Guidelines for treating dissociative identity disorder in adults, third revision

The impact of the therapeutic alliance on treatment outcome in patients with dissociative disorders

BACKGROUND

Research has shown that the therapeutic alliance plays an important role in enhancing treatment outcome among individuals with a variety of disorders, including posttraumatic stress disorder (PTSD). However, the therapeutic alliance and treatment outcome has not yet been studied in dissociative disorders (DD).

OBJECTIVES

The current study sought to investigate the impact of alliance on treatment outcome for DD patients.

METHODS

Data from a naturalistic, longitudinal international treatment study of DD patients and their therapists were analyzed to determine if the alliance, as reported by patients and therapists, was associated with treatment outcome.

RESULTS

Patients with higher self-rated alliance had fewer symptoms of dissociation, PTSD, and general distress, as well as higher levels of therapist-rated adaptive functioning. Over time, self-rated alliance scores predicted better outcomes, after controlling for patient adaptive capacities including symptom management at the time when the alliance ratings were made. Patient-rated alliance was more strongly associated with outcome than therapist-rated alliance.

CONCLUSION

Therapists who work with DD patients should understand the importance of the alliance on treatment outcome. These findings are consistent with previous literature demonstrating the importance of developing and maintaining a strong therapeutic alliance, although the effect sizes of individuals with DD were stronger than what has been found in many other patient groups. A greater understanding of the impact of the alliance in traumatized individuals may contribute to better outcomes for these individuals.

Does phasic trauma treatment make patients with dissociative identity disorder treatment more dissociative?

Proponents of the iatrogenic model of the etiology of dissociative identity disorder (DID) have expressed concern that treatment focused on direct engagement and interaction with dissociated self-states harms DID patients. However, empirical data have shown that this type of DID treatment is beneficial. Analyzing data from the prospective Treatment of Patients With Dissociative Disorders (TOP DD) Study, we test empirically whether DID treatment is associated with clinically adverse manifestations of dissociated self-states: acting so differently that one feels like different people, hearing voices, and dissociative amnesia. We show that, over the course of the study, there were significant decreases in feeling like different people and hearing voices. These results indicate that this form of DID treatment does not lead to symptomatic worsening in these dimensions, as predicted by the iatrogenic model. Indeed, treatment provided by TOP DD therapists reduced, rather than increased, the extent to which patients experienced manifestations of pathological dissociation. Because severe symptomatology and impairment are associated with DID, iatrogenic harm may come from depriving DID patients of treatment that targets DID symptomatology.

Dissociation of the Personality and EMDR Therapy in Complex Trauma-Related Disorders: Applications in Phases 2 and 3 Treatment

Eye movement desensitization and reprocessing (EMDR) psychotherapy can play a major role in phase-oriented treatment of complex trauma-related disorders. In terms of the theory of structural dissociation of the personality and its related psychology of action, a previous article described Phase 1 treatment—Stabilization, Symptom Reduction, and Skills Training—emphasizing the use of EMDR procedures in this phase. Phase 2 treatment mainly involves applications of EMDR processing in overcoming the phobia of traumatic memories and their subsequent integration. Phase 3 treatment focuses on further integration of the personality, which includes overcoming various phobias pertaining to adaptive functioning in daily life. This article emphasizes treatment approaches that assist therapists in incorporating EMDR protocols in Phases 2 and 3 of phase-oriented treatment without exceeding clients’ integrative capacity or window of tolerance.

Dissociative disorders in medical settings

Despite the challenges of conducting research on dissociation and the dissociative disorders, our understanding has grown greatly over the past three decades, including our knowledge of the often overlooked sensorimotor manifestations of dissociation, more commonly referred to as somatoform dissociation. This article will first review the definitions and presentations of dissociation in general along with recent research on the concept of somatoform dissociation. Then, each of the dissociative disorders and conversion disorder will be discussed in further detail as well as how they might present in a medical setting. Current recommendations for diagnosis and treatment will also be provided.

Impact of dissociation and interpersonal functioning on inpatient treatment for early sexually abused adults

BACKGROUND

Little is known about the possible predictors of treatment outcome in early chronically sexually abused adults. The current study aimed to investigate what impact initial levels of dissociation and pre-treatment negative change in interpersonal functioning have on treatment response after 3 months of first-phase trauma inpatient treatment as well as after a period of 1 year the patients returned to their usual lives.

METHODS

The sample comprised 48 inpatients with childhood sexual abuse histories and mixed trauma-related disorders who were examined at discharge and prospectively followed up for a period of 1 year under naturalistic conditions. Outcome variables were general psychiatric symptoms and interpersonal problems as measured with the Symptom Check List-Revised (SCL-R) and the Inventory of Interpersonal Problems (IIP) Circumplex.

