Somatoform Dissociation

Abstract

In most of the recent scientific and clinical literature, dissociation has been equated with dissociative amnesia, depersonalization, derealization, and fragmentation of identity. However, according to Pierre Janet and several World War I psychiatrists, dissociation also pertains to a lack of integration of somatoform components of experience, reactions, and functions. Some clinical observations and contemporary studies have supported this view. Somatoform dissociation, which can be measured with the Somatoform Dissociation Questionnaire (SDQ-20), is highly characteristic of dissociative disorder patients, and a core feature in many patients with somatoform disorders and in a subgroup of patients with eating disorders. It is strongly associated with reported trauma among psychiatric patients and patients with chronic pelvic pain presenting in medical healthcare settings. Motor inhibitions and anesthesia/analgesia are somatoform dissociative symptoms that are similar to animal defensive reactions to major threat and injury. Among a wider range of somatoform dissociative symptoms, these particular symptoms are highly characteristic of patients with dissociative disorders. The empirical findings reviewed in this article should have implications for the contemporary conceptualization and definition of dissociation, as well as the categorization of somatoform disorders in a future version of the DSM.     

Differentiating Dissociative Disorders from Other Diagnostic Groups Through Somatoform Dissociation in Turkey

Abstract

This study aimed to assess the reliability, validity, and psychometric characteristics of the Turkish version of the Somatoform Dissociation Questionnaire (SDQ-20). In this context, it investigated whether somatoform dissociation differentiates dissociative disorders from other diagnostic groups and non-clinical individuals. The Turkish Version of the SDQ-20 was administered to 50 patients with a dissociative disorder, 94 patients with psychiatric disorders other than dissociative disorder, and 175 non-clinical participants. To confirm the clinical diagnosis, all patients in the dissociative disorder group had been evaluated using the Structured Clinical Interview for DSM-IV Dissociative Disorders. The internal consistency and the test-retest correlation of the SDQ-20 were excellent. The scale had strong correlations with the DES and the DIS-Q. There was a statistically significant difference between dissociative patients and other diagnostic groups on the SDQ-20 total score. The discriminative power of the SDQ-20 was as robust as that of the DES. There was no significant difference between the mean SDQ-20 total scores of Turkish and Dutch patients, but Turkish dissociative patients reported pseudoseizures more frequently than Dutch patients. The specificity of the short version of the scale (SDQ-5) was weak among Turkish patients. Dissociative disorders can be differentiated from other diagnostic groups through somatoform dissociation. The good psychometric characteristics of the SDQ-20 among Turkish participants support its cross-cultural validity.     

Dissociative Symptoms and Cortisol Responses to Recounting Traumatic Experiences Among Childhood Sexual Abuse Survivors with PTSD

ABSTRACT

This study examined dissociative symptoms in relation to changes in evening salivary cortisol levels after recounting traumatic experiences among 49 women with PTSD for child sexual abuse (CSA). Each woman was interviewed to describe her sexual abuse and was assessed on acute dissociative symptoms in response to a recent stressful event in the previous month. Salivary cortisol was assessed during the interview using saliva samples taken immediately before and after the interview. Changes in cortisol levels were measured at one hour, 24 hours, and 48 hours after the interview. Acute dissociative symptoms were related to salivary cortisol levels 24 hours after the interview, with high dissociators showing elevated levels compared to low dissociators. These results suggest that dissociative symptoms in response to recent life stress are associated with cortisol dysregulation among women with PTSD for CSA.     

Validity and reliability of a Persian version of the Dissociative Experiences Scale II (DES-II) on Iranian patients diagnosed with schizophrenia and mood disorders

ABSTRACT

Dissociative Experiences Scale (DES) is a valid self-reported tool to evaluate both non-pathological and pathological dissociative experiences. This study aims at evaluating the psychometric properties of a Persian version of the DES-II on both non-clinical samples and patients with schizophrenia and mood disorders. The back-translated DES-II was administered to 370 individuals being divided into three groups (270 healthy subjects, 50 patients with mood disorders, and 50 patients with schizophrenia) recruited from Shahid Beheshti Hospital of Kerman Medical University. The results showed a good reliability (Cronbach’s alpha = 0.95), a very high item-total correlation, and a good internal consistency of 0.892 measured by split half. Moreover, the Persian version of the DES-II questionnaire demonstrated convergent validity of the scale. Analyses of the DES-II subscales revealed significant differences for amnesic experiences, absorption/imaginative involvement, and depersonalization/derealization among healthy individuals, and patients with mood disorders as well as schizophrenia. We also found significant differences among only schizophrenia group but not mood disorders group in comparison with healthy individuals (p value = .0001, and 0.70, respectively), and between patients with schizophrenia and patients with mood disorders (p value = .03) using DES-T. As a conclusion, the Persian version of the DES-II is an appropriate, reliable, and valid tool to screen dissociative experiences and discriminate subcomponents of dissociative disorders in the Iranian population.     

