Dissociative disorders unclear? Think ‘rainbows from pain blows’

Posttraumatic stress disorder
Certain personality disorders (especially borderline personality disorder)
Somatoform disorders (conversion disorders and nonepileptic seizures)
Eating disorders
Substance use disorders
Extensive history of trauma or neglect
Self-harm behavior

Differential diagnosis. Diagnosing dissociative disorders includes ruling out psychopathologies that can present with “look-alike” symptoms (Table 3).

As in Mr. D’s case, dissociative phenomena may attenuate the benefit of post-trauma therapeutic interventions, especially those involving exposure. Therefore:

• assess post-trauma patients for dissociation before you start treatment
  
• make specific alterations in psychotherapy for such patients, as described below.
  

Educating trauma patients that detachment is a normal response to threat¹⁷ can reduce shame about not fighting back.

Table 3

Differential diagnosis: Dissociation ‘look-alikes’

Dissociation symptom	Can be confused with:
Visual or auditory hallucinations, other ‘first-rank’ psychotic symptoms in dissociative identity disorder	Psychotic disorder
‘Blanking out’ (cognitive disruption)	ADHD, seizures
Somatoform (conversion) symptoms	A variety of nonpsychiatric medical problems, including pelvic or abdominal pathology and headaches
Dissociative memory lapses	Learning disability, not paying attention
‘Switching’ between states	Bipolar disorder, rapid cycling
Lack of emotional reaction to traumatic stimuli(numbing response)	Healthy coping
ADHD: attention-deficit/hyperactivity disorder

Medical causes. Because complex partial seizures can cause dissociative symptoms,²³ consider evaluating patients for seizures, head trauma, and structural lesions. Psychogenic nonepileptic seizures (PNES) often occur in conjunction with early trauma, dissociative symptoms, and PTSD.³

Recreational drugs such as ketamine, methylenedioxymethamphetamine (“Ecstasy”), hallucinogens, marijuana, and dextromethorphan also can induce dissociative states. Consider evaluating for use of these substances, some of which may not be detected on a routine drug screen.²⁴

CASE CONTINUED: A tactical shift

Internal distress—such as when remembering painful events—clearly is linked with the appearance of Mr. D’s symptoms. The therapist—recognizing unacknowledged dissociative phenomena—changes Mr. D’s therapeutic strategy from exposure therapy to affect and anxiety regulation, with an explicit focus on attachment security (safety).

The therapist explains to Mr. D that dissociation symptoms are a response to distress, and he can learn more adaptive distress regulation in therapy. The in-session focus shifts to include more direct attention to components of the therapy relationship, including overt disclosure of the therapist’s positive regard and commitment to help the patient and frequent pauses to “check in” that the patient feels present, safe, and understood. With this new focus, Mr. D’s dissociative symptoms resolve and he feels more ready to face and overcome his fear and avoided memories.

Psychotherapy: Putting pieces together

Psychotherapy is the primary treatment, based on understanding dissociative disorders as manifestations of distress-related, traumatic fragmentation of the sense of self, interpersonal relatedness, and capacity for adaptive affect regulation (Table 4).

Depersonalization disorder. Cognitive-behavioral integration has been proposed, based on the idea that detachment from one’s self creates anxiety and reinforces efforts to avoid this internal state and events that trigger it. In an open study of 21 patients with depersonalization disorder, individual cognitive-behavioral therapy (CBT) reduced avoidance, safety behaviors, and symptom monitoring. Measures of dissociation, depression, anxiety, and general functioning also improved.²⁵

Table 4

Tips for conceptualizing dissociative disorders

Ground your understanding of this class of disorders as distress-related breakdowns in functional connection and integration among components of normal consciousness
Consider the overlap among dissociation, certain somatoform disorders (conversion symptoms, pseudoseizures), and PTSD
Maintain a high index of suspicion for dissociative symptoms in patients with early trauma or neglect (consider screening for this); do further evaluation with dissociative-specific tools
Avoid the tendency to assume that reversible, unfamiliar, or peculiar symptoms imply volition or lack of an organic basis
PTSD: posttraumatic stress disorder

Dissociative identity disorder (DID)—the quintessential dissociative disorder—is usually treated by specialists. Treatment is complex, but some components are appropriate for less severe forms of dissociation, including dissociation as part of PTSD.²⁶

Safety, stabilization, and symptom reduction. Providing a safe therapeutic relationship is a primary and necessary part of DID treatment. On that platform, a first step in reintegrating distressing material into the self involves building the patient’s capacity for conscious, flexible affect regulation. This keeps anxiety and distress within a therapeutic “window.”

Graded exposure. Exposure to feared mental contents—typically traumatic memories—is central to trauma-focused therapy. Dissociation is conceptualized as driven by distress greater than the system can bear, loss of adaptive integration, and subsequent fear-based, reflexive avoidance.²⁷ Re-experiencing trauma-related memories in a safe relationship with a new regulatory capacity may work by anchoring patients in an autobiographical memory base.²⁸

Integration of identity and person. Treatment ends when formerly unintegrated or dissociated experiences or parts of the self are integrated into a coherent whole, and the patient can deal adaptively with inter-personal relationships and distress without fragmentation.