Effects of Dissociation on Treatment Outcome:

A Systematic Literature Review

Katherine L Hilton, LPCMississippi College

Evidence Based Practices (EBPs)

Applying EBP Starts with Effective Assessment

Evidence Based Practice

(Chambless, 1998; Gertlehner, Hasenc, & Nissman, 2006)

(Byng, 2012; Caldwell, Bennett, & Mellis, 2012; Rice, 2013)

Difficult with complex clinical presentations

Trauma

Something May be Missing…

Assessment

(International Society for the Study of Trauma and Dissociation [ISSTD], 2011)

(Lamagna & Gleiser, 2007; Sprang, Craig, & Clark, 2007)

(Ellason, Ross, & Fuchs, 1996)

a disruption in typically integrated mental

functioning of experience, especially in regards to consciousness, memory, identity, or perception (APA, 2000, p. 519)

50%- 65% in a lifetime – (APA, 2013; Ross, Joshi, & Currie, 1990)

“A normal process that is… used defensively by an individual to handle traumatic experiences”(Putnam, 1989, p. 9)

Dissociation

Types of Dissociation

Depersonalization & Derealization

“Unreality or Detachment”

Not delusional

Dissociative Amnesia

Localized

Selective

Generalized(APA, 2013; Schauer & Elbert, 2010)

Identity Disruption

DID

Dissociative Disorder

Characteristic of a Trauma-Related Disorder

Co-occurring Symptom

Maladaptive Dissociation

Dissociative Disorders

Depersonalization/ Derealization Disorder

50% - One Episode 2% - Lifetime

prevalence Dissociative Amnesia

Disorder

1.8% in a given year

Dissociative Identity Disorder

1.5% - Lifetime prevalence

(APA, 2013)

Dissociation in Other Disorders

Borderline Personality Disorder Dissociative

experiences Disruption of

identity

Post-Traumatic Stress Disorder Flashbacks Specifier

(APA, 2013)

Somatization Disorder/ Somatic Symptom

Disorder (Brown, Schrag, & Trimble, 2005)

OCD (Hollander & Benzaquen, 1997)

Social Anxiety (Fontonelle et al., 2007)

Panic Disorder (Pfaltz, Michael, Meyer, & Wilhelm, 2013)

Bulimia Nervosa & Binge Eating (Hallings-Pott, Waller, Watson, & Scragg, 2005)

Depression (Hagenaars, van Minnen, & Hoogduin, 2010)

Schizophrenia (Braehler et al., 2013)

Co-Occurring Disorders

“poses a serious obstacle to successful

treatment” (Schauer & Elbert, 2010, p. 109)

OCD & Dissociation - Rufer et. al (2006)

52 participants, CBT treatment Baseline DES scores positively correlated with…

Earlier Termination Lack of Treatment Response OCD Symptoms Post-Treatment

Effect on Treatment

Borderline personality disorder (Kleindienst et al.,

2011)

57 clients; 3 months of DBT

Agoraphobia with panic (Michelson et al., 1998)

89 clients; CBT treatment

Inpatient treatment for non-psychotic disorders (Spitzer et al., 2007)

133 clients; short-term CBT psychotherapy

Effect on Treatment

The problem of this literature review is to

identify and describe the effects of dissociation on treatment outcome.

An additional concern is to identify specific disorders and their treatments that are the most impacted by dissociation.

Statement of Problem

Results could improve screening and

assessment

Recommendations for improving course of treatment and outcome for co-occurring disorders

Significance

1. What effects does dissociation have on

treatment outcomes? 2. Does dissociation negatively influence

treatments for certain co-occurring disorders?3. How could screening for dissociation improve

treatment of co-occurring disorders?

Research Questions

Systematic Literature Review Preferred Reporting Items for Systematic

reviews and Meta-Analyses (PRISMA) statement PRISMA Checklist PRISMA Flowchart

Method

Method

1980 – 2014 Databases:

PscyhINFO PscyhARTICLES Sage Premier SocINDEX Wiley Online Library

Reference Lists Specific Journals

e.g. Journal of Trauma and Dissociation

Dissociation Treatment

Co-occurring

Disorders

Dissociation Treatment Comorbidity

Dissociative Outcome Co-occurring Disorders

Dissociate Efficacy Post-traumatic Stress Disorder

Depersonalization Effectiveness

Borderline Personality

Disorder

Derealization Course of Treatment

Obsessive-Compulsive

Disorder

Identity disruption Drop-Out Anxiety Disorder

  Premature Termination Panic Disorder

  Treatment Response Eating Disorder

  Post-Treatment Symptoms Bulimia Nervosa

    Depression

    Schizophrenia

Search Terms

Inclusion Criteria

Psychometric assessment(s) that have proven validity and reliability

Subscales or items from other assessments (e.g., Briere, 1995)

