders consists of Sim pie Dissociative Dis or der (with at least three). sub types), Gen er al ized Dissociative Dis or der, Major Dissociative Disorder (with two subtypes), and Dissociative Disorder Not Otherwise Specified.     

Israeli Mental Health Professionals' Attitudes Towards Dissociative Disorders,Reported Incidence and Alternative Diagnoses Considered

Abstract

Clinical diagnoses of dissociative disorders (DDs), including Dissociative Identity Disorder (DID), are controversial because there are mental health professionals in North America and elsewhere who are skeptical about whether these psychiatric disorders actually exist. This paper explores the attitudes of mental health professionals in Israel toward DDs and DID through a survey of 211 practicing clinicians (return rate of 39.5%). Of the sample, 95.5% scored at or above the point on a 5-point Likert scale measuring belief in the validity of DDs (m = 4.17, SD = 0.78); 84.5% declared at least a moderate belief in the validity of DID (M = 3.5, S.D. = 0.97). The average Israeli clinician surveyed had made 4.8 career-long DD diagnoses (S.D. = 18.06) and carried an average of 1.05 DD patients in his/her caseload (S.D. = 2.86). DID had a career-long diagnosis frequency of 0.14 patients per clinician (S.D. = 0.59) and was currently seen at a frequency of 0.03 cases per clinician (S.D. = 0.20). The five most frequently considered alternative diagnoses to DID in Israel were Borderline Personality Disorder (24%), Psychotic Disorder/Schizophrenia (23%), PTSD/Anxiety Disorder (10%), Malingering (8%) and Depressive Disorder (7%). The findings suggest that attitudes of Israeli clinicians are similar to those of North American clinicians despite the geographical and cultural differences between them.     

Rorschach indicators of dissociative identity disorders: Clinical utility and theoretical implications

The purpose of the present study was to replicate Rorschach signs of Multiple Personality Disorder (MPD) using DSM-IV criteria of Dissociative Identity Disorder (DID). Women admitted to either an inpatient dissociative disorder's unit (n = 27) or a general psychiatric unit (n = 72) were given the Rorschach, which was scored for the Labott, Barach, and Wagner Rorschach markers of MPD. Results indicated that Rorschach signs of the three different systems were significantly better than chance at classifying patients as DID or as non-DID. The Labott system, which performed the best, was able to accurately classify 92% of the sample. These results argue for the validity of the DID diagnosis. The Rorschach signs operate independent of external bias, yet correspond to the diagnoses obtained through psychiatric evaluation in an inpatient setting. The fact that two relatively rare sets of signs (DID and Rorschach) converge in the same small sector of the psychiatric population represents evidence of linkage that is clinically meaningful and not explainable on the basis of artificial creation. © 1998 John Wiley & Sons, Inc. J Clin Psychol 54: 803–810, 1998.     

Contextual Treatment of Dissociative Identity Disorder

Abstract

Evidence for the effectiveness of contextual therapy, a new approach for treating adult survivors of prolonged child abuse (PCA), is provided via case studies of three women with Dissociative Identity Disorder (DID). Contextual therapy is based on the premise that it is not only traumatic experiences that account for PCA survivors' psychological difficulties. Even more fundamentally, many survivors grow up in an interpersonal context in which adequate resources for secure attachment and acquisition of adaptive living skills are not available. As a result, they are left with lasting deficits that undermine not only their current functioning, but also their ability to cope with reliving their traumatic memories in therapy. The primary focus of this treatment approach, therefore, is on developing capacities for feeling and functioning better in the present, rather than on extensive exploration and processing of the client's trauma history or, in the case of DID, of identity fragments. Treatment of the three cases presented ranged from eight months to two and one-half years' duration, and culminated in very positive outcomes. The women's reports of achievements, such as obtaining and maintaining gainful employment, greater self-sufficiency, and the establishment of more intimate and gratifying relationships, indicated marked improvements in daily functioning. Objective test data obtained at admission and discharge, and in one case, at follow-up, documented substantial reductions in dissociative, posttraumatic stress, depressive, and other symptoms.     

Relationships among childhood trauma, posttraumatic stress disorder, and dissociation in men living with HIV/AIDS

This study examined the relationships among dissociation, childhood trauma and sexual abuse, and posttraumatic stress disorder (PTSD) symptoms in HIV-positive men. Data were collected from 167 men enrolled in a randomized clinical trial that examined a group therapy intervention to decrease HIV-related risk behavior and trauma-related stress symptoms. Participants completed the Trauma History Questionnaire, the Impact of Events Scale-Revised, and the Stanford Acute Stress Reaction Questionnaire. Overall, 35.3% of the participants reported having experienced childhood sexual abuse. A total of 55.7% of the sample met diagnostic criteria for PTSD. The intensity of dissociative symptoms that participants endorsed was positively associated with experience of childhood sexual abuse (r?=?.20, p < .01). Dissociative symptoms were also positively associated with specific PTSD symptoms, notably hyperarousal (r?=?.69, p < .001). Hierarchical regression indicated that hyperarousal symptoms accounted for more of the variance in dissociation than childhood sexual abuse. These results suggest that childhood sexual abuse may be involved in the development of dissociative symptoms in the context of adulthood stress reactions. Furthermore, the pattern of the association between dissociation and PTSD is consistent with the possibility of a dissociative PTSD subtype among HIV-positive men.     

