Daily Archives: August 27, 2010

Dissociative Disorders | Dissociative Amnesia | Dissociative Fugue | Dissociative Identity Disorder (DID) | Depersonalization Disorder | Dissociative Disorder NOS

Dissociative Disorders as a category generally encompass dissociative amnesia, dissociative fugue, dissociative identity disorder (DID), depersonalization disorder, and dissociative disorder not otherwise specified (DDNOS).  DDNOS is a residual category intended to capture clinical presentations of DID that fail to meet the full criteria, including derealization unaccompanied by depersonalization, dissociative states in individuals who have been subjected to sever coercive persuasion (makes no sense), dissociative trance disorder, medically unexplained loss of consciousness, stupor, or coma (conversion disorder?); and Ganser syndrome (nonsense, balderdash, approximate answers; syndrome).   The irony is that DDNOS represents the majority of clinical presentations, suggesting that some reorganization of the category is needed since the residual diagnostic label gets more airplay than the flagship disorders.

Structural dissociation of the personality translates into “a lack of integration among two or more psychobiological subsystems of the personality as a whole system, each endowed with at least a rudimentary sense of self.”  One person, multiple personalities; where personalities are defined as “the dynamic organization within the individual of those psychophysical systems that determine his characteristic behavior and thought.”  (Blaney & Millon, 2009, p. 453)

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“Dissociative Amnesia is the sudden inability to recall personal information that is too extensive to be explained by ordinary forgetfulness.”  (Blaney & Millon, 2009, p. 457)  Of note, is that the diagnosis requires that no other dissociative disorders be present or diagnosed… as a result, this is often a precursor to or a marker for more pervasive dissociative disorders.  Like dissociative fugue, it can be a symptom or a syndrome.  Blaney and Millon embrace an etiological background that includes environmental factors (lack of support, exposure to trauma) with biological predispositions (personal and social factors, low integrative capacity).

Dissociative fugue is similar to tic disorder in the respect that it can be either a symptom or a disorder in and of itself.  Fugue’s onset is relatively sudden in most cases, resulting when an individual travels away from one’s customary home or work.  The result is an inability to recall the past, similar to amnesia, but fugue is predicated by travel.  The amnesia aspect indicates that there may be a strong division between dissociative parts of the personality, and the normally inactive emotional personality (EP) totally dominates the apparently normal personality (ANP).  (Blaney & Millon, 2009, p. 458)

The spectrum of Dissociative Disorders culminates with Dissociative Identity Disorder (DID).  Two or more distinct identities or personality states must be present, and they must recurrently take control of the person’s behavior.  There are some inherent problems with the DID diagnosis, particularly because there is no clarity on the range of what is considered “complete control.”  The list of comorbid disorders with DID read like a laundry list (it is the longest one I have seen to date).  PTSD, self-mutilation, aggressive and suicidal behaviors, impulsivity, repetitive abusive relationships, conversion symptoms, mood, substance-related, sexual and eating disorders, as well as personality disorders are among them.  (Blaney & Millon, 2009, p. 458)  I have never seen comorbity suggestions include entire categories!

Depersonalization Disorder represents persistent or recurring episodes of “feelings of detachment or estrangement from one’s self, while reality testing remains intact.”  (Blaney & Millon, 2009, p. 459)  This reminded me of schizophrenia.  “Out of body experiences” coupled with feeling like your living in a dream or a movie sound like schizophrenia to me.  Maybe I am off here though.

DDNOS is a grab bag of disorders, including the most prevalent disorder in the dissociative family.  Specifically, I am referring to presentations of DID symptoms but are much less “extreme.”  “The identities or dissociative parts exhibit less elaboration and autohomy and are commonly not active or not as active in daily life as some dissociative parts of the personality in patients with DID.”  (Blaney & Millon, 2009, p. 459)  It’s basicly “DID Lite.”  They experience partial intrusion instead of complete switches in executive control.

Dissociative States in individuals who have experienced extreme coercive persuasion doesn’t make any sense, it sounds like it is describing the category, not a separate entity?  I’d bet it gets scratched from the DSM-V.

Dissociative Disorder that “are indigenous to particular locations and cultures” is a fascinating concept.  I am again reminded of the cultural nature of somatization disorders, and I have to wonder if this is just a difference in cultural interpretation, or if indeed cultural traditions have an impact on it’s presentation.

Dissociative stupor should be under somatoform disorders, or conversion disorder should be classified as a dissociative disorder.  They broke up a suited pair.

