European Society for Trauma & Dissociation, UK Network. Dissociative Disorders in Adults Information for clinicians and NHS fund holders
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1 European Society for Trauma & Dissociation, UK Network Dissociative Disorders in Adults Information for clinicians and NHS fund holders Introduction Although studies of dissociation date back more than a century, it has not commonly been included in medical and other professional training in the UK. There is a large and growing body of clinical and research evidence concerning the dissociative disorders and increasing numbers of patients with these conditions are presenting for help. In many NHS Trusts, awareness is growing and funding applications for assessment and treatment are becoming more common. This information is provided for clinicians such as general practitioners, psychiatrists, psychologists and psychotherapists and for fund holders to assist in assessing patients and in deciding funding applications for assessment and/or treatment Definition of dissociation A disruption in the usually integrative functions of consciousness, memory, identity, or perception ( DSM-IV). Symptom profile The dissociative conditions are characterised by symptoms in the following 5 areas: Amnesia : inability to recall personal information which is too extensive to be explained by ordinary forgetfulness. Frequently described a blank periods, blackouts or spacing out. 1
2 Depersonalisation: an alteration in the perception or experience of the self so that one feels detached from, and as if one is an outside observer of, one s mental processes or body ( e.g feeling like one is in a dream) ( DSM- IV, p. 766). Derealisation: alteration in the perception or experience of the external world so that is seems strange or unreal ( DSM- IV, p. 766). Identity confusion: Subjective feelings of uncertainty, puzzlement, or conflict regarding one s own identity ( SCID-D). Identity alteration: Objective behaviour indicating the assumption of different identities or ego sates, much more distinct than different roles ( SCID-D). Screening Tools Screening for dissociation should be considered whenever there is a history of severe or complex trauma, especially in childhood. Any doctor or suitably qualified professional can use screening tools. The Dissociative Experiences Scale ( DES) is a 28- item screening questionnaire in wide use which contains a mixture of normative & dissociative experiences. The latter are further measured by a 8- item sub-scale, the DES taxon. Its results are not diagnostic per se but a score of over 30 is held to be indicative of the presence of dissociative condition and the need for further assessment. Many patients who have experienced trauma also have a range of physical symptoms may be indicative of somatoform dissociation. If medical tests prove negative, it might be useful to consider the Somatoform Dissociation Questionnaire ( SDQ-20).The DES, SDQ-20, other tools and how to evaluate them are available via the ESTD website ( see below). Assessment Symptoms of dissociation do not necessarily appear spontaneously. Standard diagnostic interviews and mental status examinations do not 2
3 normally include questions about dissociation, posttraumatic symptoms or psychological trauma. The sine qua non for diagnosis is that specific inquiries must be made in the key symptoms listed above. The DSM IV Structured Clinical Interview for the Diagnosis of Dissociation (SCID-D) is the only evidence based assessment for the dissociative conditions with a full test retest history using the DSMIV diagnostic criteria. It has had extensive field trials and is in wide use nationally and internationally. It is part of the recommended standard of assessment for the dissociative conditions (see International Treatment Guidelines below). Diagnosis Diagnosis is based on the severity of symptoms in the 5 symptom areas above. There are 5 different diagnostic categories defined by the DSM-IV as follows: Dissociative amnesia: The predominant disturbance is one or more episodes of inability to recall personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness Dissociative fugue: The predominant disturbance is sudden, unexpected travel away from home or one s customary place of work, with inability to recall one s past. Depersonalisation Disorder: Persistent of recurrent experiences of feeling detached from, and as if one is an outside observer of, one s mental processes or body ( e.g feeling like one is in a dream). Dissociative Identity Disorder (DID): The presence of 2 or more distinct identities or personality states ( each with its own relatively enduring pattern of perceiving, relating to, and thinking about the self). Dissociative Disorder Not Otherwise Specified ( DDNOS): Disorders in which the predominant feature is a dissociative 3
