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.     

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.     

Attachment insecurity as a mediator of the relationship between childhood trauma and adult dissociation

This study aimed to investigate whether attachment insecurity mediates the relationship between childhood trauma and adult dissociation, specifically with regard to individual forms of childhood maltreatment. Psychiatric outpatients who visited a specialized trauma clinic (n = 115) participated in the study. Data were collected via the Childhood Trauma Questionnaire, Revised Adult Attachment Scale, and Dissociative Experience Scale. Structural equation modeling and path analysis were performed to analyze the mediating effects of attachment insecurity on the relationship between childhood trauma and adult dissociation. Greater childhood trauma was associated with higher dissociation, and the relationship between them was fully mediated by attachment anxiety. In path analysis of trauma subtypes, the effects of emotional abuse, physical abuse, and physical neglect as a child on adult dissociation were found to be fully mediated by attachment anxiety. The effect of sexual abuse on dissociation was mediated by a synergistic effect from both attachment anxiety and attachment avoidance. Regarding emotional neglect, a countervailing interaction was discovered between the direct and indirect effects thereof on dissociation; the indirect effect of emotional neglect on dissociation was partially mediated by attachment insecurity. Specific aspects of attachment insecurity may help explain the relationships between individual forms of childhood trauma and adult dissociative symptoms. Tailored treatments based on affected areas of attachment insecurity may improve outcomes among patients with dissociative symptoms and a history of childhood trauma.     

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.     

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).     

Effectiveness of non-pharmacological interventions on individuals with anorexia nervosa: A systematic review and meta-analysis

ObjectiveThis study aimed to synthesize the best available evidence regarding the effectiveness of non-pharmacological interventions on body mass index (BMI), body dissatisfaction, depression and anxiety among individuals with anorexia nervosa (AN).MethodsPublished studies in English were searched using seven databases (such as PubMed). Grey literature was searched using ProQuest and Scopus. Studies were screened, appraised and extracted by two independent reviewers. Meta-analysis was performed and standardized mean difference was used as an effect measure. Heterogeneity was determined by I² statistics and Cochran χ² test. Publication bias was appraised using funnel plots. Sensitivity and subgroup analyses were also conducted.ResultsNineteen RCTs from eight different countries were included in this review. Behavioral family system therapy (BFST) was found to enhance BMI while conjoint family therapy (CFT) was more effective in ameliorating depression. Studies implementing combined family and individual therapy and those with longer therapeutic durations produced larger effect sizes.ConclusionThis review provided evidence to support BSFT, CFT and combined family and individual therapy for adolescents with AN.Practical implicationsHealthcare professionals may offer the two interventions to adolescents with AN in clinical settings. Future research may further investigate the effectiveness of BSFT and CFT on BMI and depression.     

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.     

Results of a self-management program added to standard physical therapy in chronic neck pain

ObjectiveTo evaluate the effectiveness of a self-management treatment added to a physical therapy program compared to a physical therapy program in patients with chronic neck pain.MethodsFifty-three patients with chronic neck pain were randomly allocated to a physical therapy intervention (control group) or an individualized self-management combined with physical therapy intervention (experimental group). Both interventions were developed over a four-week period. Outcome measures included were Disability, Fear-Avoidance Beliefs, Health-Related Quality of Life, Pain, and Anxiety and Depression. All outcomes were measured before and after the treatment and at three-month follow-up.ResultsThere were not significant differences between groups at baseline. After the intervention both groups obtained better results in the Neck Disability Index but there were not significant differences between them (p > 0.05). At follow-up, the self-management group obtained significant better results compared to the control group (95 % CI: -5.20(-6.8 to -1.5), p = 0.032).ConclusionsAn individualized self-management program added to a physical therapy program led to a greater improvement in disability at 3 months follow up compared to a physical therapy program alone. Catastrophizing, pain, and health-related quality of life improved significantly after the intervention and at follow-up compared to the standard care alone.Practical implicationsThis study indicates that physical therapy for patients with chronic neck pain preferably should include self-management education.     

Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events

Child and adolescent trauma exposure is prevalent, with trauma exposure-related symptoms, including posttraumatic stress, depressive, and anxiety symptoms often causing substantial impairment. This article updates the evidence base on psychosocial treatments for child and adolescent trauma exposure completed for this journal by Silverman et al. (2008). For this review, we focus on 37 studies conducted during the seven years since the last review. Treatments are grouped by overall treatment family (e.g., cognitive behavioral therapy), treatment modality (e.g., individual vs. group), and treatment participants (e.g., child only vs. child and parent). All studies were evaluated for methodological rigor according to Journal of Clinical Child & Adolescent Psychology evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, 2014), with cumulative designations for level of support for each treatment family. Individual CBT with parent involvement, individual CBT, and group CBT were deemed well-established; group CBT with parent involvement and eye movement desensitization and reprocessing (EMDR) were deemed probably efficacious; individual integrated therapy for complex trauma and group mind–body skills were deemed possibly efficacious; individual client-centered play therapy, individual mind–body skills, and individual psychoanalysis were deemed experimental; and group creative expressive + CBT was deemed questionable efficacy. Advances in the evidence base, with comparisons to the state of the science at the time of the Silverman et al. (2008) review, are discussed. Finally, we present dissemination and implementation challenges and areas for future research.     

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.     

Dissociative subtype of posttraumatic stress disorder in women in partial and residential levels of psychiatric care

ABSTRACT

The dissociative subtype of posttraumatic stress disorder (PTSD) is estimated to characterize about 12-30% of those with PTSD. Some research links this subtype with increased severity of PTSD symptoms compared to samples with “classic” PTSD. However, prevalence and severity rates reported in the literature have varied. One possible explanation for these discrepancies could be related to where the populations were sampled. Therefore, we investigated whether these differences are still observed when holding level of care constant. We collected data from 104 women at a partial and residential psychiatric hospital program focused on trauma-related disorders. Participants completed self-report questionnaires assessing trauma exposure, symptoms and provisional diagnosis of PTSD, trauma-related thoughts and beliefs, and feelings of shame. All participants reported a history of childhood and/or adulthood trauma exposure. Eighty-eight (85%) met criteria for PTSD, and of those, seventy-three (83%) met criteria for the dissociative subtype as assessed by the Dissociative Subtype of PTSD Scale. A series of independent t-tests revealed no significant differences between the “classic” and dissociative PTSD groups with respect to lifetime or childhood trauma exposure, posttraumatic cognitions, shame, or overall PTSD severity. Our results suggest that samples with classic PTSD and the dissociative subtype may not differ in some types of symptom severity when holding level of care constant. Importantly, however, we found at partial/residential level of care the majority of patients with PTSD were dissociative. Given the elevated prevalence rate in this sample, these findings support the need to assess dissociative symptoms, particularly in more acute psychiatric settings.     

Long-Term Effects of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass on Body Composition and Bone Mass Density

BackgroundCurrently, the two most common bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Long-term data comparing the two interventions in terms of their effect on body composition and bone mass density (BMD) are scarce.ObjectiveThe aim of this study was to assess body composition and BMD at least 5 years after LSG and LRYGB.SettingDepartment of Endocrinology and Nutrition, St. Claraspital Basel and St. Clara Research Ltd., Basel, Switzerland.MethodsBariatric patients at least 5 years after surgery (LSG or LRYGB) were recruited, and body composition and BMD were measured by means of dual-energy X-ray absorptiometry. Data from body composition before surgery were included in the analysis. Blood samples were taken for determination of plasma calcium, parathyroid hormone, vitamin D₃, alkaline phosphatase, and C-terminal telopeptide, and the individual risk for osteoporotic fracture assessed by the Fracture Risk Assessment Tool score was calculated. After surgery, all patients received multivitamins, vitamin D₃, and zinc. In addition, LRYGB patients were prescribed calcium.ResultsA total of 142 patients were included, 72 LSG and 70 LRYGB, before surgery: median body mass index 43.1, median age 45.5 years, 62.7% females. Follow-up after a median of 6.7 years. For LRYGB, the percentage total weight loss at follow-up was 26.3% and for LSG 24.1% (p = 0.243). LRYGB led to a slightly lower fat percentage in body composition. At follow-up, 45% of both groups had a T score at the femoral neck below −1, indicating osteopenia. No clinically relevant difference in BMD was found between the groups.ConclusionsAt 6.7 years after surgery, no difference in body composition and BMD between LRYGB and LSG was found. Deficiencies and bone loss remain an issue after both interventions and should be monitored.     