Dissection of Schizotypy and Dissociation in Depersonalization Disorder

ABSTRACT

The relationship between dissociation and psychosis-proneness remains controversial to this day. We investigated this relationship in Depersonalization Disorder, a primary dissociative disorder, hypothesizing that the constructs of schizotypy and dissociation would be distinguishable. Forty-eight depersonalization disorder (DPD) and 22 healthy comparison (HC) participants were administered measures of schizotypy (Perceptual Aberration Scale, Magical Ideation Scale) and dissociation (Dissociative Experiences Scale). The DPD group had significantly higher schizotypy scores than the HC group. However, when DPD participants with Axis II disorders were excluded, the remaining “pure” DPD group (N = 22) exhibited higher perceptual aberrations but comparable magical ideations to the healthy group. Within the “pure” DPD group, dissociation and schizotypy scores were not significantly correlated. We conclude that schizotypy was readily distinguishable from dissociation in the current sample. Greater attention to methodological issues promoting the distinction between dissociation and schizotypy may prove helpful in future phenomenological research.     

分离性身份识别障碍的心理病理机制和临床评估

文章主要介绍了分离性身份识别障碍(DID)形成的四种心理学解释,以及用于DID临床评估的三类测评工具。当前关于DID心理病理机制的研究带有较为明显的心理动力学色彩,多理论整合的系统性研究和深度的个案研究有待更多的开展。早期创伤记忆的遗忘机制研究是深入研究DID心理病理机制的一个重要方向。     

The Axis-I Dissociative Disorder Comorbidity of Borderline Personality Disorder Among Psychiatric Outpatients

ABSTRACT

The aim of this study was to determine the frequency of dissociative disorders among psychiatric outpatients with borderline personality disorder (BPD). In order to ascertain the extent of the overlap between two diagnostic groups, the overall prevalence of both disorders were evaluated. Two hundred and forty (240) consecutive patients who presented to a university outpatient psychiatry unit were screened using the self-report questionnaire version of the BPD section of Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II), the Dissociative Experiences Scale (DES) and the Somatoform Dissociation Questionnaire (SDQ). One hundred and twenty-nine (129) participants who had a score above the cut-off point on at least one of these instruments were evaluated using the interview version of the BPD section of the SCID-II, the Dissociative Disorders Interview Schedule (DDIS), and the PTSD module of the Structured Clinical Interview for DSM-III-R (SCID-I). All participants who were diagnosed as having BPD or a dissociative disorder were evaluated then with the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Twenty-five (25; 10.4%) participants had BPD and 33 participants (13.8%) had dissociative disorder in the final evaluation. Sixteen participants (64.0%) with BPD had the Axis I diagnosis of a dissociative disorder; all six participants (2.5%) with dissociative identity disorder were among them. The findings demonstrate that a significant part of psychiatric outpatients who fit the criteria of BPD have a DSM-IV dissociative disorder on Axis I. The presence of dissociative symptoms as a part of BPD should not lead to overlooking the possibility of a co-occurring dissociative disorder.     

Dissociation and Schizophrenia

ABSTRACT

The authors administered the Dissociative Experiences Scale (DES), the Dissociative Disorders Interview Schedule (DDIS), the Scale for the Assessment of Positive Symptoms, and the Scale for Assessment of Negative Symptoms to 60 participants with schizophrenia. Participants were divided into two groups: those with scores below 10 on the DES and no dissociative disorder on the DDIS; and those with scores above 25 on the DES and/or a dissociative disorder on the DDIS. The dissociative participants had more severe trauma histories, more comorbidity and higher scores for both positive and negative symptoms. The authors interpret their findings as evidence in support of a trauma-dissociation subgroup within schizophrenia.     

Dissociative Experiences in China

ABSTRACT

The Dissociative Experiences Scale was administered to a non-clinical sample in Shanghai, China (N = 618) and the results were compared with a previous sample of the general population from Winnipeg, Canada (N = 1055). The Dissociative Disorders Interview Schedule was administered to the 618 Chinese participants and results were compared with those of the Canadian participants (N = 502). In addition, both measures were administered to a sample of Chinese psychiatric in-patients (N = 423) and outpatients (N = 304). Rates of childhood trauma and dissociation were far lower in the Chinese non-clinical sample than in the two Chinese psychiatric patient groups, and far lower than in the Canadian general population. Among the 618 respondents in the Chinese non-clinical sample, no childhood sexual abuse was reported and only one person reported childhood physical abuse. These rates of childhood abuse were far lower than in other non-clinical samples from China; for example, rates were 16.7% for sexual abuse of girls and 10.5% for sexual abuse of boys in a previous study. Among the more traumatized Chinese psychiatric patients, and among the Canadian respondents, dissociative experiences were much more common than in the Chinese general population. The data provide a base frequency for dissociation in non-clinical samples reporting little or no childhood physical and sexual abuse.     

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.