Authors: Alka A. Subramanyam, Mansi Somaiya, Sunitha Shankar, Minhaj Nasirabadi, Henal R. Shah, Imon Paul, Rakesh Ghildiyal
Categories: Clinical Practice Guidelines
Source: Indian Journal of Psychiatry
Dissociative disorders as described by ICD 10 include a range of disorders and combine what are conversion disorders (assumed under somatoform disorders in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and the cluster of dissociative disorders. The mutual idea shared by these disorders is a partial or complete loss of usual integration between memories, cognizance of identity, and immediate sensations and voluntary control of body movements. Conversion occurs when there are clinical symptoms representing alteration of functioning of motor or sensory systems and which do not follow a pattern of a known neurological or medical disease. Dissociation is a mechanism that allows the mind to compartmentalize certain memories or thoughts from normal consciousness. These split-off mental contents are available and may return to consciousness either by an event or spontaneously.
Broadly, dissociative disorders may be viewed as shown in Table 1.
Common dissociative disorders in the Indian setting have been dissociative motor disorders and dissociative convulsions. Dissociative stupor and possession states were next most frequent with multiple personality disorders being rather infrequent. Depression and borderline personality disorder often coexist.
The expression of disease is affected by culture, and there are distinct differences which need to be understood while planning management, particularly in the Indian context [Table 2].
To plan management, understanding some elements of etiology is important. Broadly, it may be viewed as a reaction to an external trauma or secondary to a personality attribute which incline the patient to dissociate [Table 3].
Psychotherapy is the cornerstone of treatment for dissociative disorders and hence choosing the right therapist is of paramount importance. The following section enumerates the characteristics of a therapist ideally suited to engage in therapy for dissociative disorders.
To summarize, there has to be an amalgamation of theoretical expertise, specific therapeutic knowledge and human skills encompassing a broader context on the part of the therapist for the development of an ideal therapeutic alliance.
Management of dissociative disorders begins with an accurate diagnosis, ruling out other causes for the presentation, assessing for comorbidities and predisposing trauma and personality factors. Acute conversion disorders aim at alleviating the symptom and use reassurance, narcoanalysis, and behavior therapy techniques. The aim of therapy should be immediate alleviation of symptoms as the patients ego state is not available for any other exploration. And the primary goal of this stage is also to make the patient feel safe, where he/she feels safe enough to let go of the symptoms For chronic cases, exploratory insight oriented therapy is suggested. Whilst medication has a role in treating the co-morbidities and anxieties, psychotherapy plays a large role in the eventual integration and conflict resolution. Caution is to be applied when there is associated psychosis. If there is psychosis one should NOT attempt any form of insight oriented therapy as it will cause further breakdown. When conducting therapy the therapist should continuously be alert and monitor for any psychotic symptoms, if there is a doubt then we should err on the side of caution and temporarily stop therapy and alert the psychiatrist.
The goal of therapy is to reduce dissociation and integrate the functioning of the mind. Whilst many therapies are advocated empirical evidence is lacking.
After the initial assessment of a patient with dissociative disorder, the clinician has to determine the treatment setting-whether the patient can be treated on outpatient basis or if hospitalization is warranted. In the initial phases of treatment, establishing the patients’ safety is of paramount importance and a thorough assessment regarding safety issues (particularly the risk of harm to self or others) should be made before determining the treatment setting [Table 4].
Therapy in the outpatient setting is vulnerable to disruption due to external factors like influence of family or significant others and stressors in the social context, in the acute stage or imminent threat of harm to self or others. Hence, it is important to factor in such potential disruptions during the initial assessment period to minimize the impact of pathogenic interpersonal patterns on the progress of therapy. However, in the long run, outpatient treatment is preferred.
Inpatient treatment has to be considered in the scenarios as shown in Table 5.
In certain cases of dissociative disorder with complex psychopathology, an entire treatment team maybe required, comprising of clinicians, therapists, family therapists, specialists in eye movement desensitization and reprocessing etc. In such cases, it is important that the entire team should function in a well co-ordinated and concerted manner but with clear delineation of responsibilities to restore integrated functioning of the patient.
The role of traditional group therapy in the treatment of dissociative disorders is limited. In particular, patients with dissociative identity disorder have difficulty in participating in generic therapy groups where participants are encouraged to discuss their traumatic experiences and may even have worsening of symptoms if they are unable to tolerate the distress engendered in the process. However, select groups focused on psycho-education, problem solving and specific skills development can be a valuable adjunct to individual psychotherapy.
