Dissociative Disorder
The Spectrum of Dissociative Disorders:
An Overview of Diagnosis and Treatment
by Joan A. Turkus, M.D.
As society has become increasingly aware of the prevalence of child
abuse and its serious consequences, there has been an explosion
of information on posttraumatic and dissociative disorders resulting
from abuse in childhood. Since most clinicians learned little about
childhood trauma and its aftereffects in their training, many are
struggling to build their knowledge base and clinical skills to
effectively treat survivors and their families.
Understanding dissociation and its relationship to trauma is basic
to understanding the posttraumatic and dissociative disorders. Dissociation
is the disconnection from full awareness of self, time, and/or external
circumstances. It is a complex neuropsychological process. Dissociation
exists along a continuum from normal everyday experiences to disorders
that interfere with everyday functioning. Common examples of normal
dissociation are highway hypnosis (a trance-like feeling that develops
as the miles go by), "getting lost" in a book or a movie
so that one loses a sense of passing time and surroundings, and
daydreaming.
Researchers and clinicians believe that dissociation is a common,
naturally occurring defense against childhood trauma. Children tend
to dissociate more readily than adults. Faced with overwhelming
abuse, it is not surprising that children would psychologically
flee (dissociate) from full awareness of their experience. Dissociation
may become a defensive pattern that persists into adulthood and
can result in a full-fledged dissociative disorder.
The essential feature of dissociative disorders is a disturbance
or alteration in the normally integrative functions of identity,
memory, or consciousness. If the disturbance occurs primarily in
memory, Dissociative Amnesia or Fugue (APA, 1994) results; important
personal events cannot be recalled. Dissociative Amnesia with acute
loss of memory may result from wartime trauma, a severe accident,
or rape. Dissociative Fugue is indicated by not only loss of memory,
but also travel to a new location and the assumption of a new identity.
Posttraumatic Stress Disorder (PTSD), although not officially a
dissociative disorder (it is classified as an anxiety disorder),
can be thought of as part of the dissociative spectrum. In PTSD,
recall/re-experiencing of the trauma (flashbacks) alternates with
numbing (detachment or dissociation), and avoidance. Atypical dissociative
disorders are classified as Dissociative Disorders Not Otherwise
Specified (DDNOS). If the disturbance occurs primarily in identity
with parts of the self assuming separate identities, the resulting
disorder is Dissociative Identity Disorder (DID), formerly called
Multiple Personality Disorder.
The Dissociative Spectrum
The dissociative spectrum (Braun, 1988) extends from normal dissociation
to poly-fragmented DID. All of the disorders are trauma-based, and
symptoms result from the habitual dissociation of traumatic memories.
For example, a rape victim with Dissociative Amnesia may have no
conscious memory of the attack, yet experience depression, numbness,
and distress resulting from environmental stimuli such as colors,
odors, sounds, and images that recall the traumatic experience.
The dissociated memory is alive and active--not forgotten, merely
submerged (Tasman & Goldfinger, 1991). Major studies have confirmed
the traumatic origin of DID (Putnam, 1989, and Ross, 1989), which
arises before the age of 12 (and often before age 5) as a result
of severe physical, sexual, and/or emotional abuse. Poly-fragmented
DID (involving over 100 personality states) may be the result of
sadistic abuse by multiple perpetrators over an extended period
of time.
Although DID is a common disorder (perhaps as common as one in
100) (Ross, 1989), the combination of PTSD-DDNOS is the most frequent
diagnosis in survivors of childhood abuse. These survivors experience
the flashbacks and intrusion of trauma memories, sometimes not until
years after the childhood abuse, with dissociative experiences of
distancing, "trancing out", feeling unreal, the ability
to ignore pain, and feeling as if they were looking at the world
through a fog.
The symptom profile of adults who were abuse as children includes
posttraumatic and dissociative disorders combined with depression,
anxiety syndromes, and addictions. These symptoms include (1) recurrent
depression; (2) anxiety, panic, and phobias; (3) anger and rage;
(4) low self-esteem, and feeling damaged and/or worthless; (5) shame;
(6) somatic pain syndromes (7) self-destructive thoughts and/or
behavior; (8) substance abuse; (9) eating disorders: bulimia, anorexia,
and compulsive overeating; (10) relationship and intimacy difficulties;
(11) sexual dysfunction, including addictions and avoidance; (12)
time loss, memory gaps, and a sense of unreality; (13) flashbacks,
intrusive thoughts and images of trauma; (14) hypervigilance; (15)
sleep disturbances: nightmares, insomnia, and sleepwalking; and
(16) alternative states of consciousness or personalities.
