David Baxter PhD
Late Founder
[h=2]Dissociative PTSD May Become DSM-5 Subtype[/h]
By DAMIAN MCNAMARA, Clinical Psychiatry News
June 14, 2011
Growing recognition of a distinct dissociative subtype of posttraumatic stress disorder is reflected in diagnostic changes proposed for the next edition of the Diagnostic and Statistical Manual of Mental Disorders, Dr. David Spiegel said.
In the meantime, recent evidence suggests that the psychotherapy often prescribed for patients with the hyperarousal subtype of PTSD might be insufficient for those with predominantly dissociative symptoms, Dr. Spiegel said at the annual meeting of the American Psychiatric Association.
"The idea is to have a dissociative subtype for PTSD," Dr. Spiegel said. "This is an important addition to PTSD in the DSM-5."
A combination of supportive care and prolonged exposure therapy might be the optimal approach. "This is pretty clear evidence that for those who are high in dissociative symptoms, prolonged exposure alone is not as effective as a more cognitive and supportive psychotherapy," Dr. Spiegel said. With hyperarousal PTSD, exposure-based therapy is designed to teach patients to regulate their own emotional arousals. They are systematically exposed to various traumatic memories, see them from a different point of view (cognitive restructuring), and decondition the fear-based reactions. "It?s focused on fear as a primary affect and the amygdala fear system as an aroused system."
In contrast, "for the dissociative subtype, we recommend phase-oriented treatment," Dr. Spiegel said. "You want to identify the dissociative symptomatology, stabilize the patient, discuss and clarify the meaning of the dissociative symptoms, explore stressors that might lead to dissociative episodes, and reduce the risk of revictimization, which is a major problem," Dr. Spiegel said. People with dissociative PTSD tend to detach themselves from fear and risk so well that they are at risk of experiencing another dangerous situation, he said.
"You teach people (in more detail) mood regulation and abilities to self-soothe, the ability to access dissociative material in a controlled manner, and to identify attachment schemas." For example, a "traumatic transference" can arise whereby the patient identifies the therapist with whoever or whatever inflicted the trauma. "Invariably, they will be expecting you to reinjure them rather than to help them. Dealing with those transference issues is a crucial part of psychotherapy, especially [for] those with dissociative-type trauma."
People with the dissociative subtype also are more likely to have a history of early life trauma (including physical or sexual abuse), compared with those who have hyperarousal PTSD, so they will be more sensitive to traumatic transference issues, Dr. Spiegel said.
"Dissociation is a common and adaptive response to acute trauma," Dr. Spiegel said. However, it can be too much of a good thing if it persists. During a traumatic experience, dissociation can help a person focus on whatever strategy they need to get out of the difficult situation and to stay alive. "Most rape victims will tell you they experienced the rape as if they were floating above themselves."
Continued dissociation can inhibit the processing of traumatic experiences during psychotherapy. "What may be helpful at the time of trauma may actually predict poor outcome over the long run. We have evidence ... that people who engage in a dissociative response weeks after the traumatic event are, if anything, at higher risk for developing [PTSD] later on."
Cognitive-restructuring psychotherapy might be beneficial for dissociative PTSD because it focuses on a broader array of emotions: not just fear, but also shame, guilt, anger, and other adverse affects related to trauma. "You want to facilitate the integration of dissociated memories," Dr. Spiegel said.
Dr. Spiegel recommends teaching people to imagine that they are in a physically safe place. No matter how upsetting the emotion or memory events are, their body can feel differently. "This can be very helpful in teaching them to manage these traumatic and dissociative recollections.
"One technique I find very useful with these patients is to have them picture an imaginary split screen. Picture on one side some element of the trauma, and on the other side, some solution to the problem or something they did that was adaptive."
Another new section proposed for PTSD would address negative alterations in cognitions and mood associated with the traumatic events. Dissociative amnesia, an inability to recall traumatic events, would be one element. Another would be persistent and exaggerated negative expectations about ones self, others, or the world. "You can hear an opportunity for cognitive-type psychotherapy [with] these negative expectations," said Dr. Spiegel, director of the center on stress and health at Stanford (Calif.) University.
Persistent, distorted blame of self or others about the cause or consequences of the traumatic events; a pervasive negative emotional state (for example, fear, anger, guilt, or shame); marked diminished participation in significant activities; feeling detached or estranged from others; and an inability to experience positive emotions are other potential additions to the PTSD section.
In contrast, hyperarousal symptoms (including irritability, recklessness, hypervigilance, and an exaggerated startle response) are expected to remain relatively similar to those in the DSM-IV-TR.
Continuum measures for PTSD in the DSM-5 likely will replace current categorical measures, Dr. Spiegel said. Like many other disorders, the PTSD section is expected to include a brief rating scale that allows clinicians to rate the severity of symptoms and to track changes over time.