Structured Clinical Interview for DSM–IV Dissociative Disorders–Revised (SCID-D-R; Steinberg, 1994)

Multidimensional Inventory of Dissociation (MID; Dell, 2006)

Dissociative Experiences Scale (DES; Bernstein & Putnam, 1993)

Dissociative Disorders Interview Schedule (DDIS; Ross et al., 1989)

Non-English

Non-peer reviewed

Focus of Treatment is a Dissociative Disorder

Exclusion Criteria

Definition of Terms

Dissociation - “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, motor control, and behavior” (APA, 2013, p. 519)

Dissociation - Not inherently pathological

Definition of Terms

Depersonalization –”the experience of unreality or detachment from one’s mind, self, or body”(APA, 2013, p. 291)

Derealization – “the experience of unreality or detachment from ” (APA, 2013, p. 291) the environment

Dissociative amnesia –the “inability to recall autobiographical information that is inconsistent with normal forgetting” (APA, 2013, p. 291)

Definition of Terms

Treatment - any number of interventions in the counseling and psychotherapy field

Treatment Outcome -changes made and/or maintained throughout treatment that can be reasonably attributed to the treatment

Remainder of Study

Chapter 2 1. Theories of

development2. Current views on

how dissociation operates

3. Common co-occurring disorders

4. Available assessment procedures and treatments

Chapter 3 Methodology Procedures

Chapter 4 Literature Review

Chapter 5 Implications

American Psychiatric Association. (2000). Diagnostic and

statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Barlow, M. R., & Freyd, J. F. (2009). Adaptive dissociation: Information processing and response to betrayal. In P. F. Dell & J. A. O’Neil (Eds.). The Dissociative Disorders: DSM-V and Beyond (pp. 93-106). New York, NY: Routledge.

Bernstein, E. M., & Putnam, F. W. (1993). An update on the Dissociative Experiences Scale. Dissociation, 6, 16–27.

References

Bonanno, G. A., Keltner, D., Holen, A., & Horowitz, M. J. (1995).

When avoiding unpleasant emotions might not be such a bad thing: Verbal-autonomic response dissociation and midlife conjugal bereavement. Journal of Personality and Social Psychology, 69(5), 975-989.

Braehler, C., Valiquette, L., Holowka, D., Malla, A. K., Joober, R., Ciampi, A., & ... King, S. (2013). Childhood trauma and dissociation in first-episode psychosis, chronic schizophrenia and community controls. Psychiatry Research, 210(1), 36-42. doi:10.1016/j.psychres.2013.05.033

Briere, J. (1995). Trauma Symptom Inventory (TSI) Professional Manual. Odessa, FL: Psychological Assessment Resources.

Brown, R. J., Schrag, A., & Trimble, M. R. (2005). Dissociation, childhood interpersonal trauma, and family functioning in patients with somatization disorder. American Journal of Psychiatry, 162, 899-905.

References

Byng, R. (2012). Care for common mental health problems:

Applying evidence beyond RCTs. Family Practice, 29(1), 3-7. doi:10.1093/fampra/cmr132

Caldwell, P., Bennett, T., & Mellis, C. (2012). Easy guide to searching for evidence for the busy clinician. Journal Of Paediatrics And Child Health, 48(12), 1095-1100. doi:10.1111/j.1440-1754.2012.02503.x

Chambless, D. L. & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7-18.

Dell, P. F. (2006). The Multidimensional Inventory of Dissociation (MID): A comprehensive measure of pathological dissociation. Journal of Trauma & Dissociation, 7(2), 77–106.

References

Dell, P. F. (2009). Understanding dissociation. In P. F. Dell & J. A.

O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-V and beyond (pp. 709-825). New York, NY: Routledge.

Ellason, J. W., Ross, A. C., & Fuchs, D. L. (1996). Lifetime axis I and axis II comorbidity and childhood trauma history in dissociative identity disorder. Psychiatry: Interpersonal and Biological Processes, 59, 255-266.

