Saturday, August 25, 2012

Dissociative Disorders

Dissociative Disorders in DSMV, Spiegel, Loewenstein, Lewis-Fernandez, Sar, Simeon, Vermetten, Cardena, and Dell, Depression and Anxiety 28:E17-E45 (2011) is really the definitive article regarding Dissociative Disorders today. It's extremely well researched and clearly thought through. David Spiegel, Department of Psychiatry, Stanford University, Palo Alto, California has long been a seminal thinker in the area of dissociative disorders as well as in hypnosis and hypnotic states.

The introduction asks the following questions in recommending revisions for the DSM5 due out next year, having not made this year's planned deadline due to the controversies surrounding it.

1) Should Depersonalization Disorder (DPD) remain or be moved to another section of DSM5?
2) Should Dissociative Amnesia (DA) continue to be conceptualized as a Dissociative Disorder or be moved to another section to emphasize its relationship to trauma, ie as part of PTSD or ASD -- stress disorders.
3) Does the data support Dissociative Fugue as a separate category or better be seen as part of DID (Dissociative Identity Disorder) or Dissociative Amnesia or as not yet specified.
4) Should Dissociative Identity Disorder criteria be changed?
5) Should Dissociative Trance Disorder be included in appendix or be a specific dx.
6) What examples should be generated as not yet diagnosed categories?

The group reviews the recent data particularly neurobiological data supportig dx of Dissociative Disorders addressing controverises.

They recommend that recent research documents the utility of combining concepts of the domain of dissociative symptons from both DSM IV and the ICD 10.

"Dissociation is a disruption of and/or discontinuity in the normal, subjective integration of one or more aspects of psychological functioning,including - but not limited to - memory, identity, consciousness, perception and motor control. In essence, aspects of psychological functioning that should be associated, coordinated, and/or linked are not." p E19

"ICD-10 describes DD's as primarily acute disorders contrast, the DSMIVtr conceptualizes several DD's as long-term, chronic disorders, including DID and some forms of DPD, DA, and DDNOS."

"The term dissociation has been used to describe a variety of processes of the human mind, including "normal" aspects of focusses or divided attention and absorption, some of which underlie hypnotic capacity, "semi-independent mental modules" that are not consciously accessible, and altered states of consciousness that can be activated in a variety of contexts such as religious ecstacies, hypnotic experience, and/or during traumatic or overwhelming experiences." p E20

"Dissociation also describes a psychobiological trait that can be measured in various populations.....may be two categorically distinct dissociative dimensions: "nonpathological" and "pathological".

"In addition, dissociation is used to described an intrapsychic experience of trauma, conceptualized in psychodynamic terms, ....."

"Dissociative Identity Disorder is currently understood as a complex posttraumatic developmental disorder that usually begins before the age of 5-6." p20

"individuals with childhood-onset DD's may have a different relationship to these life-long symptons than individuals who develop adult-onset dissociative symptons during an episode of acute trauma' p21

"It is hypothesized that dissociative symptons reduce subjective distress both in the immediate context of stress or trauma, as well as later when the dissociative processes protect the individual from full awareness of stressful, disquieting, and/or traumatic information" p21

"The notion that dissociative processes exist to reduce at least some aspects of subjective distress is consistent with the neurobiological data that individuals with dissociative forms of the PTSD show "emotional overmodulation" with increased activation of the orbitofrontal cortex inhibiting activation of the amygdala and insular cortex" p21

"Metaphorically speaking, fundamental aspects of dissociative responding can be conceptualized in terms of 'detachment' or 'compartmentalization'. Detachment includes depersonalization/derealization experiences; and compartmentalization includes dissociative experiences such as amnesia or separation of memory material from one's ongoing sense of self, etc."

"Unfortunately, dissociation generally interferes with processing of traumatic experiences, leaving memory material in nonverbal, emotionally overwhelming, usually imagic and sensory form."

Phenomenological studies show that psychotic and dissociative processes may produce symptons that superficially resemble each other, but have differing etiologies, treatment response, and presumptive psychobiology."

"Dissociative patients may have reexperiences or reenactments of trauma during which they believe that they are actually in a different time/place undergoing that traumatic experience." p22

"Dissociative patients do not report delusional explanations for hallucinations or FRS. Rather they tend to experience these symptons as inexplicable and frightening, indicators that they are 'crazy'. "

This is my first pass reviewing this extraordinary paper by Spiegel et al. I'll put it up here and come back to it another time. I've a committment to seeing some friends read from their recent books or I'd continue through this really inspiring and thought provoking discussion.

- Posted using BlogPress from my iPad

No comments: