Developmental Needs Meeting Strategy: A New Treatment Approach Applied to Dissociative Identity Disorder

ABSTRACT

This article describes the use of the Developmental Needs Meeting Strategy (DNMS) for the treatment of dissociative identity disorder (DID). The DNMS is an ego state therapy which guides a client's own internal resources to meet developmental needs that were not met in childhood. After 17 months of DNMS treatment, a client with DID reported a near total elimination in frequency and severity of symptoms of depression, anxiety and suicidal thoughts, her Trauma Symptom Inventory scores indicated no trauma-related symptoms, and her Multidimensional Inventory of Dissociation scores indicated she no longer met the diagnostic criteria for DID. She was functioning well without any medication. Further research concerning this treatment strategy is warranted.     

Investigating Cognitive Inhibition in Dissociative Identity Disorder Compared to Depression,Posttraumatic Stress Disorder and Psychosis

ABSTRACT

Cognitive inhibition refers to the mental capacity to suppress distracting stimuli that compete with target stimuli for processing resources. Using neutral word stimuli in a flanker task, a recent study suggested that dissociative identity disorder (DID) is characterized by weakened cognitive inhibitory functioning (Dorahy, Irwin, & Middleton, 2002). The current study used single digit stimuli in the flanker task and tested cognitive inhibitory ability in samples with DID, depression, posttraumatic stress disorder and psychosis. The DID, depressed and PTSD groups displayed no evidence of weakened cognitive inhibitory functioning. Consistent with previous research, however, the psychosis sample displayed a reduced capacity to engage in cognitive inhibition. Cognitive inhibitory ability was not related to measures of dissociation, childhood traumatic experience or schizotypy. Results are discussed in terms of the positive symptoms of schizophrenia and the nature of stimuli used in the flanker task.     

Memory Fragmentation in Dissociative Identity Disorder

ABSTRACT

This study examined the quality of self-reported memories of traumatic experiences in participants with dissociative identity disorder (DID) and compared them with their memories of non-traumatic, but emotionally significant life experiences. Systematic interview data were gathered from 30 DID patients in The Netherlands. All participants reported a history of severe childhood abuse; 93.3% reported some period of amnesia for the index traumatic event, and 33.3% reported periods of amnesia for significant non-traumatic childhood experiences. All participants who had been amnestic for their trauma reported that their memories were initially retrieved in the form of somatosensory flashbacks. This suggests that, like PTSD patients, DID patients at least initially recall their trauma not as a narrative, but as somatosensory re-experiencing. Surprisingly, however, DID participants also recalled emotionally charged non-traumatic life events with significant somatosensory components, a phenomenon that has not been previously reported. This finding raises important issues regarding basic memory processing abnormalities in DID patients.     

Incorporating EMDR and EMDR Adaptations into the Treatment of Clients with Dissociative Identity Disorder

Abstract

This paper offers ways to incorporate Eye Movement Desensitization and Reprocessing (EMDR) in the treatment of clients with Dissociative Identity Disorder (DID). Uses of EMDR detailed can be applied to Dissociative Disorder, Not Otherwise Specified (DDNOS) and ego state work. EMDR is a therapeutic method using alternating bilateral stimulation (ABS) that integrates traumatic memories with adaptive reasoning and the patient's own resources, resulting in accelerated information processing and healing. DID is a complex disorder suffered by clients who have often experienced multiple childhood traumas. They live with what Kluft (1993) terms a “multiple reality disorder,” and describes as living in “… several parallel but incompletely overlapping constructions of the world and of life experience.” An asset with EMDR is that it can accelerate the treatment process. A liability is that its incorrect use can accelerate decompensation for fragile clients, e.g., those with complex trauma histories or DID. This paper offers suggested uses of EMDR and EMDR adaptations to facilitate learning, intervene in multiple reality disorder, decrease some negative transferences and to provide a protective format for processing traumatic material.     