Diagnosis
The diagnosis of dissociative disorders starts with an awareness
of the prevalence of childhood abuse and its relation to these clinical
disorders with their complex symptomatology. A clinical interview,
whether the client is male or female, should always include questions
about significant childhood and adult trauma. The interview should
include questions related to the above list of symptoms with a particular
focus on dissociative experiences. Pertinent questions include those
related to blackouts/time loss, disremembered behaviors, fugues,
unexplained possessions, inexplicable changes in relationships,
fluctuations in skills and knowledge, fragmentary recall of life
history, spontaneous trances, enthrallment, spontaneous age regression,
out-of-body experiences, and awareness of other parts of self (Loewenstein,
1991).
Structured diagnostic interviews such as the Dissociative Experiences
Scale (DES) (Putnam, 1989), the Dissociative Disorders Interview
Schedule (DDIS) (Ross, 1989), and the Structured Clinical Interview
for Dissociative Disorders (SCID-D) (Steinberg, 1990) are now available
for the assessment of dissociative disorders. This can result in
more rapid and appropriate help for survivors. Dissociative disorders
can also be diagnosed by the Diagnostic Drawing Series (DDS) (Mills
& Cohen, 1993).
The diagnostic criteria for the diagnosis of DID are (1) the existence
within the person of two or more distinct personalities or personality
states, each with its own relatively enduring pattern of perceiving,
relating to, and thinking about the environment and self, (2) at
least two of these personality states recurrently take full control
of the person's behavior, (3) the inability to recall important
personal information that is to extensive to be explained by ordinary
forgetfulness, and (4) the disturbance is not due to the direct
physiological effects of a substance (blackouts due to alcohol intoxication)
or a general medical condition (APA, 1994). The clinician must,
therefore, "meet" and observe the "switch process"
between at least two personalities. The dissociative personality
system usually includes a number of personality states (alter personalities)
of varying ages (many are child alters) and of both sexes.
In the past, individuals with dissociative disorders were often
in the mental health system for years before receiving an accurate
diagnosis and appropriate treatment. As clinicians become more skilled
in the identification and treatment dissociative disorders, there
should no longer be such delay.
Treatment
The heart of the treatment of dissociative disorders is long-term
psychodynamic/cognitive psychotherapy facilitated by hypnotherapy.
It is not uncommon for survivors to need three to five years of
intensive therapy work. Setting the frame for the trauma work is
the most important part of therapy. One cannot do trauma work without
some destabilization, so the therapy starts with assessment and
stabilization before any abreactive work (revisiting the trauma).
A careful assessment should cover the basic issues of history (what
happened to you?), sense of self (how do you think/feel about yourself?),
symptoms (e.g., depression, anxiety, hypervigilance, rage, flashbacks,
intrusive memories, inner voices, amnesias, numbing, nightmares,
recurrent dreams), safety (of self, to and from others), relationship
difficulties, substance abuse, eating disorders, family history
(family of origin and current), social support system, and medical
status.
After gathering important information, the therapist and client
should jointly develop a plan for stabilization (Turkus, 1991).
Treatment modalities should be carefully considered. These include
individual psychotherapy, group therapy, expressive therapies (art,
poetry, movement, psychodrama, music), family therapy (current family),
psychoeducation, and pharmacotherapy. Hospital treatment may be
necessary in some cases for a comprehensive assessment and stabilization.
The Empowerment Model (Turkus, Cohen, & Courtois, 1991) for
the treatment of survivors of childhood abuse--which can be adapted
to outpatient treatment--uses ego-enhancing, progressive treatment
to encourage the highest level of function ("how to keep your
life together while doing the work"). The use of sequenced
treatment using the above modalities for safe expression and processing
of painful material within the structure of a therapeutic community
of connectedness with healthy boundaries is particularly effective.
Group experiences are critical to all survivors if they are to overcome
the secrecy, shame, and isolation of survivorship.
Stabilization may include contracts to ensure physical and emotional
safety and discussion before any disclosure or confrontation related
to the abuse, and to prevent any precipitous stop in therapy. Physician
consultants should be selected for medical needs or psychopharmacologic
treatment. Antidepressant and antianxiety medications can be helpful
adjunctive treatment for survivors, but they should be viewed as
adjunctive to the psychotherapy, not as an alternative to it.
Developing a cognitive framework is also an essential part of stabilization.
This involves sorting out how an abused child thinks and feels,
undoing damaging self-concepts, and learning about what is "normal".
Stabilization is a time to learn how to ask for help and build support
networks. The stabilization stage may take a year or longer--as
much time as is necessary for the patient to move safely into the
next phase of treatment.
If the dissociative disorder is DID, stabilization involves the
survivor's acceptance of the diagnosis and commitment to treatment.
Diagnosis is in itself a crisis, and much work must be done to reframe
DID as a creative survival tool (which it is) rather than a disease
or stigma. The treatment frame for DID includes developing acceptance
and respect for each alter as a part of the internal system. Each
alter must be treated equally, whether it presents as a delightful
child or an angry persecutor. Mapping of the dissociative personality
system is the next step, followed by the work of internal dialogue
and cooperation between alters. This is the critical stage in DID
therapy, one that must be in place before trauma work begins. Communication
and cooperation among the alters facilitates the gathering of ego
strength that stabilizes the internal system, hence the whole person.
