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Dissociation, Dissociative Disorders, and PTSD

  • Amie C. MyrickEmail author
  • Bethany L. Brand
Reference work entry

Abstract

Dissociative experiences are common among children and adults, ranging from normative to pathological frequency and severity. This chapter details important aspects of dissociation following traumatic experiences, including empirical support for the trauma model of dissociation, psychobiological processes involved in dissociative experiences, and the presence of both dissociative symptomatology and dissociative disorders in patients diagnosed with post-traumatic stress disorder. Additionally, the authors discuss the complexities of conducting trauma treatment with dissociative individuals, including differential diagnosis and treatment approaches grounded in current treatment outcome research. Finally, key points to further inform readers about assessment and treatment of dissociative disorders are included at the conclusion of the chapter.

Keywords

Childhood abuse Complex PTSD Dissociation Dissociative disorders Dissociative identity disorder 

List of Abbreviations

ACES

Adverse Childhood Experiences Study

BPD

Borderline personality disorder

CSA

Childhood sexual abuse

DD

Dissociative disorders

DDNOS

Dissociative disorder not otherwise specified

DID

Dissociative identity disorder

DPTSD

Dissociative subtype of PTSD

DSM-5

Diagnostic and statistical manual of mental disorders, fifth edition

NIS

Neutral identity states

PTSD

Post-traumatic stress disorder

SIB

Self-injurious behavior

TIS

Trauma identity states

TOP DD

Treatment Outcome of Patients with Dissociative Disorders Study

References

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed.Washington, DC: American Psychiatric Publishing; 2013.Google Scholar
  2. Bernstein E, Putnam FW. Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis. 1986;174:727–35.CrossRefPubMedGoogle Scholar
  3. Boon S, Draijer N. Multiple personality disorder in the Netherlands: a clinical investigation of 71 patients. Am J Psychiatry. 1993;150:489–94.CrossRefPubMedGoogle Scholar
  4. Brand B. Establishing safety with patients with dissociative identity disorder. J Trauma Dissociation. 2001;2(4):133–55. doi:10.1300/J229v02n04_07.CrossRefGoogle Scholar
  5. Brand BL, Chasson GS. Distinguishing simulated from genuine dissociative identity disorder on the MMPI-2. Psychol Trauma. 2014. doi:10.1037/a0035181.PubMedGoogle Scholar
  6. Brand BL, Lanius RA. Chronic complex dissociative disorders and borderline personality disorder: disorders of emotion dysregulation? Borderline Personality Disorder and Emotion Dysregulation 2014 1:13Google Scholar
  7. Brand BL, Loewenstein RJ. Dissociative disorders: an overview of assessment, phenomenology and treatment. Psychiatr Times. 2010;27(10):62–9.Google Scholar
  8. Brand B, Armstrong JA, Loewenstein RJ, McNary SW. Personality differences on the Rorschach of dissociative identity disorder, borderline personality disorder, and psychotic inpatients. Psychol Trauma. 2009;1(3):188–205.CrossRefGoogle Scholar
  9. Brand BL, Myrick AC, Loewenstein RJ, Classen CC, Lanius R, McNary SW, . . . Putnam FW. A survey of practices and recommended treatment interventions among expert therapists treating patients with dissociative identity disorder and dissociative disorder not otherwise specified. Psychol Trauma. 2012;4(5):490–500. doi:10.1037/a0026487.Google Scholar
  10. Brand BL, McNary SW, Myrick AC, Classen CC, Lanius R, Loewenstein RJ, . . . Putnam FW. A longitudinal naturalistic study of patients with dissociative disorders treated by community clinicians. Psychol Trauma. 2013;5(4):301–8. doi:10.1037/a0027654.Google Scholar
  11. Brand BL, Loewenstein RJ, Speigel D. Dispelling myths about dissociative identity disorder treatment: an empirically based approach. Psychiatry. 2014a;77:169–89.CrossRefPubMedGoogle Scholar
  12. Brand BL, Tursich M, Tzall D, Loewenstein RJ. Utility of the SIRS-2 in distinguishing genuine from simulated dissociative identity disorder. Psychol Trauma. 2014b. doi:10.1037/a0036064.PubMedGoogle Scholar
  13. Bremner JD. Acute and chronic responses to psychological trauma: where do we go from here? Am J Psychiatry. 1999;156(3):349–51.PubMedGoogle Scholar
  14. Bremner JD, Marmer CR, editors. Trauma, memory, and dissociation. Washington, DC: American Psychiatric Press; 1998.Google Scholar
  15. Briere J, Weathers FW, Runtz M. Is dissociation a multidimensional construct? Data from the Multiscale Dissociation Inventory. J Trauma Stress. 2005;18:221–31.CrossRefPubMedGoogle Scholar
  16. Butler LD. Disclosure of sexual abuse during childhood and subsequent memory for the trauma. Paper presented at the International Society for the Study of Dissociation, New Orleans. 2001.Google Scholar
  17. Chu JA. Rebuilding shattered lives: treating complex PTSD and dissociative disorders. 2nd ed. Hoboken: Wiley; 2011.CrossRefGoogle Scholar
  18. Cloitre M, Koenen K, Cohen L, Han H. Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse. J Consult Clin Psychol. 2002;70(5):1067–74.CrossRefPubMedGoogle Scholar
  19. Cloitre M, Courtois CA, Charuvastra A, Carapezza R, Stolbach BC, Green BL. Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices. J Trauma Stress. 2011;24(6):615–27. doi:10.1002/jts.20697.CrossRefPubMedGoogle Scholar
  20. Cloitre M, Stolbach BC, Herman JL, van der Kolk B, Pynoos R, Wang J, et al. Developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. J Trauma Stress. 2009;22:399–408.Google Scholar
  21. Courtois CA, Ford JD, editors. Treating complex traumatic stress disorders: an evidence-based guide. New York: Guilford Press; 2009.Google Scholar
  22. Cronin E, Brand BL, Mattanah JF. The impact of the therapeutic alliance on treatment outcome in patients with dissociative disorders. Eur J Psychotraumatol. 2014;5. doi:10.3402/ejpt.v5.22676.Google Scholar
  23. Dalenberg CJ, Brand BL, Gleaves DH, Dorahy MJ, Loewenstein RJ, Cardena E, . . . Spiegel D. Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychol Bull. 2012;138(3):550–88. doi:10.1037/a0027447.Google Scholar
  24. Dalenberg CJ, Loewenstein RJ, Dorahy MJ, Frewen PA, Brand BL, Gleaves DH, . . . Spiegel D. Reality versus fantasy: reply to Lynn et al. (2014). Psychol Bull. 2014;140(3):911–20. doi:10.1037/a0036685.Google Scholar
  25. Dell PF. The multidimensional inventory of dissociation (MID): a comprehensive measure of pathological dissociation. J Trauma Dissociation. 2006;7:77–106.CrossRefPubMedGoogle Scholar
  26. Dorahy MJ, Corry M, Shannon M, Webb K, McDermott B, Ryan M, Dyer KF. Complex trauma and intimate relationships: the impact of shame, guilt and dissociation. J Affect Disord. 2013;147(1–3):72–9.CrossRefPubMedGoogle Scholar
  27. Dorrepaal E, Thomaes K, Smit JH, Veltman DJ, Hoogendoorn AW, van Balkom AJLM, Draijer N. Treatment compliance and effectiveness in complex PTSD patients with co-morbid personality disorder undergoing stabilizing cognitive behavioral group treatment: a preliminary study. Eur J Psychotraumatol. 2013;4, p. 1–7.Google Scholar
  28. Ebner-Priemer UW, Mauchnik J, Kleindienst N, Schmahl C, Peper M, Rosenthal MZ, . . . Bohus M. Emotional learning during dissociative states in borderline personality disorder. J Psychiatry Neurosci. 2009;34(3):214–22.Google Scholar