4 symptom ( i.e a disruption in the usually integrative functions of consciousness, memory, identity, or perception of the environment) that does not meet the criteria for any specific dissociative disorder. Treatment The International Guidelines (see below) note, that while it resembles that for complex PTSD, treatment has specific features based on specialist knowledge of dissociation. The recommended treatment is phase-orientated, using individual psychodynamically orientated psychotherapy on an outpatient basis. The phases are: 1. Safety, stablisation and symptom reduction. Some patients will not proceed beyond this stage and most will need to revisit it regularly. 2. Processing and integrating traumatic memories. This is often the longest phase of treatment, given the severity of childhood trauma common to this patient group. 3. Identity integration and rehabilitation. Therapeutic input remains needed during this stage. It is useful to support the above phases by psycho-educational in-put and skills training provided it is specific to the needs of this patient group. While inpatient treatment may be necessary to contain crises and restore functioning, it is not the primary treatment of choice. There is no medication which can treat dissociation although medications may help with some associated symptoms. See International Guidelines referred to below for further information on medication and other relevant treatment modalities. Prognosis Case studies, case series and naturalistic outcome studies have shown the above treatment to be effective, not only for dissociation but a wide range of related symptoms. See International Guidelines for details of such studies including cost effectiveness studies. 4
5 Relevant guidelines NICE has not yet produced any for guidelines for the dissociative conditions. These conditions belong to the spectrum of post-traumatic disorders, specifically complex post-traumatic stress usually originating in childhood. When formulating guidelines concerning PTSD, NICE specifically excluded consideration of complex post traumatic conditions originating in childhood as follows: The guideline does not apply to people whose main problem is the ICD 10 diagnosis of Enduring personality changes after catastrophic experience (F62.0), the concept corresponding to Disorders of extreme distress not otherwise specified/complex PTSD (see definition ), which may develop after extreme prolonged or repeated trauma, such as repeated childhood sexual abuse or prolonged captivity involving torture. The guideline does not address dissociative disorders, which may develop after traumatic events, or adjustment disorders (F43.2), which may develop after less severe stressors (NICE Guidelines for PTSD, Para. 2.1, p. 13). This clarification in the NICE guidelines for PTSD means that, at present, the Standards for assessment and treatment of dissociative conditions can only 5
6 be found in the International Treatment Guidelines of the International Society for The Study of Trauma Dissociation. A free downloadable copy, available via the ISSTD website ( The information in the Guidelines may be new to NHS Funding Committees. The ISSTD Guidelines meet the standards normally expected by NICE. They summarize expert consensus concerning effective assessment and treatment for patients suffering from dissociation and present key findings and generally accepted principles that reflect current scientific knowledge and clinical experience specific to the diagnosis and treatment of dissociative disorders. They were developed by psychiatrists, psychologists, and other mental health practitioners in active clinical practice, research or other academic endeavours. The Guidelines, now in their 3 rd edition (2010), have been extensively reviewed by members of ISSTD. Contributors and reviewers are asked to base their recommendations on an objective evaluation of available evidence. Evidence-base The Guidelines summarise their evidence-base as follows: Over the past 30 years, the diagnosis, assessment, and treatment of dissociative disorders have been enhanced by increased clinical recognition of dissociative conditions, the publication of numerous research and scholarly works on the subject, and the development of specialized diagnostic instruments. Peer reviewed publications have appeared in the international literature from clinicians and investigators in at least 26 countries, including the United States, Canada, Puerto Rico, Argentina, The Netherlands, Norway, 6
7 Switzerland, Northern Ireland, Great Britain, Germany, Italy, France, Sweden, Spain, Turkey, Israel, Australia, Oman, Iran, India, New Zealand, The Philippines, Uganda, China and Japan. These publications include clinical case series and case reports; psychophysiological, neurobiological and neuroimaging research; discussion of the development of diagnostic instruments; descriptions of open clinical trials and treatment outcome studies; and descriptions of treatment, treatment modalities, and treatment dilemmas. Dissociative disorders in children and adolescents The dissociative conditions have their origins in childhood and also present in children and adolescents. Separate screening and assessment tools and international guidelines are available for these age groups. See for a free downloadable copy of the Guidelines for the Evaluation and Treatment of Children and Adolescents, published in the Journal of Trauma & Dissociation, Vol. 5(3) A separate information sheet has been prepared by ETSD UK, available via the UK home page of the ESTD website ( Further information and resources Professional bodies European Society for Trauma and Dissociation ( 7
8 International Society for the Study of Trauma and Dissociation ( Clinical and research literature John O Neill and Paul Dell (Eds.) (2009): Dissociative Disorders: DSMV and Beyond. Brunner-Routledge Other material Introductory Training DVD: A Logical Way of Being: The reality of Dissociative Identity Disorder and other complex dissociative conditions. First Person Plural:fpp@firstpersonplural.org.uk Suzette Boon, Kathy Steele & Onno van der Hart ( 2011).Coping with Trauma-Related Dissociation: Skills Training for Patients and Their Therapists. London: Norton. 8
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