Client‐centred therapy,post‐traumatic stress disorder and post‐traumatic growth: Theoretical perspectives and practical implications

In practice it is not unusual for client‐centred therapists to work with people who have experienced traumatic events. However, client‐centred therapy is not usually considered within texts on traumatic stress and questions have been raised over the appropriateness of client‐centred therapy with trauma survivors. The present study shows how, although he was writing well before the introduction of the term ‘posttraumatic stress disorder’, Carl Rogers provided a theory of therapy and personality that contains an account of threat‐related psychological processes largely consistent with contemporary trauma theory. Rogers' theory provides the conceptual underpinnings to the client‐centred and experiential ways of working with traumatized people. Furthermore, Rogers' theory provides an understanding of post‐traumatic growth processes, and encourages therapists to adopt a more positive psychological perspective to their understanding of how people adjust to traumatic events.     

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。     

Assessment of Genuine and Simulated Dissociative Identity Disorder on the Structured Interview of Reported Symptoms

ABSTRACT

Little is known about how to detect malingered dissociative identity disorder (DID). This study presents preliminary data from an ongoing study about the performance of DID patients on the Structured Interview of Reported Symptoms (SIRS, Rogers, Bagby, & Dickens, 1992), considered to be a “gold standard” structured interview in forensic psychology to detect feigning of psychological symptoms. Test responses from 20 dissociative identity disorder (DID) patients are compared to those of 43 well informed and motivated DID simulators. Both the simulators and DID patients endorsed such a high number of symptoms that their average overall scores would typically be interpreted as indicative of feigning. The simulators' mean scores were significantly higher than those of the DID patients on only four out of 13 scales. These results provide preliminary evidence that well informed and motivated simulators are able to fairly successfully simulate DID patients and avoid detection on the SIRS. Furthermore, many DID patients may be at risk for being inaccurately labeled as feigning on the SIRS.     

‘Janet vs Freud’ on Traumatization: A Critique of the Theory of Structural Dissociation from an Object Relations Perspective

It is still ‘Janet vs Freud’. We present ‘The theory of structural dissociation’ and the three‐phase treatment programme that provides the basis for treatment of traumatized patients in many services in Europe, exploring its shortcomings. With roots in Janet's work it displays a behaviouristic, systemic view of the human being that allows for an understanding of traumatic experience as preventing natural development of the personality towards an integrated unit, or disrupting integration, causing splits along fault lines between major personality systems. Traumatization, structural dissociation, produces patients with multiple inner parts, each with a subjective first person perspective of experience not (necessarily) shared with other parts. With our roots in Freud, from an object relations perspective, we illustrate, through clinical example with two traumatized female patients, how (1) the transference and countertransference provides a unique, alternative understanding of the traumatized patient determining the direction of the therapeutic process, thus making a phase‐orientated therapy moot; (2) the patient's functioning prior to traumatization influences the actual traumatic experience, reactions to it and the treatment process; and (3) a patient's attachment needs and way of handling these, brings the traumatic experience into the treatment room from the first contact, providing a core process in the transference and countertransference throughout the therapy.     

Risk Factor Effect Sizes in PTSD: What This Means for Intervention

SUMMARY

This paper reviews evidence concerning the major risk factors for posttraumatic stress disorder. Although there are a number of consistent risk factors, their effects tend to be small and to vary according to the nature of the study. This suggests that they are not well suited to identifying individuals who require early intervention following a traumatic event. In contrast, methods based on symptom reports offer a much more sensitive and practicable approach to screening. A recent instrument, the Trauma Screening Questionnaire, is brief, simple to administer, and highly efficient at identifying survivors in need of intervention.     

Delusional Misidentification of Inanimate Objects: A Literature Review and Neuropsychological Analysis of Cognitive Deficits in Two Cases

Following a brief review of the literature on Delusions of Inanimate Doubles (DID), compared with other similar delusions, two cases are presented. Each completed a battery of tests designed to explore their cognitive abilities. In both cases, familiar and unfamiliar face-processing skills remained intact and word memory was unaffected. Their abilities to identify famous buildings and recognise unfamiliar houses were impaired. We propose that an extension of Ellis and Young's (1990) account of Capgras delusion can explain the cognitive impairments in case of DID. A comparison of the hypotheses of Staton et el. (1982), Ellis and Young (1990), and Van Lancker (1991) is also made. The last two have obvious similarities and seem to provide the best general approach. Finally, we caution the need to consider how a mood of suspiciousness may be needed to distort attribution processes that sustain delusional thinking.     