Of all the theories of dissociation disorders, the one I identified with the most was the “theory of structural dissociation of the personality.”  The basic premise “involves the role of evolutionary prepared actions systems as the underlying psychobiosocial systems that become dissociative in an individual.  The categorization of the systems into 1) systems that promote adaptive functioning and 2) mammalian action systems for defense against bodily threat make sense to me.  The distinction between the ANP and the EP makes sense to me.  It makes me wonder, can you provoke the EP into “coming out” by threatening someone with DID?

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Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Adverse Childhood Experiences | ACE Study | Effects on the Autonomic Nervous System (ANS)

The ACE Study focuses on the effects of “Adverse Childhood Experiences” on adult health.  It would suffice to say that the epidemiological data they accumulated suggests an overwhelming correlation between childhood trauma and our health as adults.  My initial reaction is one of shock and awe, although I was equally surprised by the depth and breadth of research to support their findings.   (Cavalcade Productions, Inc. [CP], 2004)

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Palaszynski and colleagues concluded that adverse childhood experiences could produce long-term effects on a number of biological systems, including the endocrine, nervous, immune, and cardiovascular systems.  Generally speaking, they found that any system involved in the acute stress response system could be affected.  (Palaszynski & Nemeroff, 2009)  Since examining all of these biological systems is beyond the scope of this short article, we will focus on the Autonomic Nervous System (ANS).

Chartier and associates (2009) found empirical evidence that childhood abuse exacerbated chronic health conditions through a number of mechanisms, including increased autonomic nervous system or hypothalamic-pituitary-adrenal axis activity.  Other research, conducted by Farrugia and Fetter (2009), implicated the brain processing centers for pain, emotion, and other autonomic physiologic behavior; suggesting that relative proximity and plasticity (less specific) functioning the sub-cortex of the brain may account for a cross-over of neurological activity.  Chapman, Dube, and Anda (2007) found that the “autonomic nervous system and hypothalamic-pituitary-adrenal axis hyper-reactivity may be a consequence of childhood abuse, heightening the subsequent risk for depression.”  Furthermore, dysregulation of the hypothalamic-pituitary-adrenal axis has been documented in individuals with other forms of psychological stress, including childhood abuse.  (Brotman, Golden, & Wittstein, 2007)

Although the depth of the research that has been conducted so far is impressive, additional research is needed to add clarity and depth to the current compendium of information we have at our disposal.

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Brotman, D. J., Golden, S. H., & Wittstein, I. S. (2007,  Sep 22-Sep 28). The cardiovascular toll of stress. The Lancet, 370(9592), 1089-1101. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1367219481&sid=5&Fmt=4&clientId=4683&RQT=309&VName=PQD

Cavalcade Productions, Inc. . (Producer). (2004). The ace study: Childhood trauma and adult health [Video]. Available from http://idcontent.bellevue.edu/content/CAS/HS/513/ace_study1.html.

Chapman, D. P., Dube, S. R., & Anda, R. F. (2007, May). Adverse childhood events as risk factors for negative mental health outcomes.  Psychiatric Annals, 37(5), 359-364. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1275282761&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Chartier, M. J., Walker, J. R., & Naimark, B. (2009, May). Health risk behaviors and mental health problems as mediators of the relationship between childhood abuse and adult health. American Journal of Public Health, 99(5), 847-855. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1683162771&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Farrugia, D., & Fetter, H. (2009, Jul). Chronic pain: Biological understanding and treatment suggestions for mental health counselors.  Journal of Mental Health Counseling, 31(3), 189-201. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1835886381&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Palaszynski, K. M., & Nemeroff, C. B. (2009, Dec). The medical consequences of child abuse and neglect. Psychiatric Annals, 39(12), 1004-1010. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1938538251&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Examining the Relationships between PTSD, Somatization, and Disassociation

There are clinically significant relationships that can be drawn between PTSD and Somatization Disorder, first and foremost because dissociative symptoms are included in the criteria for both.  The disassociation spectrum of disorders culminates in Dissociative Identity Disorder, where an individual has two or more distinct personalities that serve different functions in a person’s life.  Although pure cases of Dissociative Identity Disorder are extremely rare, the occurrence of dissociative-like symptoms is relatively common (especially in patients that are diagnosed with Somatization Disorder and PTSD).  We can visualize these symptoms as a form of psychological defense mechanism which results in an inability to recall events; a selective memory of sorts.  Reports of “disturbances in time” are not uncommon, for example when someone is unable to remember how they arrived at a certain location.  Disassociation sometimes manifests in depersonalization, or the sensation of “not being in one’s own body.”  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 519)