  29. Edwards VJ, Fivush R, Anda RF, Felitti VJ, Nordenberg DF. Autobiographical memory disturbances in childhood abuse survivors. In: Freyd JJ, DePrince AP, editors. Trauma and cognitive science: a meeting of minds, science, and human experience. Binghamton: Howarth; 2001.Google Scholar
  30. Ellason JW, Ross CA, Fuchs DL. Lifetime axis I and II comorbidity and childhood trauma history in dissociative identity disorder. Psychiatry. 1996;59(3):255–66.PubMedGoogle Scholar
  31. Elliott DM, Briere J. Posttraumatic stress associated with delayed recall of sexual abuse: a general population study. J Interpers Violence. 1995;8:628–47.Google Scholar
  32. Foote B. Dissociative identity disorder: epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. In: Speigel D, Hermann R, editors. UpToDate. Waltham: UpToDate; 2013.Google Scholar
  33. Foote B, Smolin Y, Neft DI, Lipschitz D. Dissociative disorders and suicidality in psychiatric outpatients. J Nerv Ment Dis. 2008;196(1):29–36.CrossRefPubMedGoogle Scholar
  34. Giesbrecht T, Lynn SJ, Lilienfeld SO, Merckelbach H. Cognitive processes in dissociation: an analysis of core theoretical assumptions. Psychol Bull. 2008;134:614–47.CrossRefGoogle Scholar
  35. Hagenaars MA, van Minnen A, Hoogduin KAL. The impact of dissociation and depression on the efficacy of prolonged exposure treatment for PTSD. Behav Res Ther. 2010;48(1):19–27. doi:10.1016/j.brat.2009.09.001.CrossRefPubMedGoogle Scholar
  36. Herman JL. Trauma and recovery. New York: Basic Books; 1992.Google Scholar
  37. International Society for the Study of Dissociation, Chu JA, Dell PF, Somer E, Van der Hart O, Cardeña E, . . . Twombly J. Guidelines for treating dissociative identity disorder in adults, third revision: summary version. J Trauma Dissociation. 2011;12(2):188–212. doi:10.1080/15299732.2011.537248.Google Scholar
  38. International Society for the Study of Trauma and Dissociation. Guidelines for treating dissociative identity disorder in adults, third revision. J Trauma Dissociation. 2011;12(2):115–87. doi:10.1080/15299732.2011.537247.CrossRefGoogle Scholar
  39. Jepsen EK, Langeland WS, Sexton H, Heir T. Inpatient treatment for early sexually abused adults: a naturalistic 12-month follow-up study. Psychol Trauma. 2014;6:142–51.CrossRefGoogle Scholar
  40. Kluft RP. Clinical approaches to the integration of personalities. In: Kluft RP, Fine CG, editors. Clinical perspectives on multiple personality disorder. Arlington: American Psychiatric Association; 1993a. p. 101–33.Google Scholar
  41. Kluft RP. Initial stages of psychotherapy in the treatment of multiple personality disorder. Dissociation. 1993b;6:145–61.Google Scholar
  42. Kucukgoncu S, Yildirim Ornek F, Cabalar M, Yayla V, Bestepe E. Childhood trauma and dissociation in tertiary care patients with migraine and tension type headache: a controlled study. J Psychosom Res. 2014. doi:10.1016/j.jpsychores.2014.04.007.PubMedGoogle Scholar
  43. Lanius RA, Bluhm RL, Lanius U, Pain C. A review of neuroimaging studies in PTSD: heterogeneity of response to symptom provocation. J Psychiatr Res. 2006;40(8):709–29.CrossRefPubMedGoogle Scholar
  44. Lanius RA, Vermetten E, Loewenstein RJ, Brand BL, Schmahl C, Bremner JD, Spiegel D. Emotional modulation in PTSD: clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatry. 2010;167:640–7.CrossRefPubMedPubMedCentralGoogle Scholar
  45. Lanius RA, Wolf EJ, Miller MW, Frewen PA, Vermetten E, Brand B, Spiegel D. The dissociative subtype of PTSD. In: Friedman MJ, Keane TM, Resick PA, editors. The handbook of PTSD: science and practice. New York: Guilford; 2014. p. 234–50.Google Scholar