RESULTS

The central findings were that pathological dissociation and deterioration in interpersonal functioning prior to admittance predicted general psychiatric symptom levels and interpersonal problems at the end of treatment and at 1-year follow-up. Pathological dissociation, involving memory and identity problems, alone predicted negative outcome at the end of treatment. The findings at 1-year follow-up indicate that it is not pathological dissociation in isolation that affects outcomes, but rather the interaction between dissociation and change in interpersonal functioning prior to treatment.

CONCLUSION

These findings indicate the need of addressing dissociation and interpersonal problems in treatment planning and favor an integrated treatment approach for complex trauma patients. Future research should investigate whether and how this leads to better outcome, including long-term maintenance of gains after the end of treatment.

The shaping and integration of a trauma therapist

This article proposes a multifaceted model for the professional development of trauma therapists throughout their professional careers. Education, clinical practice, research, and self-reflection are critical, interacting components of this model for the competent practice of trauma psychotherapy. The International Society for the Study of Trauma and Dissociation (ISSTD), through its members, professional literature, trainings, and meetings, provides expertise in this area of mental health. ISSTD, in facing its responsibility for educational leadership, has developed a core curriculum of knowledge and a standard of training.

For better or worse: the role of revictimization and stress in the course of treatment for dissociative disorders

Revictimization and life stressors are common among dissociative disorder (DD) patients, yet no studies have examined the prevalence rates for these experiences or their relationships with treatment outcome. This study aimed to examine the rates of revictimization and victimization of others using therapist-DD patient pairs from the naturalistic Treatment of Patients with Dissociative Disorders (TOP DD) study while also considering the role of revictimization and life stressors among 49 patients who greatly improved or worsened during 30 months of treatment. Therapists reported that sexual and physical revictimization in the previous 6 months was high among the patients (3.5%-7.0% and 4.1%-7.1% in the overall TOP DD sample, respectively), and emotional revictimization was quite high (29%-36%). Revictimization showed a decreasing trend over the 30 months of the study. Therapists reported that more than a quarter of the patients who were revictimized were also occasionally emotionally or physically abusive to others. More patients showed sudden improvement versus sudden worsening in patient-reported symptoms at 1 or more time point(s). Patients who improved had significantly fewer revictimizations and stressors overall than patients who worsened, suggesting that revictimization and/or stressors may contribute to worsening in treatment. Further research is needed to learn more about the roles of revictimization, victimization of others, and stressors in DD treatment. [Supplementary material is available for this article. Go to the publisher's online edition of Journal of Trauma & Dissociation for the following supplemental resource: Baseline Demographic Information of TOP DD Improving and Worsening Subgroups].

Parent-child incest that extends into adulthood: a survey of international press reports, 2007-2011

Although the subject of ongoing incestuous abuse during adulthood has never been addressed in a systematic way in the professional literature, accounts of such cases have been appearing for many years. The Josef Fritzl case added a new impetus to reporting such abuses in the popular press. The current study presents 44 such cases from 24 countries that appeared in English-language press accounts over 5 years commencing January 2007. These cases are discussed in light of the minimal coverage of such issues in the professional literature. The results of this study suggest that cases of enduring incest are not rare and typically incorporate decades of sexual abuse, frequently result in pregnancies, and commonly incorporate ongoing violence and death threats.

What contributes to predicting change in the treatment of dissociation: initial levels of dissociation, PTSD, or overall distress?

Individuals with dissociative disorders (DDs) suffer from high levels of dissociation as well as posttraumatic stress disorder (PTSD) and general distress. No research has investigated how changes in dissociation relate to changes in other symptoms over the course of treatment in patients with DD. Using a prospective, naturalistic design, we collected reports of symptoms from a sample of therapists and their patients diagnosed with dissociative identity disorder or dissociative disorder not otherwise specified who participated in the Treatment Outcome of Patients with Dissociative Disorders study. The patients completed surveys at intake (Time 1) into the study and at 30-month follow-up (Time 4). We found that dissociative symptoms, including amnesia, depersonalization/derealization, and absorption, at the initial assessment of the study ("initial") were related to initial levels of PTSD and general distress and that changes in dissociative symptoms were related to changes in PTSD and general distress. Initial dissociation was a significant predictor of change in dissociation at 30 months when we controlled for length of time for follow-up, length of time practicing therapy, and length of time treating dissociative patients. Our results suggest that a reduction in dissociative symptoms in DD patients is associated with reductions in the overall severity of dissociative, posttraumatic stress, and distress symptoms.