THE DAWN OF A NEW IDENTITY: ASPECTS OF A RELATIONAL APPROACH TO PSYCHOTHERAPY WITH A TRANSSEXUAL CLIENT

The importance of developing a certain consciousness in which one is present and autonomous while being intimately interconnected with larger meaning is an important dimension of a relational approach to psychotherapy. Based on the premise that both client and therapist bring something of themselves and of their respective past emotional experience to the therapeutic relationship, a relational approach to therapy is very attentive to the dynamics in the therapy room. It stresses the co‐creation of the therapeutic relationship at conscious, explicit verbal levels and unconscious, implicit levels of functioning, and establishes the therapist's emotional behaviour as a significant factor in fostering change ( Aron, 1996 ). Therapist responsiveness to client's affective impact is discussed with emphasis on its centrality to clinical practice and its relationship to countertransference. A case study of the psychotherapeutic journey with ‘Dawn’ (previously ‘David’), a 53 year‐old client who was awaiting sex‐reassignment surgery, is presented which illustrates how the therapist's struggle in the countertransference represents part of a complex relational body/mind system of parallel processes, re‐enactment and potential for therapeutic change.     

Possession Phenomena in North America: A Case Study with Ethnographic,Psychodynamic, Religious and Clinical Implications

ABSTRACT

Despite a paucity of attention within the scholarly literature, possession experiences among DID patients in North America are relatively commonplace. Because these phenomena are overrepresented among conservatively religious patients, some of these individuals may request expulsion rituals sanctioned by their belief systems. Although the ISSD guidelines rightly advise therapists to use extreme caution when considering such rituals, they provide virtually no assistance with how such caution might be measured and what, if any, expulsion procedure might be experienced as non-abusive by patients. The author's psychotherapy of a conservatively religious woman reporting possession is presented in detail as a springboard for exploring the potential ethnographic, psychodynamic, religious, and clinical implications of her experience. Knowledge of these considerations can assist therapists in evaluating and therapeutically managing DID patients who present with possession states.     

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.     

Cross-Cultural Adaptation of the Korean Version of the Minneapolis-Manchester Quality of Life Instrument-Adolescent Form

We verified the reliability and validity of the Korean version of the Minneapolis-Manchester Quality of Life Instrument-Adolescent Form (KMMQL-AF) among Korean childhood cancer survivors. A total of 107 childhood cancer patients undergoing cancer treatment and 98 childhood cancer survivors who completed cancer treatment were recruited. To assess the internal structure of the KMMQL-AF, we performed multi-trait scaling analyses and exploratory factor analysis. Additionally, we compared each domains of the KMMQL-AF with those of the Karnofsky Performance Status Scale and the Revised Children''s Manifest Anxiety Scale (RCMAS). Internal consistency of the KMMQL-AF was sufficient (Cronbach''s alpha: 0.78-0.92). In multi-trait scaling analyses, the KMMQL-AF showed sufficient construct validity. The "physical functioning" domain showed moderate correlation with Karnofsky scores and the "psychological functioning" domain showed moderate-to-high correlation with the RCMAS. The KMMQL-AF discriminated between subgroups of different adolescent cancer survivors depending on treatment completion. The KMMQL-AF is a sufficiently reliable and valid instrument for measuring quality of life among Korean childhood cancer survivors.     