This term is another name for dissociative disorders. As per ICD 10, they are a host of dissociative disorders with partial or complete loss of the normal integration between memories of the past, awareness of identity, immediate sensations and control of bodily movement. As per Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, conversion disorders also called the Functional Neurological Symptom Disorder is a type of Somatic Symptom and related disorder is characterized by alteration in voluntary motor or sensory symptom characterized by similar features as described above. The assessment and management of this disorder is similar to as mentioned in the dissociative disorders.
A broad overview of the treatment of dissociative disorders is outlined in Figure 1. Based on the type of dissociative disorder, the choice is shown in Figure 2.
Figure 1 Overview of approach to treatment of dissociative disorders
Figure 2 Choice of therapy based on type of disorder
In order to decide the form of therapy needed in dissociative states, it is important to understand the possible genesis of dissociation [Figure 3].
Figure 3 Possible genesis of dissociation
A few techniques which may be practised while managing the patient are as follows.
Psychoeducation is an inevitable aspect in the management of dissociative disorder. Psychoeducation should focus on normalizing and acknowledging patient's symptoms and relating them with dysfunction in daily life. It also enables an understanding in the patient and family members about the intellectual strengths and the key role of coping skills in therapy. Psycho-education must focus on the biological and neural basis of the involved feature and as a result shift focus away from victimization. Another aspect, knowing what is wrong with them enables them to give some meaning to symptoms and help them feel safe and under control. The therapist must explain in simple terms and must be easy to understand exercising caution to avoid making them sound manipulative.
Grounding helps the patient detach from emotional pain, regain focus from the intense emotional sensation. Often patients experience symptoms in relation to the trauma that are associated with past events in their life. They get consumed by emotion and don’t have the immediate tools to manage them. This subsequently overwhelms them, which may cause the need to dissociate. Grounding helps to shift their attention from the negative emotions to the external world and also enables them to anchor to the present moment. They are taught coping responses like washing hands, describe their immediate external environment, describe the texture of the sofa, identify 10 colours in the room etc., These techniques allow them to detach from strong emotions and establish contact with the present moment in the immediate external world through sensory and cognitive awareness. This will help manage overwhelming anxiety and limit the panic.
Patient is asked to answer cognitively oriented questions Where am I? What is today? What is the date? What is the month and year? How old am I? What season is this?
This technique involves using the senses to anchor to the present moment. For example; feel the back of the chair and describe its texture, count all the red items in this rooms, identify 5 sounds around you, name two things you can smell right now, place a cool cloth on your face and describe how it feels, have a cup of tea and focus on its warmth, etc., [Table 6].
Distress Tolerance skills teaches the patients to tolerate painful emotions and uncomfortable feelings without resorting to impulsive and unhealthy behavior like substance abuse, self-harm, dissociation etc., It does not aim to solve the core issue and to bring about long term conflict resolution. The aim of distress tolerance is to increase the patient's capacity to bare the painful emotion when the situation cannot be changed immediately. First the patient is taught the role of emotions in life and the consequences of resisting them. They are then taught how to identify and label an emotion; after which they are a taught various tools to handle the emotion. It is observed that once the patient learns this emotional first-aid, they start to feel relatively confident and safe in the face of an emotion because now they have tools to manage them.
Various distraction and other related DBT skills are taught under DT:
Figure 4 Radical acceptance
For example, when a patient ABC diagnosed with a chronic illness, understands from the doctors about the chronicity and restriction it will pose in his life. He goes through various thoughts, “Why me,” This is not fair,” “how can this be my life ahead” and many such thoughts which reflect the inability or difficulty in accepting a situation.
Another example, when a person XYZ is concerned about an argument they had with a family member and called her by a nasty name, XYZ may find herself constantly worried about the consequences and is anxious or goes through guilt.
During such instances, the patient can be asked to list out various
(Readers may refer to other books and resources on each of these DBT skills for comprehensive understanding of the concepts).
It is also referred to talking to the personality system as a whole. It is an effective and useful technique in working with a patient with Dissociative identity disorder. The therapist can approach this situation by means of being directive and asking the different identities to acknowledge the presence of a conflict and unmet needs. Emphasizing that working together is essential to enable the functioning. “Listening in” and cooperating is the requirement in this procedure. Every session can have the therapist sharing and emphasizing this. This enables coconsciousness and awareness of one's own internal process.
Co consciousness involves internal awareness of existence and experiences of other self-states. The process allows self-aspects to align to one's directives. This allows symptom reduction, fewer episodes of time loss, fewer behaviors outside of awareness and improves general functioning.
It is inevitable for the therapist to take into account the different self-states. Initial stages of treatment is challenging as the different self-states may not cooperate. Internal meetings are taught, also a part of the Dissociative table technique where the patient recognizes internal ego and control switching and internal communication. This strategy is effective in reducing internal conflict and resolving safety issues. They are important in safety planning and identifying a self which is suicidal and hopeless self-aspect. Furthermore, the more organized the meetings are, the more successful the outcome; this enables problem-solving.