Dissociation of the Personality and EMDR Therapy in Complex Trauma-Related Disorders: Applications in the Stabilization Phase

As proposed in a previous article in this journal, eye movement desensitization and reprocessing (EMDR) clinicians treating clients with complex trauma-related disorders may benefit from knowing and applying the theory of structural dissociation of the personality (TSDP) and its accompanying psychology of action. TSDP postulates that dissociation of the personality is the main feature of traumatization and a wide range of trauma-related disorders from simple posttraumatic stress disorder (PTSD) to dissociative identity disorder (DID). The theory may help EMDR therapists to develop a comprehensive map for understanding the problems of clients with complex trauma-related disorders and to formulate and carry out a treatment plan. The expert consensus model in complex trauma is phase-oriented treatment in which a stabilization and preparation phase precedes the treatment of traumatic memories. This article focuses on the initial stabilization and preparatory phase, which is very important to safely and effectively use EMDR in treating complex trauma. Central themes are (a) working with maladaptive beliefs, (b) overcoming dissociative phobias, and © an extended application of resourcing.

Ongoing incestuous abuse during adulthood

Individual cases of adult incestuous abuse have surfaced repeatedly in the lay and professional literature of the past 1.5 centuries without it occasioning systematic investigation, such as the reporting of a case series of individuals subjected to such extreme abuse. Yet substantial numbers of patients with dissociative identity disorder at the time of presentation report incestuous abuse continuing into the adult years, and for many the abuse is ongoing. Data relating to a series of 10 such incestuously abused women are presented. These patients were sexually abused from a very early age (typically from before age 3), with the manipulation of their sexual response a key component in conditioning an enduring sexualized attachment. Shame and fear were also used to ensure compliance and silence. The women, when able to speak of it, describe the induction by their paternal abuser of orgasm at an early age, typically around the age of 6. The women have high indices of self-harm and suicidality and are prone to placing themselves in dangerous reenactment scenarios. The average duration of incestuous abuse for this group of women was 31 years, and the average estimate of total episodes of sexual abuse was 3,320. Most women do not feel that they own their body and experience being "fused" to their father. Their mother was reported as an active participant in the sexual abuse or as having done nothing to protect their daughter despite seeing obvious evidence of incest. The fathers, despite a propensity to use or threaten violence, were generally outwardly productively employed, financially comfortable, and stably married and half had close church involvement. However, suicide and murder occurred within the 1st- or 2nd-degree relatives of these women at a high frequency. All 10 had been sexually abused by various groupings of individuals connected to their fathers.

Global functioning and disability in dissociative disorders

Dissociative disorders are frequent comorbid conditions of other mental disorders. Yet, there is controversy about their clinical relevance, and little systematic research has been done on how they influence global functioning. Outpatients and day care patients (N=160) of several psychiatric units in Switzerland were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV Axis I Disorders, Structured Clinical Interview for DSM-IV Dissociative Disorders, Global Assessment of Functioning Scale, and World Health Organization Disability Assessment Schedule-II. The association between subjects with a dissociative disorder (N=30) and functional impairment after accounting for non-dissociative axis I disorders was evaluated by linear regression models. We found a proportion of 18.8% dissociative disorders (dissociative amnesia=0%, dissociative fugue=0.6%, depersonalization disorder=4.4%, dissociative identity disorder=7.5%, dissociative disorder-not-otherwise-specified=6.3%) across treatment settings. Adjusted for other axis I disorders, subjects with a comorbid dissociative identity disorder or dissociative disorder-not-otherwise-specified had a median global assessment of functioning score that was 0.86 and 0.88 times, respectively, the score of subjects without a comorbid dissociative disorder. These findings support the hypothesis that complex dissociative disorders, i.e., dissociative identity disorder and dissociative disorder-not-otherwise-specified, contribute to functional impairment above and beyond the impact of co-existing non-dissociative axis I disorders, and that they qualify as "serious mental illness".

Organised abuse: a neglected category of sexual abuse with significant lifetime mental healthcare sequelae

BACKGROUND

Organised abuse (where multiple adults conspire to sexually abuse multiple children) has been one of the most controversial issues in debates over mental health practice with survivors of child sexual abuse.

AIMS

The aim of this paper is to summarise and analyse the available prevalence data pertinent to organised abuse and to identify the challenges that organised abuse poses for mental health policy and practice.