Fontenelle, L. F., Domingues, A. M., Souza, W. F., Mendlowicz, M. V., de Menezes, G. B., Figueira, I. L., & Versiani, M. (2007). History of trauma and dissociative symptoms among patients with obsessive-compulsive disorder and social anxiety disorder. Psychiatric Quarterly, 78(3), 241-250. doi:10.1007/s11126-007-9043-1

Freyd, J. J. (1994). Betrayal trauma: Traumatic amnesia as an adaptive response to childhood abuse. Ethics & Behavior, 4, 307–329.

References

Gertlehner, G., Hasenc, R. A., & Nissman, D. (2006). Criteria for

distinguishing effectiveness from efficacy trials in systematic reviews. Rockville, MD: Agency for Healthcare Research and Quality.

Hallings-Pott, C., Waller, G., Watson, D., & Scragg, P. (2005). State Dissociation in Bulimic Eating Disorders: An Experimental Study. International Journal Of Eating Disorders, 38(1), 37-41. doi:10.1002/eat.20146

Hagenaars, M. A., van Minnen, A., & Hoogduin, K. L. (2010). The impact of dissociation and depression on the efficacy of prolonged exposure treatment for PTSD. Behaviour Research and Therapy, 48(1), 19-27. doi:10.1016/j.brat.2009.09.001

References

Hollander, E., & Benzaquen, S. (1997). The obsessive-

compulsive spectrum disorders. International Review Of Psychiatry, 9(1), 99-110. doi:10.1080/09540269775628

International Society for the Study of Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, 3rd Revision. Journal of Trauma & Dissociation, 12(2), 115-187.

Lamagna, J., & Gleiser, K. A. (2007). Building a secure internal attachment: An Ingra-relational approach to ego strengthening and emotional processing with chronically traumatized clients. Journal of Trauma and Dissociation, 8(1), 25-52.

References

Marmar, C. R., Weiss, D. S., Schlenger, W. E., Fairbank, J. A.,

Jordan, B. K., Kulka, R. A., & Hough, R. L. (1994). Peritraumatic dissociation and posttraumatic stress in male Vietnam theater veterans. American Journal of Psychiatry, 151, 902–907.

National Institute of Mental Health. (2014a). Any disorder among adults. Retrieved from http://www.nimh.nih.gov/statistics/1ANYDIS_ADULT.shtml

National Institute of Mental Health. (2014b). Mental healthcare cost data for all Americans (2006). Retrieved from www.nimh.nih.gov/statistics/4COST_AM2006.shtml

References

National Institute of Mental Health. (2014c). Use of

mental health services and treatment among adults. Retrieved from http://www.nimh.nih.gov/statistics/3use_mt_adult.shtml

Pfaltz, M. C., Michael, T., Meyer, A. H., & Wilhelm, F. H. (2013). Reexperiencing symptoms, dissociation, and avoidance behaviors in daily life of patients with PTSD and patients with panic disorder with agoraphobia. Journal Of Traumatic Stress, 26(4), 443-450. doi:10.1002/jts.21822

Putnam, F. W. (1989). The diagnosis and treatment of multiple personality disorder. New York, NY: Guilford Press.

References

Rice, M. J. (2013). Evidence-based practice: A model for clinical

application. Journal of the American Psychiatric Nurses Association, 19(4), 217-221.

Rischel, C. W. (2007). Evidence based prevention practice in mental health: What is it and how do we get there? American Journal of Orthopsychiatry, 77(1), 153-164.

Ross, C. A., Heber, S., Norton, G. R., Anderson, D., Anderson, G., & Barchet, P. (1989). The dissociative disorders interview schedule: A structured Interview. Dissociation, 11(3), 69-189.

Ross, C. A., Joshi, S., Currie, R. (1990). Dissociative experiences in the general population. American Journal of Psychiatry, 147(11), 1547-1552.

References

Rufer, M., Held, D., Cremer, J., Fricke, S., Moritz, S., Peter, H., &

Hand, I. (2006). Dissociation as a Predictor of Cognitive Behavior Therapy Outcome in Patients with Obsessive-Compulsive Disorder. Psychotherapy And Psychosomatics, 75(1), 40-46. doi:10.1159/000089225

Schauer, M., & Elbert, T. (2010). Dissociation following traumatic stress: Etiology and treatment. Journal of Psychology, 218(2), 109-127. doi:10.1027/0044-3409/a000018’

Sprang, G., Carlton, C., & Clark, J. (2008). Factors impacting trauma treatment practice patterns: The convergence/divergence of science and practice. Anxiety Disorders, 22, 162-174.

Steinberg, M. (1994b). Structured Clinical Interview for DSM-IV Dissociative Disorders–Revised (SCID-D-R) (2nd ed.). Washington, DC: American Psychiatric Press.

References