The internal meetings start with “introduction” describing the age, interests, needs, wants, roles, etc. Second, it can focus asking the needs towards which one needs to work on. Also, record the verbatim in a diary. This enables the patient to also look within and identify the conflict, bringing about a deeper level of awareness.
This phenomena occurs which occurs at an external or internal level. There are several biologic and psychological theories which explain the re-enactment of memories, learned behaviour, disorganized attachment. Vulnerability to re victimization which results in traumatic re-enactment can be explained by Karpman Drama triangle. The trauma triangle also includes the “bystander.” The self which internalizes the persecutor, victimized self and the rescuer. Acceptance and calmness from the part of the therapist is essential as is working with the needs of self and address the aggression.
The process of dealing with the reality, what actually is happening and figure out what the situation calls for.
In the first instance, it could involve accepting the situation of illness, understanding that illness is a reality, however despite it one need not suffer, that is an attempt to radically accept deeply and willingly following the help required.
In the second example, apologizing, working on improving communication, asking the family member on how one can contribute toward repairing conflicts.
Acceptance is a choice and turning the mind involves practising the skill of acceptance in a particular situation. Furthermore, acceptance does not involve approval. It involves understanding the reality for what it is, painful emotions that one can cope with by means expression of emotions in an adaptive way and getting adequate support.
Emotional regulation is a term that is often used to understand how people manage and respond to their internal emotional experiences. And emotional dysregulation can be understood as a person's inability to use healthy strategies to moderate or diffuse negative emotions. Learning ER skills enables individuals to identify why emotions are important, the identification of emotions and process of change in emotions. It also involves how to evaluate emotional responses which are effective. Patients with dissociative experiences and symptoms often present with emotional dysregulation. The process of dealing with intense emotions involves the following
Steps
Interpersonal effectiveness skills consists of social skills training, assertiveness training and listening skills.
These are particularly inevitable as interpersonal behaviors and patterns influence relationships. It involves the individual identifying the pattern of interpersonal style and behavior – passive or aggressive. Both patterns can result in unhealthy and destructive relationships. The key interpersonal skills which facilitate change Knowing what you want, asking for what you want, negotiating conflicting wants, getting information, saying “no” in a way that protects the relationship and acting according to values.
These are particularly required in cases where interpersonal conflicts exacerbate dissociative experiences and also the goal is to improve the overall health of the relationship.
It is a form of psychotherapy that helps people address and process traumatic life experiences and systematically facilitate adaptive responses to the conflicts created. It is a psychotherapeutic technique that engages clients in traditional elements of therapeutic methods which are organized in a unique way. This technique is used especially in patients with posttraumatic stress disorder. The technique
The process of desensitization
At a glance one can see the various types of coping skills in Table 7.
When dealing with dissociative disorder, the approach to dissociative identity disorder must be mentioned in a little more detail.
While approaching dissociative identity disorder, it is preferable to work through 3 stages, for the purpose of chalking out a plan or understanding. It is also important to keep in mind that integration of all identities as one may not occur, and treatment goals have to be small and tailored accordingly [Figure 5].
Figure 5 Approach to dissociative identity disorder
Phase oriented treatment approach is widely used and is a sequenced staged process given by for dissociative disorders.
Goals:
Self-soothing and self-regulatory strategies are used to reduce the physiological and dissociative symptom.
Skills training is an inevitable part of safety and stabilization phase.
Goals of skills training
Also, the process of working with different identities is by means of talking through and internal meetings.
Focus:
Specific
Integrating traumatic memories is meant by bringing together the different aspects of traumatic experiences, memories and sequence of events, associated affects and physiological and somatic representations. It also involves establishing a sense of self and the impact of trauma from the past into their life. As traumatic memories integrate, the different identities tend to be less distinct [Table 8].
Achieve a solid and stable sense of how they relate to others and to the outside world. Also, patient may begin to focus more on the channelizing their energy towards living in present and a purpose instead of the traumatic memories.
Once the patient has stabilized and the therapist based on her/his judgment of the patient's ego strength may want to attempt CBT or other cognitively oriented therapies. This allows the patient a different and more structured view of his/her emotional life. These therapies through their psycho educational methods teach the patient how to identify and challenge irrational core beliefs. In the long run this knowledge helps develop meta-cognitive skills and helps in relapse prevention too. Understanding this helps many patients realize that they have the power to influence their emotional world. Moreover, the tools to change them that are taught in cognitive therapies create a sense of empowerment.
Points to
Nil.
There are no conflicts of interest.