Indirect (chronic) self-destructiveness and modes of suicide attempts

Introduction

Suicides and suicide attempts may be considered as manifestations not only of direct self-destructiveness, but also of indirect (chronic) self-destructiveness. The aim of this work is to assess the relation between intensity of indirect self-destructiveness and suicide attempt modes.

Material and methods

The research was conducted among 147 persons after suicide attempts (114 women and 33 men) aged 14-33 years. The Polish version of the “Chronic Self-Destructiveness Scale” by Kelley (CS-DS) in Suchańska''s adaptation was used.

Results

Examined persons applied several modes of committing suicide: pharmacological drugs, exsanguination, hanging, jumping from a height, asphyxia, poisoning, and throwing oneself under a moving car. The most frequent are pharmacological drugs (42.31%) and exsanguination (25.60%); the rarest is throwing oneself under a car (1.28%). Relations between indirect self-destructiveness and the following suicide attempt modes were found: pharmacological drugs (0.366, p = 0.00001), poisoning (0.667, p = 0.01), and throwing oneself under a car (0.542, p = 0.04). There were found three clusters regarding the intensity of indirect self-destructiveness (low, medium and high). The largest differences concerned hanging, jumping from a height (medium CS-DS), poisoning and throwing oneself under a car (high CS-DS). There is a relation between indirect self-destructiveness and recurrence of suicide attempts (Kendall Tau = 0.217, p = 0.007); the intensity of indirect self-destructiveness differentiates the risk of consecutive suicide attempts (F = 2.871, p = 0.05).

Conclusions

The implications of the findings are mainly of preventive and therapeutic nature. In the preventative aspect, the subject of interest should be not only persons with a tendency to the active form of indirect self-destructiveness, but also persons exhibiting its passive form.     

Participation in War-Zone Atrocities and Trait Dissociation Among Vietnam Veterans with Combat-Related Posttraumatic Stress Disorder

Abstract

Objective: This study tested the hypothesis that participation in war-zone atrocities would be significantly related to long-standing dissociative symptomatology among Vietnam veterans with combat-related PTSD.

Method: Self-report data concerning childhood sexual/physical abuse, combat exposure, participation in war-zone atrocities, and trait dissociation were examined.

Conclusion: Vietnam veterans who participated in war-zone atrocities are more likely to report long-standing dissociative symptoms.

Results: Exposure to childhood abuse, as well as exposure to general combat events, was not correlated with trait dissociation. However, participation in war-zone atrocities was correlated with trait dissociation.     

Psychotherapy of an Adolescent with Dissociative Identity Disorder

Abstract

A female adolescent with dissociative identity disorder was assessed using structured interviews and the Rorschach test before and after one year of individual psychotherapy. In addition to improvement in several comorbid psychiatric disorders, according to the structured evaluation, criteria for neither dissociative identity disorder nor borderline personality disorder were met at the second evaluation. The main differences on the Rorschach assessments before and after integration were in the development of form-dominated color and human movement responses and a diminution in the externally focused coping style. The differences were interpreted as improvement in aggressiveness, impulsivity, anxiety, and better identification with social environment. This case study suggests that the Rorschach test can be used to evaluate the change of patients with dissociative identity disorder in psychotherapy.     

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.     

Obsessive Compulsive Spectrum Disorders in Individuals with Dissociative Disorders

Abstract

The spectrum of Obsessive Compulsive Disorders is briefly presented. The phenomenological and neurophysiological overlap of these conditions with dissociation is described. Three case reports are used to illustrate these overlaps. All three cases have histories of early childhood trauma, dissociative symptoms and features of Obsessive Compulsive Spectrum Disorders that have proven to be treatment resistant with previous cognitive/behavioural and pharmacological interventions. The three cases illustrate that, in at least some individuals with dissociative disorders, a psychodynamic understanding of their Obsessive Compulsive symptoms is an important part of their successful treatment.     

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.     