METHODS

Prevalence studies of sexual abuse based on community and clinical samples were reviewed for findings pertinent to organised abuse. Key indicators of organised abuse were selected and summarised on the basis of their association with the known characteristics of organised abuse. The literature regarding the health impacts of these indicators was also reviewed.

RESULTS

A minority of people reporting contact sexual abuse in the community report experiences indicative of organised abuse. These indicators are elevated in particular settings and they are associated with poor mental and physical health.

CONCLUSIONS

Organised abuse is rare but it is associated with poor mental and physical health outcomes. There is currently no source of integrated care for adults with histories of organised abuse. Many survivors end up in prison or homeless, chronically disabled by illness, or dead.

The use of imagery in phase 1 treatment of clients with complex dissociative disorders

The "standard of care" for clients with complex dissociative disorders and other complex trauma-related disorders is phase-oriented treatment. Within this frame, therapeutic progress can be enhanced by the use of imagery-based therapeutic techniques. In this article, the emphasis is on their application in phase 1 treatment, stabilization, symptom reduction, and skills training, but attention is also paid to applications in phase 2 and phase 3 treatment. Many of the existing imagery techniques are geared toward clients becoming more able to function in a more adaptive way in daily life, which, however, requires the involvement of various dissociative parts of the personality. Such collaborative involvement is also essential in the later treatment phases. Therefore, understanding the dissociative nature of these disorders is helpful in the judicious application of these techniques.

Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5

This article provides an overview of the process of developing the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association with a focus on issues related to the trauma-related disorders, particularly the dissociative disorders (DD). We also discuss the highlights of research within the past 5 years in the assessment, treatment, and neurobiological basis of trauma disorders. Recent research shows that DD are associated with severe symptoms as well as a higher rate of utilization of mental health treatment compared with other psychiatric disorders. As a result, DD, like other complex posttraumatic disorders, exact a high economic as well as personal burden for patients and society. The latest research indicates that DD patients show a suboptimal response to standard exposure-based treatments for posttraumatic stress disorder as well as high levels of attrition from treatment. An emerging body of research on DD treatment, primarily of naturalistic and open trials, indicates that patients who receive specialized treatment that addresses their trauma-based, dissociative symptoms show improved functioning and reduced symptoms. Recent studies of the underlying neurobiological basis for dissociation support a model of excessive limbic inhibition in DD that is consistent with the phenomenology and clinical presentation of these patients. We are optimistic that the forthcoming DSM-5 will stimulate research on dissociation and the DD and suggest areas for future studies.

An exploration of young adults' progress in treatment for dissociative disorder

Although treatment outcome research on dissociative disorders (DD) is increasing, an examination of treatment progress in young adults with these disorders remains noticeably absent from the literature. Many studies of DD patients report mean ages over 35. The present study examined the response to treatment of a subsample of young adults ages 18-30 with dissociative identity disorder and dissociative disorder not otherwise specified who participated in a naturalistic, longitudinal study of DD treatment outcome. Over 30 months, these patients demonstrated decreases in destructive behaviors and symptomatology as well as improved adaptive capacities. Compared to the older adult participants in the study, the young adults were more impaired initially. However, these younger patients improved at a rapid pace, such that their clinical presentations were similar to or more improved than those of the older adults at the 30-month follow-up. This brief report suggests not only that young adult DD patients can benefit from a trauma-focused, phasic treatment approach but that their treatment may progress at a faster pace than that of older adults with DD.

Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices

This study provides a summary of the results of an expert opinion survey initiated by the International Society for Traumatic Stress Studies Complex Trauma Task Force regarding best practices for the treatment of complex posttraumatic stress disorder (PTSD). Ratings from a mail-in survey from 25 complex PTSD experts and 25 classic PTSD experts regarding the most appropriate treatment approaches and interventions for complex PTSD were examined for areas of consensus and disagreement. Experts agreed on several aspects of treatment, with 84% endorsing a phase-based or sequenced therapy as the most appropriate treatment approach with interventions tailored to specific symptom sets. First-line interventions matched to specific symptoms included emotion regulation strategies, narration of trauma memory, cognitive restructuring, anxiety and stress management, and interpersonal skills. Meditation and mindfulness interventions were frequently identified as an effective second-line approach for emotional, attentional, and behavioral (e.g., aggression) disturbances. Agreement was not obtained on either the expected course of improvement or on duration of treatment. The survey results provide a strong rationale for conducting research focusing on the relative merits of traditional trauma-focused therapies and sequenced multicomponent approaches applied to different patient populations with a range of symptom profiles. Sustained symptom monitoring during the course of treatment and during extended follow-up would advance knowledge about both the speed and durability of treatment effects.