Dr. Elizabeth Gruber Dr. Dawn Moeller. California University of PA. ACCA Conference 2012

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1 Dr. Elizabeth Gruber Dr. Dawn Moeller California University of PA ACCA Conference 2012

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3 Dissociative Identity Disorder- case presentation Diagnostic criteria Recognize signs Treatment Concerns Lack of ability to refer in rural areas Risk Ethics Treatment Considerations

4 The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self). At least two of these identities or personality states recurrently take control of the person's behavior Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures).

5 Counseling 5-7 Grandmother took her to therapy age 10 Age holding therapy Age 15-3 sessions- suicide attempt - residential rehabilitation for alcohol & acid - ECT

6 While it is clear that ordinary, healthy people may become entrapped in prolonged abusive situations, it is equally clear that after their escape they are no longer ordinary or healthy. Chronic abuse causes serious psychological harm. (loc. 1618). Herman, Judith (1992). Trauma and Recovery: The Aftermath of Violence From Domestic Abuse to Political Terror, NY: Basic Books.

7 Referred by faculty concerned Lived in an apartment with boyfriend Symptoms: Difficulty with trust Cyclical depression Relationship- boyfriend hit her Occasional suicidal thoughts Cutting Dissociative Identity Disorder Self reports OCD and trichotillomania

8 Under the most extreme conditions of early, severe, and prolonged abuse, some children, perhaps those already endowed with strong capacities for trance states, begin to form separated personality fragments with their own names, psychological functions, and sequestered memories. Dissociation thus becomes not merely a defensive adaptation but the fundamental principle of personality organization. (loc. 1415). Herman, Judith (1992). Trauma and Recovery: The Aftermath of Violence From Domestic Abuse to Political Terror, NY: Basic Books.

9 Disruption of identity characterized by two or more distinct personality states or an experience of possession. This involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory- motor functioning. These signs and symptoms may be observed by others or reported by the individual. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (continued on next slide)

10 The disturbance is not a normal part of a broadly accepted cultural or religious practice. (Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.) The symptoms are not attributable to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or another medical condition (e.g., complex partial seizures). Specify if: With prominent non- epileptic seizures and/or other sensory- motor (functional neurologic) symptoms From proposedrevision.aspx?rid=57#

11 Many fit with her symptoms In addition to DID PTSD Borderline Personality Disorder Depression Complex PTSD DESNOS

12 Even the diagnosis of post- traumatic stress disorder, as it is presently defined, does not fit accurately enough. The existing diagnostic criteria for this disorder are derived mainly from survivors of circumscribed traumatic events. They are based on the prototypes of combat, disaster, and rape. In survivors of prolonged, repeated trauma, the symptom picture is often far more complex. (loc. 1651). Herman, Judith (1992). Trauma and Recovery: The Aftermath of Violence From Domestic Abuse to Political Terror, NY: Basic Books.

13 The syndrome that follows upon prolonged, repeated trauma needs its own name. I propose to call it complex post- traumatic stress disorder. (loc. 1657) Herman, Judith (1992). Trauma and Recovery: The Aftermath of Violence From Domestic Abuse to Political Terror, NY: Basic Books.

14 A history of subjection to totalitarian control over a prolonged period (months to years) Alterations in affect regulation Alterations in consciousness Alterations in self- perception Alterations in perception of perpetrator Alterations in relations with others Alterations in systems of meaning From Judith Herman s book, Trauma and Recovery: The Aftermath of Violence from domestic abuse to political terror. (Published by Basic Books in NY, NY in 1992 and 1997). (loc 1687)

15 One critical element in determining psychopathology outcomes is the developmental level at which the trauma occurs and whether it occurs in the context of a relationship with a caregiver or intimate partner. For example, victims of car accidents and natural disasters often have quite different clinical presentations than those who experienced abuse, deprivation, and/or neglect at the hands of their caregivers. In addition, the age at which the trauma occurred also shapes subsequent adaptation patterns. While the symptomatology of victims of single- incident traumas are fairly well captured in the DSM- IV diagnosis of PTSD, victims of interpersonal trauma present with a more complex picture. Toni Luxenber, PsyD, Joseph Spinazzola, PhD, and Bessel A. van der Kolk, MD (2001). Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis,Part One: Assessment,Directions in Psychiatry, Vol. 21.

16 Disorders of Extreme Stress Not Otherwise Specified (DESNOS) has a symptom constellation delineated in the DSM- IV under associated features of PTSD. Though DESNOS is not currently a distinct diagnosis identified in the DSM- IV, its symptom constellation has been identified in numerous research studies and is currently being researched and considered for inclusion, as a free- standing diagnosis, in the DSM V. Toni Luxenber, PsyD, Joseph Spinazzola, PhD, and Bessel A. van der Kolk, MD (2001). Complex Trauma and Disorders of Extreme Stress (DESNOS) Diagnosis,Part One: Assessment, Directions in Psychiatry, Vol. 21.

17 I. Alteration in Regulation of Affect and Impulses (A and 1 of B F required): A. Affect Regulation (2) B. Modulation of Anger (2) C. Self- Destructive D. Suicidal Preoccupation E. Difficulty Modulating Sexual Involvement F. Excessive Risk- taking II. Alterations in Attention or Consciousness (A or B required): A. Amnesia B. Transient Dissociative Episodes and Depersonalization See next slide

18 III. Alterations in Self- Perception (Two of A F required): A. Ineffectiveness B. Permanent Damage C. Guilt and Responsibility D. Shame E. Nobody Can Understand F. Minimizing IV. Alterations in Relations With Others (One of A C required): A. Inability to Trust B. Revictimization C. Victimizing Others see next slide

19 V. Somatization (Two of A E required): A. Digestive System B. Chronic Pain C. Cardiopulmonary Symptoms D. Conversion Symptoms E. Sexual Symptoms VI. Alterations in Systems of Meaning (A or B required): A. Despair and Hopelessness B. Loss of Previously

20 Limited referral options due to lack of transportation, money/insurance, and trained therapists Risk to client and liability to university Decision to take N. on as a client Lack of understanding on campus Suggestions for treating someone with a severe disorder Refer to the level of specialized care the client needs, if possible The importance of peer and specialized supervision Document your reasoning

21 Four stages of treatment: 1. Stabilization accepting the trauma and diagnosis, managing current symptoms and stress, recognizing the dissociation 2. Trauma work processing the memories. Split off material is brought into consciousness 3. Integration when you observe that the client switches, ask her to notice what happened. Approach the alters as a part of a unified self. 4. Post- integration life sills, managing emotions Haddock, D.B. (2001). The dissociative identity sourcebook. New York: McGraw Hill.

22 Name the dissociation and call it a defense Explain the defense is not needed now and likely does more harm than good Treatment aim is to increase awareness and internal cooperation Client does not have to relive every terrible memory she carries Do not keep secrets given by alters from the host. Integration vs. co- consciousness Haddock, D.B. (2001). The dissociative identity sourcebook. New York: McGraw Hill.

23 Questions Thank you Dr Dawn Moeller Dr. Liz Gruber

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