Cognitive Inhibition in Dissociative Identity Disorder (DID): Developing an Understanding of Working Memory Function in DID

ABSTRACT

The current study examined cognitive inhibition, a mechanism of working memory, in dissociative identity disorder (DID). A negative priming procedure was used to assess inhibitory functioning in DID patients, as well as in a general population sample and a psychiatric comparison sample. Results from the first study show a significant interaction between group and experimental condition; the general population sample showed an independently non-significant trend towards negative priming while the two psychiatric groups showed no evidence of negative priming. Using different stimuli and a new priming procedure, Study 2 essentially replicated the findings of Study 1 with the control sample displaying significant negative priming and the two psychiatric samples producing no negative priming. High dissociativity was significantly related to reduced negative priming in Study 2. Findings suggest a relationship between DID and weakened inhibitory functioning and are discussed with reference to the negative priming and dissociation literatures.     

Using Psychomotor to Treat Dissociative Identity Disorder

Abstract

Pesso Boyden System Psychomotor Therapy (Psycho-motor) is offered as a useful approach to treating Dissociative Identity Disorder. Originally developed for group work, this therapy can be modified so that the alters can learn to play roles for one another that promote resolution of childhood injury, enhance internal communication and cooperation, and ultimately support the prospect of integration. Psycho-motor is unique in that it helps in the creation of synthesizing memories that provide antidotes for early traumas; not only can childhood abuse and neglect be metabolized, but also images of needs being met can be added. Moreover, Psychomotor develops the “Pilot” or adult functioning so that there is less likelihood of regression or dependence on the therapist. A four-stage progression of treatment is outlined: development of the “Pilot,” teaching the system's adults to engage in parenting the child alters, healing the wounds and the defensiveness of the “Protector/Controller,” and the internalization of the image of “Ideal Parents” so that the client can continue to resolve any surfacing memories of trauma or inadequate rearing.     

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.     

Inter-identity amnesia in dissociative identity disorder: a simulated memory impairment?

BACKGROUND: Although included in the current edition of the DSM, there does not seem to be consensus among mental health professionals regarding the diagnostic status and scientific validity of dissociative identity disorder (DID). This study was aimed at the detection of simulation of inter-identity amnesia in DID. METHOD: A sample of 22 DID patients was included, together with a matched control sample of subjects instructed to simulate inter-identity amnesia, a guessor group that had no knowledge of the stimulus material and a normal control group. A multiple-choice recognition test was included. The rate of incorrect answers was determined. Moreover, the specific simulation strategy used was examined by providing subjects with a range of choices that varied in extent of disagreement with the correct answer and determining whether plausible or implausible answer alternatives were selected. RESULTS: On the recognition test DID patients selected incorrect answers above chance like simulators. Patients thus seem to use their knowledge of the correct answer in determining their given answer. They were not characterized by a well-thought-out simulating behaviour style, as indicated by the differences in selection of specific answer alternatives found between patients and simulators. CONCLUSIONS: DID patients were found not to be characterized by an actual memory retrieval inability, in contrast to their subjective reports. Instead, it is suggested that DID may more accurately be considered a disorder characterized by meta-memory problems, holding incorrect beliefs about their own memory functioning.     

Symptoms of Traumatic Stress after Coronary Artery Bypass Grafting

Background: Traumatic stress symptoms have only recently been studied in association with medical treatment procedures. Purpose: The study examined associations of physical and psychological functioning during hospitalization to symptoms of traumatic stress after cardiac surgery. Methods: One hundred thirteen patients admitted for coronary artery bypass grafting participated in the study. Symptoms of traumatic stress were assessed one and six months after surgery, with the Impact of Event Scale. Preoperative stress and ruminative thinking, length of preoperative waiting, duration of surgery, and postoperative recovery indices (length of stay in the intensive care unit, cognitive functioning during intensive care, length of stay in the hospital) were examined. Results: Ten percent of the patients reported severe (> 19) symptoms of avoidance, and five percent reported severe symptoms of intrusion in both follow-ups. Hierarchical regression analyses showed that preoperative stress was positively associated to avoidance symptoms in both follow-ups (p < .01). Preoperative stress and ruminative thinking was positively associated to intrusion symptoms one month after surgery (p < .01). Disease related factors were not related to symptoms of traumatic stress during the postoperative period. Conclusion: This study highlights the role of preoperative surgery-related stress as a risk factor for traumatic stress in the postoperative period.