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Although the DSM-IV-TR has conveniently compartmentalized diagnoses into categorical systems, we should “apply skilled clinical judgment to establish functional relationships among various symptom clusters in any given patient.”  (Van Der Kolk, Pelcovitz, Roth, & Mandel, 1996, expression DISCUSSION)  There is no better forum to explore functional relationships between and among specific diagnosis than the exploration of the interrelationship between PTSD, Somatization Disorder, and Dissociative Disorders.  After all, the disassociations associated with these disorders will frequently present at the same time to the extent that it may be difficult to distinguish where one begins and the other ends.

The DSM-IV-TR diagnostic criteria for 309.81 Posttraumatic Stress Disorder (PTSD) include being exposed to a traumatic event that involved a threat to the physical integrity of self or others.  Secondly, the event must be persistently experienced through recurrent recollections, dreams, flashbacks, illusions, or hallucinations.  Third, the client should demonstrate active and persistent avoidance of stimuli associated with the trauma, and/or a general numbing of general responsiveness.  This frequently manifests in dissociative symptoms, serving as a conscious or unconscious effort to avoid thoughts, feelings, conversations, activities, places, or people.  The resulting disassociation results in feelings of detachment or estrangement, restricted range of affect, or a sense of a foreshortened future.  Finally, the client may present with symptoms of increased arousal including difficulty sleeping, irritability, outbursts of anger, difficulty concentrating, hypervigilance, and/or exaggerated startle response.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 467-468)

In contrast, the DSM-IV-TR diagnostic criterions for 300.81 Somatization Disorder are characterized by a pattern of recurring clinically significant somatic complaints.  The somatic complaints cannot be fully explained by any known general medical condition or the direct effects of a substance.  If they occur in the presence of a general medical condition, the resulting impairment is in excess of what would be expected based on the norm for the general medical condition.  Finally, there are criterions regarding the quantitative and qualitative aspects of the somatic complaints, requiring that individuals present with a relatively wide variance of physical effects.  We could describe this disorder as a form of “somatic dissociation” whereby the client has lost their ability to perceive somatic sensory information, ultimately resulting in a distorted sense of self.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 486)

In a controlled study of Vietnam-era combat veterans, researchers found that combat veterans with PTSD reported and were rated as having a greater number of health problems than combat veterans without PTSD.  They had a greater number of total illnesses across a wider number of medical categories, contributing to the belief that as part of their PTSD, “PTSD patients have difficulty determining the salience of information and that this deficit in information processing may contribute to a patient’s focus on and misinterpretation of somatic sensations.”  (Beckham, Moore, Feldman, & Hertzberg, 1998, expression DISCUSSION)

In another study, researchers attempted to investigate the relationships between exposure to extreme stress, the emergence of PTSD, and the symptoms traditionally associated with “hysteria.”  They found that exposure to extreme stress may result in a variety of combinations of symptoms over time, including symptoms characteristic of somatization disorder and PTSD.  (Van Der Kolk, Pelcovitz, Roth, & Mandel, 1996, expression MODERN TRENDS)

In yet another study that focused primarily on pediatric cancer survivors, researchers found empirical support for the “trauma spectrum model” within which “somatic symptoms may play an instrumental role in the presentation and subsequent detection” of PTSD.  Although we cannot eliminate the possibility that somatic complaints represent true physical symptoms, children with chronic illness typical report higher levels of somatic complaints than healthy peers.  Researchers concluded that “long-term pediatric cancer survivors appear to exhibit somatic symptoms,” as well as PTSD-like symptoms, years after treatment completion.  (Erickson & Steiner, 2000)

Without, all three of these studies strengthen the argument for an interrelationship between stress, the presentation of unexplained physical symptoms, and dissociation.  Despite our best effort to compartmentalize disorders in the DSM-IV-TR, it is critical for us as clinicians to recognize and interrelationships between and among these disorders.  Despite an abundance of applicable research, more study is needed to establish the definitive relationship between and among PTSD, somatization disorder, and the spectrum of disassociation disorders.