The Treatment of Dissociative Identity Disorder with Cognitive Analytic Therapy: Experimental Evidence of Sudden Gains

ABSTRACT

The central aim of this study was to assess the effectiveness of cognitive analytic therapy (CAT) with a patient presenting with DID. The methodology employed an A/B single case experimental design with six-months continuous follow-up in seven experimental measures. A and B represent the assessment of seven dissociative experimental variables under two conditions: baseline (A) and treatment (B). Treatment consisted of 24 sessions of CAT with four follow-up sessions, which is standard within the CAT model for personality disorder patients. A battery of measures of general psychological functioning was also completed at assessment, termination, and follow-up. During treatment the intensity of a range of dissociative symptoms was observed to be reduced, with sudden gains evident due to specific CAT interventions in specific dissociative symptoms. The long-term effectiveness of the intervention was established by the illustration of either continued stability or continued improvement in experimental variables across the follow-up period. Analysis of the general measures illustrates clinically significant change across a variety of robust psychometric measures. The study illustrates the utility of single-case approaches with dissociative disorders and the potential for utilizing CAT generally with such presentations.     

The Structure of Dissociative Fugue: A Case Report

ABSTRACT

Classically, when an episode of dissociative fugue resolves, there is enduring amnesia for the period of fugue, with normal pre- and post-fugue memory. The authors describe a case in which their treatment goal was to reverse the amnesia for the period of fugue. In the course of treatment, the authors learned that dissociative fugue has a complex internal structure, is often preceded by major depression, and can be difficult to differentiate from other dissociative disorders. There is often a history of childhood trauma. Rather than being a simple dissociative disorder, as the authors had believed, fugue is complex, structured, and often accompanied by depression.     

Ten-Year Follow-Up Study of Patients with Dissociative Identity Disorder

Abstract

Lit tie fol low-up data has been pub lished on in di vid u als with dissociative iden tity dis or der (DID). In this study, DID was di agnosed in 25 pa tients by two sea soned dissociative dis or der clinician/researchers be ginning in 1986. The initial evaluationin cludedacomprehensive med i cal and psy chi at ric eval u a tion and Min ne sota Multiphasic Per sonal ity In ven tory (MMPI). A ten-year fol low-up eval u a tion in eluded the Dissociative Experi ences Scale, Ci vil ian Mis sis sippi PTSD Scale, Beck Inventory for De pres sion, Life Ex pe ri ences Sur vey, the MMPI Hypochondriasis scale, and a dissociative dis or ders fol low-up ques tion naire. The pa tients were also asked to write a nar ra tive about their life and treatment since intake. Twelve patients provided follow-up data. Of these twelve, six ul ti mately achieved full in te gra tion of their per son al ity states, although two of them subsequently dissociated into alter personality states again. The two teen-aged pa tients achieved full in te gra tion within two years, while the older pa tients took con sid er ably Ion ger. Of the patients who elected to con tinue in treat ment for their dissociative dis or der and who con tinued to dis so ci ate into al ter per son al ity states, all have experienced major symptomatic improvement in both dissociative and non-dissociative symptomatology. Of the two therapy dropouts, both con tinue to have dissociative symp toms at fol low-up. We con elude that treatmentforDIDfollowingtreatmentguidelinespromulgated by the International Societyforthe Study of Dis so ciation brings about symptomatic im prove merit in both dissociative and non-dissociative symp toms. Ig noring symp toms of dis so ci a tion, as has been ad vo cated by some, resuits in no im prove ment.     

Evidence for a Dissociative Subtype of Post-Traumatic Stress Disorder Among Help-Seeking Childhood Sexual Abuse Survivors

ABSTRACT

This study examined evidence for a dissociative subtype of post-traumatic stress disorder (PTSD) among women seeking psychotherapy for childhood sexual abuse (CSA). One hundred and twenty-two women seeking treatment for CSA completed a battery of questionnaires assessing PTSD, dissociative symptoms, and child maltreatment. Using signal detection analysis, we identified high and low dissociation PTSD subgroups. A constellation of three PTSD symptoms-hypervigilance, sense of foreshortened future, and sleep difficulties–discriminated between these two subgroups (OR = 8.15). Further evidence was provided by the finding of a nonlinear relationship between severity of childhood maltreatment and dissociation in the women with PTSD. These results provide support for a dissociative subtype of PTSD that may stem from more severe childhood experiences of neglect and abuse.     