Trauma and anxious attachment influence the relationship between suggestibility and dissociation: a moderated-moderation analysis

Introduction: Hypnotic suggestibility is elevated in the dissociative disorders but the relationship between dissociative tendencies and suggestibility in the general population seems to be constrained by additional factors. The diathesis-stress (DS) model stipulates that suggestibility interacts with trauma exposure to augment the propensity for dissociative states whereas the dual pathway to suggestibility (DPS) model proposes two developmental routes involving either dissociation preceded by trauma, or a healthy cognitive profile characterised by superior imagination.

Methods: This study sought to discriminate between these partially competing accounts and further considered the moderating role of anxious attachment. 209 participants completed psychometric measures of dissociative tendencies, trauma, and attachment, and a behavioural measure of suggestibility.

Results: In support of the DS model, trauma moderated the relationship between suggestibility and dissociation and, as predicted by the DPS model, dissociation moderated the relationship between trauma and suggestibility. Anxious attachment additionally moderated both effects. Model comparisons indicated that the DS model consistently provided a superior fit to the data. Further analyses showed that secure attachment independently predicted suggestibility, thereby supporting the non-dissociative pathway in the DPS model.

Conclusions: These results suggest that high suggestibility confers vulnerability to dissociative states in individuals exposed to trauma and displaying an anxious attachment style.     

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.     

Trauma unit management and outcomes at an urban tertiary hospital in sub-Saharan Africa: a descriptive study

BackgroundInjuries are a neglected burden despite accounting for 9% of deaths worldwide which is 1.7 times that of hiv, tb and malaria combined. Trauma remains overlooked as research and resources are focused on infectious diseases. Uganda with limited trauma epidemiological data has one of the highest traumatic injury rates. This study describes demographics, management and outcomes of patients admitted to mulago hospital trauma unit.Materials and methodsThis study was a retrospective record review from july 2012 to december 2015. A data collected included age, time and vitals of admission plus interventions, management and outcomes after which it was analyzed.Results834 patient records were reviewed. The predominant age group was 18–35 and 86% of the patients were male. 54% of the patients presented during day and majority of the admission had gcs of less than 8. Antibiotics were given to 467 patients with mechanical ventilation (301) and intubation (289) as the frequent interventions done. 52% of admitted patients were discharged and 40% died.ConclusionMost admissions'' were of youthful age and had severe head injuries (gcs<8). 56% received antibiotics with frequent interventions beig mechanical ventilation and intubation. 52% of admitted patients were discharged and 40% died     

Hearing voices,dissociation, and the self: A functional-analytic perspective

In the current article, we review existing models of the etiology of voice hearing. We summarize the argument and evidence that voice hearing is primarily a dissociative process involving critical aspects of self. We propose a complementary perspective on these phenomena that is based on a modern behavioral account of complex behavior known as relational frame theory. This type of approach to voice hearing concerns itself with the functions served for the individual by this voice hearing; the necessary history, such as trauma, that establishes these functions; and the relevant dissociative processes involving self and others. In short, we propose a trauma–dissociation developmental trajectory in which trauma impacts negatively on the development of self through the process of dissociation. Using the relational frame theory concept of relations of perspective taking, our dissociation model purports that trauma gives rise to more coordination than distinction relations between self and others, thus weakening an individual’s sense of a distinct self. Voice hearing experiences, therefore, reflect an individual’s perceptions of self and others and may indicate impairments in the natural psychological boundaries between these critical related concepts. One clinical implication suggested by this model is that therapeutic intervention should understand the behaviors associated with a sense of self that is fragile and threatened by others. Relations with self and others should be a key focus of therapy as well as interventions designed to enhance a coherent distinct sense of self.     

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.     

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.     

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.