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Beckham, J. C., Moore, S. D., Feldman, M. E., & Hertzberg, M. A. (1998, Nov). Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder.  The American Journal of Psychiatry, 155(11), 1565-1570. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=36011996&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Erickson, S. J., & Steiner, H. (2000, Jul/Aug). Trauma spectrum adaptation: Somatic symptoms in long-term pediatric cancer survivors. Psychosomatics, 41(4), 339-347. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=56303410&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Van Der Kolk, B. A., Pelcovitz, D., Roth, S., & Mandel, F. S. (1996, Jul). Dissociation, somatization, and affect dysregulation. The American Journal of Psychiatry, 153(7), 83-94. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=9840989&sid=3&Fmt=2&clientId=4683&RQT=309&VName=PQD

Psychological Factors Affecting Medical Conditions – 316 diagnosis

Psychological Factors Affecting Medical Conditions (PFAMC) represents an attempt on the part of the mental health community to “take down the barrier” between mind and body.  “The classical Western medical model of illness has favored the clear demarcation between “physical” and “mental” illnesses.  (Netherton, Holmes, & Walker, 1999, p. 549)  The PFAMC diagnosis removes that demarcation, acknowledging that there are interrelationships between psychological and physical factors in the scope of “well-being” and that each has an effect on the other.  To me, this makes sense… if I was diagnosed with cancer, for example, there would likely be an immediate and clinically significant impact to my mental health as well.  I would fully expect a degree of anxiety, perhaps depression… inevitably, the client would have to find some way to cope, and we could assist in the process by allowing the client to develop healthy coping mechanisms.

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The definition of “clinical significant” is a source of ambiguity, since the criterion is very much subjective.  Typically, the significance takes shape in the form of compliance, or lack thereof, placing the individual at a higher risk of an adverse outcome.

I would acknowledge and support (put forth by Engel, 1977) that behavior is an interaction among psychological, physical and social elements.  He regards the three as a system composed of three subsystems, with each having effects and interrelationships with the other.  This brings the assessment of social systems (peer, familiar, school, etc) to the forefront, since all three have the opportunity to have significant social consequences.  “When the patient is a child, there must also be an assessment of family functioning, communication, and decision-making processes.”  (Netherton et al., 1999, p. 553)

The “316” diagnosis becomes relevant particularly when children are chronically ill and must comply with complex medical regimens.  In the case of Cystic Fibrosis, this may manifest in compliance with medical regimen or adherence to an appropriate diet.  In cancer patients, physical side effects place them at risk for psychosocial difficulties (e.g., loss of hair, weight loss or gain from medication, fatigue, etc).  Any disease that has “high visibility”, or might require the need for care from others, has the potential to raise these concerns for social impacts.  One particular aspect I had not taken into consideration is acne, which has the potential to have significant impacts on self-esteem and self-image.  Although acne is certainly less than fatal, it is no less debilitating that life threatening diseases in our image conscious society.  “Social support, acceptance from peers, and family functioning has all been identified as significant predictor variables of adjustment to illness.”  (Netherton et al., 1999, p. 556)

Insulin-Dependent Diabetes Mellitus (IDDM) got significant treatment in the text due to the depth and breadth of research available on the topic.  “The immediate consequence of following the regiment involves inconvenience and physical discomfort, while the long-term reward is the avoidance of health complications.”  Ideally, through patient and parent education, we can impress the importance of compliance to long term health.  Our goal, or objective, would be to draw a relationship between a client’s health status and diabetes-related adherence.

Developmental considerations need to be taken into account, considering that a child may be cognitively limited, rather than noncompliant in some other sense.  (Netherton et al., 1999, p. 558)  For young children, parent training may be the most effective route to increasing compliance with insulin injections.  However, if the client approaches adolescences, or young adulthood, the intervention should inevitably be focused on the client themselves.

Aside from treating the client themselves, opportunity presents itself to treat the parents as well, since “mild parental anxiety and depression were associated with the diagnosis of diabetes in the first six months after diagnosis.”  (Netherton et al., 1999, p. 558)  We may also want to access attitudes of the child and the parents with regard to their attitudes toward the medical staff who are treating the child for diabetes.

Treatment could focus on a number of different aspects depending on the presented situation, but it could focus on identifying and treating maladaptive coping strategies in ill children, or helping children and/or parents master the anxiety associated with their physical condition.  We might focus on enhancing communication within the family unit itself, facilitating acceptance of the diagnosis and increasing the level of emotional support with and within the family.  (Netherton et al., 1999, p. 561)

In conclusion, it is increasingly evident that there is a definite interrelationship between physical ailments and mental health.  Some might suggest that Western Medicine and it’s repeated attempts to separate the two disciplines are doing more harm than good… perhaps we could take a page from Eastern Medicine and begin to integrate the two?

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Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.