Day # 115: Treatment of Dissociative Disorders
Today we will discuss the treatment of dissociative disorders. We will summarize pharmacological and non-pharmacological options and provide a framework for when to consider specific treatments.
Today's Content Level: Intermediate
•The first-line treatment for all dissociative disorders is psychotherapy.
•There are no FDA-approved medications for dissociative disorders. No pharmacotherapy has demonstrated a clear reduction of dissociative symptoms. Pharmacotherapy is typically used for treatment of comorbid conditions or targeted symptoms.
•Numerous specific therapies have shown an overall effect size in reducing dissociative symptoms as well as other comorbid symptoms (depression, anxiety, personality disorder-based symptoms), however it is generally accepted that the supporting research suffers from flaws in methodology. It also does not help that many patients with dissociative disorders are excluded from treatment studies. 1
There are a number of different modalities of psychotherapy that demonstrate favorable outcomes for patients suffering from dissociative disorders. We will highlight some of the most commonly used techniques.
Cognitive Therapy (CBT or DBT)
The basic idea of cognitive and related therapies is that our thoughts (cognitions), behaviors, and emotions are all interrelated, so that if we change one then we can change the rest.
Therapists aim to identify automatic negative thoughts and core beliefs with the use of socratic questioning.
Treatment involves education about dissociative symptoms and how they may be related to trauma. Therapists help patients correct cognitive distortions, challenge their thoughts, examine the evidence for a belief, and many other techniques.
Behavioral techniques include identifying and removing unwanted behaviors. Therapists use various behavioral techniques and "activation" to help improve the patients self-reliance and find new healthy ways to cope. This may include activity scheduling, SMART goals, and graded task assignments.
Phase-Oriented Therapy +/- Trauma-Focused Therapy
An approach to therapy in patients with complex trauma and dissociation that addresses domains of functioning impacted by a trauma in a sequential matter.
Prioritizes the establishment of client safety and coping prior to working directly with traumatic memories.
There are a number of different ways this can be performed but common phases include: Safety; Stabilization; Desensitization; Reconnection. 2
Many authorities believe that trauma-focused therapies such as Eye Movement Desensitization and Reprocessing (EMDR) or Cognitive Processing Therapy (CPT) can be used in the later phases of treatment in well-stabilized patients with dissociative disorders.
Hypnotherapy is used to create a state of focused attention and increased suggestibility in order to assist with altering behaviors patterns, gaining insight, or increase motivation.
Hypnosis can be used in a number of different ways in the treatment of dissociative disorders. For example, hypnosis may be used to contain or modulate the intensity of dissociative symptoms. The therapist may be able to facilitate controlled recall of dissociated memories and provide support and ego strengthening for the patient.
It has been shown to alleviate self-destructive impulses or reduce symptoms such as flashbacks, dissociative hallucinations, and passive-influence experiences.
Therapists may teach self-hypnosis to the patient to apply containment and calming techniques in order to increase the patient's sense of control over their symptoms.
A psychodynamic approach focuses on making connections between what the patient is currently experiencing and their experiences during childhood. Areas of focus include unconscious conflicts, repressed feelings, family issues from early in life, and difficulty with current relationships.
Therapists attempt to improve dissociative symptoms in their patients by helping them confront and resolve unconscious conflicts in order to bring disparate elements of the psyche together. 4
Pharmacologically facilitated interviews
Pharmacologically facilitated interviews are controversial, however they are sometimes recommended when interviewing patients with specific diagnoses. These may include include chronic dissociative amnesia, catatonia, confusion, conversion disorder, factitious disorder, or mutism. 5
A variety of agents have been used for this purpose, including amobarbital, thiopental (Pentothal), oral benzodiazepines, and amphetamines.
The material uncovered in a pharmacologically facilitated interview needs to be processed by the patient in his or her usual conscious state.
Other Interventions 6
Group Therapy: Therapy groups composed only of patients with dissociative disorders are reported to be more successful. Patients may recover memories for which they have had amnesia. Supportive interventions by the group members or the group therapist, or both, may facilitate integration and mastery of the dissociated material. Groups for dissociative identity disorder specifically must be carefully structured, provide firm limits, and generally focus only on here-and-now issues of coping and adaptation.
Occupational/Expressive Therapies: These approaches such as art and movement therapy have proved particularly helped in patients with dissociative disorders. It may permit safer expression of thoughts, feelings, mental images, and conflicts they have trouble verbalizing. Movement therapy may facilitate normalization of body sense and body image for severely traumatized patients.
Family/Couples Therapy: It is important to address family and marital processes to help facilitate long-term stabilization. This includes education about dissociative disorder and its treatment.
Supportive techniques: Relaxation training, stress management, distraction techniques, and physical exercise may be helpful in some patients with dissociative disorders.
•There are no FDA-approved medications for dissociative disorders. No pharmacotherapy has demonstrated a clear reduction of dissociative symptoms. 7
Pharmacotherapy is typically used for treatment of comorbid conditions or targeted symptoms. Commonly used medications include:
Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs): Treat comorbid conditions such as depressive disorders, anxiety disorders, and post-traumatic stress disorder. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are used second-line.
Prazosin: Commonly used to treat nightmares and sleep disturbance in PTSD and dissociative disorders.
Propranolol or Clonidine: Sometimes used to target symptoms of hypervigilance, aggression, or insomnia.
Naltrexone: Limited evidence that supports the efficacy of naltrexone in reducing self-harm and dissociative symptoms. 8
Other agents have been tried with mixed results including antipsychotics and mood stabilizers.
Congratulations. You have now finished the topics in the dissociative disorders theme. Next post will be the last quiz for this section before we move on to psychosomatic disorders.
Resources used today include the many articles linked in the body of this post, as well as the following books: Pocket psychiatry and Kaplan and Sadock's Synopsis of Psychiatry.
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