Complex Trauma and Complex Dissociative Disorders Part 2

DID: More Prevalent than you Think!  1%-2% of the general population (Johnson et al., 2006)  1%-9% in clinical populations in North America, Europe, Turkey  96% of DID cases associated with CSA & severe physical abuse  Female to male ratio:1:1 in childhood to 9:1 in adulthood  “Only 6% make their DID obvious on an ongoing basis” and  Less than 20% exhibit dramatic shifts in alters (Kluft, 1991) Physiological Differences Among Alternate Identities  visual acuity,  medication responses,  allergies,  plasma glucose levels in diabetic patients,  heart rate,  blood pressure,  galvanic skin response,  muscle tension,  immune function,  electroencephalography and evoked potential patterns,  brain activation and regional blood flow (Loewenstein & Putnam, 2004) Theories of DID  Developmental models: a failure of normal developmental integration caused by overwhelming experiences and disturbed caregiver–child interactions  Structural Dissociation of the Personality: Failure to integrate systems of ideas and personality due to trauma resulting in encapsulation of intolerable memories Structural Dissociation of Personality (van der Hart)  Apparently normal part (ANP) and emotional parts of personality (EPP)  Primary: one predominant ANP and one EPP (not well elaborated or autonomous); ASD, PTSD, BPD  Secondary: one predominant ANP and more than one EPP (more elaborated and autonomous than Primary); cPTSD, OSDD; BPD  Tertiary: Multiple ANPs and EPPs; more elaborated and autonomous with different names and features; DID, DID/cPTSD Clinical Impact of DID  Can disrupt or prevent formation of therapeutic alliance  Client’s changing perceptions of therapist and environment  Higher alliance associated with less dissociative symptoms (Cronin et al.).  Solves a problem, conscious absence during abuse, but creates a long-term problem, fragmented sense of self  Underdiagnosed due to skepticism and lack of training  Often takes years in treatment before getting an accurate diagnoses Include in Intake Interviews  History of physical/sexual abuse or other maltreatment  Gaps in memory/loosing time/amnesia  Hearing voices  Imaginary companions  Trance states Differential Diagnosis  DID vs BPD- less volatile emotions; amnesia between emotion states; less identity confusion; BDP recall shifts across emotional states  DID vs Psychotic disorder- DID voices begin in childhood, child and adult voices, parts have a sense of self, passive control.  Bi-polar disorder: lacks memory deficits and distinctive parts  Ego states are normal phenomena without autonomy; maintain a shared sense of belonging Recognizing Dissociative Parts  Sense of fragmentation, division of self, involuntariness, “not me”  You hear yourself talking, but it seems as though the thoughts or words you hear are not your own and you have no control over it.  Amnesia- Swiss cheese memory, blanks, foggy, time loss  You discover that something has been done that only you could have done, yet you have no memory of it.  Depersonalization/derealization  You experience yourself outside your body and/or your perceptions of the environment looks different, distorted, unreal, surrealistic  You have body sensations/movements that seem to be other controlled (passive influence) Assessment Instruments for DID  Multiscale Dissociative Inventory- 30-items, 6 scales (disengagement, emotional constriction, depersonalization, derealization, memory disturbance, and identity dissociation)  Multidimensional Inventory of Dissociation-218 items  Somatoform Dissociative Questionnaire-20: 20 items  Dissociative Disorders Interview Scale- 30-45 minute interview. DSM-5 diagnoses: somatic symptom disorder, BPD, MDD, positive symptoms of schizophrenia and all DDs  Structured Clinical Interview for Dissociative Disorders Incest  Associated with severe symptoms (e.g., DID, self-harm, disturbance in self-organization)  1 in 20 families father-daughter incest  1 in 7 stepfather-daughter incest  Characterized by: secrecy, betrayal, powerlessness, guilt, conflicted loyalty, fear of reprisal, and self-blame/shame,  Creates sense of being damaged, contaminated, self-loathing  Only 30% of incest cases reported by victims voluntarily