Revisiting and reworking the trauma is the next stage. This may
involve abreactions, which can release pain and allow dissociated
trauma back into the normal memory track. An abreaction might be
described as the vivid re-experiencing of a traumatic event accompanied
by the release of related emotion and the recovery of repressed
or dissociated aspects of that event (Steele & Colrain, 1990).
The retrieval of traumatic memories should be staged with planned
abreactions. Hypnosis, when facilitated by a trained professional,
is extremely useful in abreactive work to safely contain the abreaction
and release the painful emotions more quickly. Some survivors may
only be able to do abreactive work on an inpatient basis in a safe
and supportive environment. In any setting, the work must be paced
and contained to prevent retraumatization and to give the client
a feeling of mastery. This means that the speed of the work must
be carefully monitored, and the release painful material must be
thoughtfully managed and controlled, so as not to be overwhelming.
An abreaction of a person diagnosed with DID may involve a number
of different alters, who must all participate in the work. The reworking
of the trauma involves sharing the abuse story, undoing unnecessary
shame and guilt, doing some anger work, and grieving. Grief work
pertains to both the abuse and abandonment and the damage to one's
life. Throughout this mid-level work, there is integration of memories
and, in DID, alternate personalities; the substitution of adult
methods of coping for dissociation; and the learning of new life
skills.
This leads into the final phase of the therapy work. There is continued
processing of traumatic memories and cognitive distortions, and
further letting go of shame. At the end of the grieving process,
creative energy is released. The survivor can reclaim self-worth
and personal power and rebuild life after so much focus on healing.
There are often important life choices to be made about vocation
and relationships at this time, as well as solidifying gains from
treatment.
This is challenging and satisfying work for both survivors and
therapists. The journey is painful, but the rewards are great. Successfully
working through the healing journey can significantly impact a survivor's
life and philosophy. Coming through this intense, self-reflective
process might lead one to discover a desire to contribute to society
in a variety of vital ways.
References
Braun, B. (1988). The BASK model of dissociation. DISSOCIATION,
1, 4-23. American Psychiatric Association. (1994). Diagnostic and
statistical manual of mental disorders (4th ed.). Washington, DC:
Author. Loewenstein, R.J. (1991). An office mental status examination
for complex chronic dissociative symptoms and multiple personality
disorder. Psychiatric Clinics of North America, 14(3), 567-604.
Mills, A. & Cohen, B.M. (1993). Facilitating the identification
of multiple personality disorder through art: The Diagnostic Drawing
Series. In E. Kluft (Ed.), Expressive and functional therapies in
the treatment of multiple personality disorder. Springfield: Charles
C. Thomas.
Putnam, F.W. (1989). Diagnosis and treatment of multiple personality
disorder. New York: Guilford Press.
Ross, C.A. (1989). Multiple personality disorder: Diagnosis, clinical
features, and treatment. New York: Wiley.
Steele, K., & Colrain, J. (1990). Abreactive work with sexual
abuse survivors: Concepts and techniques. In Hunter, M. (Ed.), The
sexually abused male, 2, 1-55. Lexington, MA: Lexington Books.
Steinberg, M., et al. (1990). The structured clinical interview
for DSM III-R dissociative disorders: Preliminary report on a new
diagnostic instrument. American Journal of Psychiatry, 147, 1.
Tasman, A., & Goldfinger, S. (1991). American psychiatric press
review of psychiatry. Washington, DC: American Psychiatric Press.
Turkus, J.A. (1991). Psychotherapy and case management for multiple
personality disorder: Synthesis for continuity of care. Psychiatric
Clinics of North America, 14(3), 649-660.
Turkus, J.A., Cohen, B.M., & Courtois, C.A. (1991). The empowerment
model for the treatment of post-abuse and dissociative disorders.
In B. Braun (Ed.), Proceedings of the 8th International Conference
on Multiple Personality/Dissociative States (p. 58). Skokie, IL:
International Society for the Study of Multiple Personality Disorder.
Joan A. Turkus, M.D., has extensive clinical experience in the
diagnosis and treatment of post-abuse syndromes and DID. She is
the medical director of The Center: Post-Traumatic & Dissociative
Disorders Program at The Psychiatric Institute of Washington. A
general and forensic psychiatrist in private practice, Dr. Turkus
frequently provides supervision, consultation, and teaching for
therapists on a national basis. She is co-editor of the forthcoming
book, Multiple Personality Disorder: Continuum of Care.
* This article has been adapted by Barry M. Cohen, M.A., A.T.R.,
for publication in this format. It was originally published in the
May/June, 1992, issue of Moving Forward, a semi-annual newsletter
for survivors of childhood sexual abuse and those who care about
them. For subscription information, write P.O. Box 4426, Arlington,
VA, 22204, or call 703/271-4024.
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