By DAMIAN MCNAMARA, Clinical Psychiatry News
June 14, 2011
Growing recognition of a distinct dissociative subtype of posttraumatic stress disorder is reflected in diagnostic changes proposed for the next edition of the Diagnostic and Statistical Manual of Mental Disorders, Dr. David Spiegel said.
In the meantime, recent evidence suggests that the psychotherapy often prescribed for patients with the hyperarousal subtype of PTSD might be insufficient for those with predominantly dissociative symptoms, Dr. Spiegel said at the annual meeting of the American Psychiatric Association.
"The idea is to have a dissociative subtype for PTSD," Dr. Spiegel said. "This is an important addition to PTSD in the DSM-5."
A combination of supportive care and prolonged exposure therapy might be the optimal approach. "This is pretty clear evidence that for those who are high in dissociative symptoms, prolonged exposure alone is not as effective as a more cognitive and supportive psychotherapy," Dr. Spiegel said. With hyperarousal PTSD, exposure-based therapy is designed to teach patients to regulate their own emotional arousals. They are systematically exposed to various traumatic memories, see them from a different point of view (cognitive restructuring), and decondition the fear-based reactions. "It?s focused on fear as a primary affect and the amygdala fear system as an aroused system."
In contrast, "for the dissociative subtype, we recommend phase-oriented treatment," Dr. Spiegel said. "You want to identify the dissociative symptomatology, stabilize the patient, discuss and clarify the meaning of the dissociative symptoms, explore stressors that might lead to dissociative episodes, and reduce the risk of revictimization, which is a major problem," Dr. Spiegel said. People with dissociative PTSD tend to detach themselves from fear and risk so well that they are at risk of experiencing another dangerous situation, he said.
"You teach people (in more detail) mood regulation and abilities to self-soothe, the ability to access dissociative material in a controlled manner, and to identify attachment schemas." For example, a "traumatic transference" can arise whereby the patient identifies the therapist with whoever or whatever inflicted the trauma. "Invariably, they will be expecting you to reinjure them rather than to help them. Dealing with those transference issues is a crucial part of psychotherapy, especially [for] those with dissociative-type trauma."
People with the dissociative subtype also are more likely to have a history of early life trauma (including physical or sexual abuse), compared with those who have hyperarousal PTSD, so they will be more sensitive to traumatic transference issues, Dr. Spiegel said.
"Dissociation is a common and adaptive response to acute trauma," Dr. Spiegel said. However, it can be too much of a good thing if it persists. During a traumatic experience, dissociation can help a person focus on whatever strategy they need to get out of the difficult situation and to stay alive. "Most rape victims will tell you they experienced the rape as if they were floating above themselves."
Continued dissociation can inhibit the processing of traumatic experiences during psychotherapy. "What may be helpful at the time of trauma may actually predict poor outcome over the long run. We have evidence ... that people who engage in a dissociative response weeks after the traumatic event are, if anything, at higher risk for developing [PTSD] later on."
Cognitive-restructuring psychotherapy might be beneficial for dissociative PTSD because it focuses on a broader array of emotions: not just fear, but also shame, guilt, anger, and other adverse affects related to trauma. "You want to facilitate the integration of dissociated memories," Dr. Spiegel said.
Dr. Spiegel recommends teaching people to imagine that they are in a physically safe place. No matter how upsetting the emotion or memory events are, their body can feel differently. "This can be very helpful in teaching them to manage these traumatic and dissociative recollections.
"One technique I find very useful with these patients is to have them picture an imaginary split screen. Picture on one side some element of the trauma, and on the other side, some solution to the problem or something they did that was adaptive."
Another new section proposed for PTSD would address negative alterations in cognitions and mood associated with the traumatic events. Dissociative amnesia, an inability to recall traumatic events, would be one element. Another would be persistent and exaggerated negative expectations about ones self, others, or the world. "You can hear an opportunity for cognitive-type psychotherapy [with] these negative expectations," said Dr. Spiegel, director of the center on stress and health at Stanford (Calif.) University.
Persistent, distorted blame of self or others about the cause or consequences of the traumatic events; a pervasive negative emotional state (for example, fear, anger, guilt, or shame); marked diminished participation in significant activities; feeling detached or estranged from others; and an inability to experience positive emotions are other potential additions to the PTSD section.
In contrast, hyperarousal symptoms (including irritability, recklessness, hypervigilance, and an exaggerated startle response) are expected to remain relatively similar to those in the DSM-IV-TR.
Continuum measures for PTSD in the DSM-5 likely will replace current categorical measures, Dr. Spiegel said. Like many other disorders, the PTSD section is expected to include a brief rating scale that allows clinicians to rate the severity of symptoms and to track changes over time.