  46. Loewenstein RJ. An office mental status examination for chronic complex dissociative symptoms and multiple personality disorder. Psychiatr Clin North Am. 1991;14:567–604.PubMedGoogle Scholar
  47. Lynn SJ, Merckelbach H, Giesbrecht T, Loftus EF, Garry M, Lilienfeld SO, . . . Malaktaris A. The trauma model of dissociation: inconvenient truths and stubborn fictions. Comment on Dalenberg et al. (2012). Psychol Bull.2014;140(3):896–910. doi:10.1037/a0035570.Google Scholar
  48. Myrick AC, Brand BL, McNary SW, Classen CC, Lanius R, Loewenstein RJ, . . . Putnam FW. An exploration of young adults’ progress in treatment for dissociative disorder. J Trauma Dissociation. 2012;13(5):582–95. doi:10.1080/15299732.2012.694841.Google Scholar
  49. Myrick AC, Brand BL, Putnam FW. For better or worse: the role of revictimization and stress in the course of treatment for dissociative disorders. J Trauma Dissociation. 2013;14(4):375–89. doi:10.1080/15299732.2012.736931.CrossRefPubMedGoogle Scholar
  50. Myrick AC, Chasson GS, Lanius RA, Leventhal BL, Brand BL. Treatment of complex dissociative disorders: a comparison of interventions reported by community therapists versus those recommended by experts. J Trauma Dissociation. 2015;16:51.CrossRefPubMedGoogle Scholar
  51. Nijenhuis ER, Den Boer JA. Psychobiology of traumatization and trauma-related structural dissociation of the personality. In: Dell PF, O’Neill JA, editors. Dissociation and the dissociative disorders: DSM-V and beyond. New York: Routledge; 2009. p. 337–67.Google Scholar
  52. Nijenhuis ERS, Spinhoven P, Van Dyck R, Van der Hart O, Vanderlinden J. The development and the psychometric characteristics of the Somatoform Dissociation Questionnaire (SDQ-20). J Nerv Ment Dis. 1996;184:688–94.CrossRefPubMedGoogle Scholar
  53. Nijenhuis ERS, Vanderlinden J, Spinhoven P. Animal defensive reactions as a model for trauma-induced dissociative reactions. J Trauma Stress. 1998;11(2):243–60. doi:10.1023/A:1024447003022.CrossRefPubMedGoogle Scholar
  54. Putnam FW. Dissociation in children and adolescents: a developmental model. New York: Guilford; 1997.Google Scholar
  55. Putnam FW, Guroff JJ, Silberman EK, Barban L, Post RM. The clinical phenomenology of multiple personality disorder: a review of 100 recent cases. J Clin Psychiatry. 1986;47:285–93.PubMedGoogle Scholar
  56. Putnam FW, Carlson EB, Ross CA, Anderson G, Clark P, Torem M, . . . Braun BG. Patterns of dissociation in clinical and nonclinical samples. J Nerv Ment Dis. 1996;184:673–9.Google Scholar
  57. Putnam KT, Harris WW, Putnam FW. Synergistic childhood adversities and complex adult psychopathology. J Trauma Stress. 2013;26(4):435–42.CrossRefPubMedGoogle Scholar
  58. Reinders AA, Nijenhuis ER, Quak J, Korf J, Haaksma J, Paans AM, Willemsen AT, den Boer JA. Psychobiological characteristics of dissociative identity disorder: a symptom provocation study. Biol Psychiatry. 2006;60(7):730–40.CrossRefPubMedGoogle Scholar
  59. Reinders AA, Willemsen AT, den Boer JA, Vos HP, Veltman DJ, Loewenstein RJ. Opposite brain emotion-regulation patterns in identity states of dissociative identity disorder: a PET study and neurobiological model. Psychiatry Res. 2014;223(3):236–43. doi:10.1016/j.pscychresns.2014.05.005.CrossRefPubMedGoogle Scholar
  60. Resick PA, Suvak MK, Johnides BD, Mitchell KS, Iverson KM. The impact of dissociation on PTSD treatment with cognitive processing therapy. Depress Anxiety. 2012;29(8):718–30. doi:10.1002/da.21938.CrossRefPubMedGoogle Scholar