Reconsidering the autohypnotic model of the dissociative disorders

The dissociative disorders field and the hypnosis field currently reject the autohypnotic model of the dissociative disorders, largely because many correlational studies have shown hypnotizability and dissociation to be minimally related (r = .12). Curiously, it is also widely accepted that dissociative patients are highly hypnotizable. If dissociative patients are highly hypnotizable because only highly hypnotizable individuals can develop a dissociative disorder – as the author proposes – then the methodology of correlational studies of hypnotizability and dissociation in random clinical and community samples would necessarily be constitutively unable to detect, and statistically unable to reflect, that fact. That is, the autohypnotic, dissociative distancing of that small subset of highly hypnotizable individuals who repeatedly encountered intolerable circumstances is statistically lost among the data of (1) the highly hypnotizable subjects who do not dissociate and (2) subjects (of all levels of hypnotizability) who manifest other kinds of dissociation. The author proposes that, when highly hypnotizable individuals repeatedly engage in autohypnotic distancing from intolerable circumstances, they develop an overlearned, highly-motivated, automatized pattern of dissociative self-protection (i.e., a dissociative disorder). The author urges that theorists of hypnosis and the dissociative disorders explicitly include in their theories (a) the trait of high hypnotizability, (b) the phenomena of autohypnosis, and (c) the manifestations of systematized, autohypnotic pathology. Said differently, the author is suggesting that autohypnosis and autohypnotic pathology are unacknowledged nodes in the nomothetic networks of both hypnosis and dissociation.     

Depressive Symptoms and Sleep Disturbance in Adults with Histories of Childhood Abuse

Abstract

Depressive symptoms including sleep disturbance are clinically apparent in many patients with histories of childhood abuse. This study investigated the nature and severity of depressive symptoms, sleep disturbance, and trauma-related symptoms in a group of female participants with abuse histories, as compared to a non-abused group of female participants with major depression. Sixty (60) participants with a history of childhood abuse and 13 participants with major depression completed several self-report instruments which examine past life experiences, depressive symptoms, post-traumatic symptoms, dissociative symptoms, and sleep problems. To control for differences in background characteristics, a subset of participants with abuse histories were matched to and compared with the 13 depressed participants. Both the abused and depressed groups showed high levels of depressive symptoms, but there were no significant differences between the groups. The abused group had significantly more intrusive post-traumatic symptoms, more dissociative symptoms, and were more likely to be afraid of falling asleep and more anxious upon mid-sleep awakening. Severity of depressive symptoms in the abused group was correlated with severity of intrusive post-traumatic symptomatology. The investigators conclude that symptoms of major depression in some patients with abuse histories may have a post-traumatic etiology, especially since intrusive reexperi-encing of past trauma may produce severe dysphoria and hopelessness. The nature of sleep disturbance in patients with abuse histories may be a clinical tool to identify patients whose depressive symptoms may be post-traumatic in origin.     

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.     

Demographic and Seizure Variables,But Not Hypnotizability or Dissociation,Differentiated Psychogenic from Organic Seizures

Abstract

Early detection and differential diagnosis of psychogenic non-epileptic seizures (PNES) and epileptic seizures (ES) is a major clinical issue in comprehensive epilepsy centers. Using blind conditions with patients with PNES (N= 10) and ES (N= 31) before diagnosis, we tested the hypotheses that individuals with PNES would exhibit significantly greater dissociativity, hypnotizability, absorption, and history of early abuse than ES patients. Although PNES patients tended to show greater dissociative phenomena, only the last of our hypotheses was fully supported. Although absorption did not discriminate between the two diagnostic groups, it was significantly higher among those reporting early abuse. A logistic regression analysis using scores on dissociation, hypnotizability and absorption showed them to be poor predictors of diagnosis; however, other analyses revealed that female gender, reports of multiple trauma incidents lasting months or years, initial seizure onset in late teens or twenties, and daily seizure attacks significantly differentiated PNES from ES patients. Thus, demographic and seizure variables proved to be much better predictors of diagnosis than psychological dimensions often associated with PNES.     

Client Satisfaction Survey of Inpatient Trauma and Dissociative Disorders Program

Abstract

Treatment interventions from a specialized multi-disciplinary inpatient trauma and dissociative disorders program were evaluated by 43 patients through the use of a satisfaction survey questionnaire. Interventions with the highest ranking means of usefulness, as perceived by participants, included individual therapy sessions by both the psychiatrist and the psychotherapist, trauma group, psychodrama, and goals-and-closure group. Body awareness group, led by nurses, and body movement group, led by expressive therapists, were rated the lowest. These results indicate the importance for specialized trauma programs to address body distorted perceptions of the dissociative patients while maintaining frequent individual treatment interventions that address the patients' existing problems they bring to therapy.