  61. Rodewald F, Wilhelm-Goling C, Emrich HM, Reddemann L, Gast U. Axis-I comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified. J Nerv Ment Dis. 2011;199(2):122–31. doi:10.1097/NMD.0b013e318208314e.CrossRefPubMedGoogle Scholar
  62. Rogers R, Payne JW, Correa AA, Gillard ND, Ross CA. A study of the SIRS with severely traumatized patients. J Pers Assess. 2009;91(5):429–38. doi:10.1080/00223890903087745.CrossRefPubMedGoogle Scholar
  63. Sar V. Epidemiology of dissociative disorders: an overview. Epidemiol Res Int. 2011. doi:10.1155/2011/404538.Google Scholar
  64. Schauer M, Elbert T. Dissociation following traumatic stress. Z Psychol/J Psychol. 2010;218(2):109–27. doi:10.1027/0044-3409/a000018.Google Scholar
  65. Schlumpf YR, Reinders AA, Nijenhuis ER, Luechinger R, van Osch MJ, Jancke L. Dissociative part-dependent resting-state activity in dissociative identity disorder: a controlled FMRI perfusion study. PLoS One. 2014;9(6):e98795. doi:10.1371/journal.pone.0098795.CrossRefPubMedPubMedCentralGoogle Scholar
  66. Silberg JL, Dallum S. Dissociation in children. In: O’Neill PFDO, editor. Dissociation and the dissociative disorders. New York: Routledge; 2009. p. 67–81.Google Scholar
  67. Simeon D, Loewenstein RJ. Dissociative disorders. In: Sadock BJ, Sadock VA, Ruiz P, editors. Comprehensive textbook of psychiatry, vol. 1. 9th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2009. p. 1965–2026.Google Scholar
  68. Spiegel D. Multiple personality as a post-traumatic stress disorder. Psychiatr Clin North Am. 1984;7:101–10.PubMedGoogle Scholar
  69. Spiegel D, Lewis-Fernández R, Lanius R, Vermetten E, Simeon D, Friedman M. Dissociative disorders in DSM-5. Annu Rev Clin Psychol. 2013;9:299–326. doi:10.1146/annurev-clinpsy-050212-185531.CrossRefPubMedGoogle Scholar
  70. Stein DJ, Koenen KC, Friedman MJ, Hill E, McLaughlin KA, Petukhova M, . . . Kessler RC. Dissociation in posttraumatic stress disorder: evidence from the world mental health surveys. Biol Psychiatry. 2013;73(4):302–12. doi:10.1016/j.biopsych.2012.08.022.Google Scholar
  71. Thomaes K, Dorrepaal E, Draijer N, Jansma EP, Veltman DJ, van Balkom AJ. Can pharmacological and psychological treatment change brain structure and function in PTSD? A systematic review. J Psychiatr Res. 2014;50:1–15.CrossRefPubMedGoogle Scholar
  72. Van der Hart O, Nijenhuis ER, Steele K. The haunted self: structural dissociation and the treatment of chronic traumatization. New York: W.W. Norton; 2006.Google Scholar
  73. Webermann AR, Myrick AC, Taylor CL, Chasson GS, Brand BL. Predictors of self-injurious behavior and suicidality in dissociative disorder patients. Journal of Trauma and Dissociation. submitted.Google Scholar
  74. Wolf MR, Nochajski TH. Child sexual abuse survivors with dissociative amnesia: what’s the difference? J Child Sex Abus. 2013;22:462–80. doi:10.1080/10538712.2013.781094.CrossRefPubMedGoogle Scholar
  75. Yargiç L, Şar V, Tutkun H, Alyanak B. Comparison of dissociative identity disorder with other diagnostic groups using a structured interview in Turkey. Compr Psychiatry. 1998;39:345–51.CrossRefPubMedGoogle Scholar
  76. Zoroglu SS, Tuzun U, Sar V, Tutkun H, Savas HA, Ozturk M, . . . Kora ME. Suicide attempt and self-mutilation among Turkish high school students in relation with abuse, neglect and dissociation. Psychiatry Clin Neurosci. 2003;57:119–26.Google Scholar
  77. Zucker M, Spinazzola J, Blaustein M, van der Kolk BA. Dissociative symptomatology in posttraumatic stress disorder and disorders of extreme stress. J Trauma Dissociation. 2006;7:19–31.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Family and Children’sBel AirUSA
  2. 2.Psychology DepartmentTowson UniversityTowsonUSA

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