The DSM5 and Dissociation

| By Paul | | Comments (18)

In an editorial to the most recent Journal of Trauma and Dissociation (Vol. 11, pp. 261-5), Dr. David Spiegel writes about how dissociation will likely be addressed in the forthcoming DSM5. For those of you not familiar, the Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the DSM, is psychiatry's approach to standardizing mental disorders. I understand how many look askew at any psychiatric labels, myself sometimes included. But there is the reality that correct diagnoses are an important component to healing. Having a manual and common language helps to increase recognition, accurate assessment, and align treatments.

There has been some concern that the dissociative disorders, especially dissociative identity disorder, would be subsumed under other diagnoses and thereby essentially be "declassified." Even now, despite their presence in the current DSM, they are not well integrated into the psychiatric community. There are large biases against dissociation, that strangely do not seem to be as apparent in illnesses such as depression or schizophrenia. Probably this is due to the sometimes ephemeral nature of impairment. To the observer, it often appears that dissociatives can just pull themselves together, lending some credence to the belief that no real disorder exists. Yet, to the dissociative, we know there is much more to what we deal with than just being able to pull ourselves together. We know about what it means to lose our identity, to have huge gaps in memory, to have wild swings of consciousness. And, as I have said before, I believe one of the main reasons for the bias is that many clinicians and lay people are uncomfortable with the notion that an adult human being can have a fragmented sense of identity or lose control of their minds and bodies.

In his editorial, Spiegel, a member of the DSM5 Task Force, asserts that the dissociative disorders will be included in the revision which will come out in 2013. He gave a summary of what the task force is proposing. They are proposing that there be a stress and trauma spectrum section which will include PTSD and the dissociative disorders. In so doing, the DSM5 will emphasis the common etiology of these "disorders." This would be a controversial move, since the current version focuses more on description of symptoms. Even though there would still not be a diagnostic requirement of a trauma for a dissociative disorder to exist, placing dissociation squarely into a section with an emphasis on trauma etiology would be a blow to the false memory advocates. It would be a validation and positive step for those of us who appreciate that dissociative disorders do have a strong basis in trauma.

In fact, it appears that this trauma etiology will be pursued even further based on studies by Ruth Lanius and colleagues that there is a substantial subgroup, of nearly one third, of those with post-traumatic stress disorder showing mainly symptoms of dissociation which are far different from the "classic" PTSD symptoms. These clinical findings are supported by functional MRI studies which show that the dissociative subgroup has increased prefrontal cortical activity and reduced limbic activity in response to traumatic stimuli, which is opposite of the typical PTSD response.

One of the proposed changes to the criteria for dissociative identity disorder I believe is a step back. It states that the disruption of identity "may be observed by others, or reported by the patient." Detractors of dissociative identity disorder will say that there is no clinical input. On the other hand, there are clearly disorders where there is primarily patient reporting. Depression comes to mind. The onus would then be on the clinician to determine whether the self-reporting of the patient is consistent with the rest of the criteria for the disorder to warrant the diagnosis.

Complex PTSD, as proposed by Judith Herman in 1992, is not addressed in the current DSM and appears not to be addressed in the DSM5. I think this is for good reason. To do so, would confound matters. The commonly understood symptoms of complex PTSD are basically PTSD symptoms plus overlap with many other areas (such as anxiety, personality, and dissociative disorders). I believe we all, patients and clinicians alike, need to appreciate that the DSM will always have limitations. The manifestations of all of these disorders in practice are almost always more complex than any manual can ever hope to capture. But the goal of the manual should be to make a best effort and provide a guidepost.

To learn more about the recent studies showing the dissociative subgroup of PTSD, see the home page of Dr. Ruth Lanius at the University of Western Ontario. She does not have her most recent journal articles listed. If interested, check out: Emotion Modulation in PTSD: Clinical and Neurobiological Evidence for a Dissociative Subtype (in American Journal of Psychiatry). To read the Spiegel editorial, see Dissociation in the DSM5 (in Journal of Trauma and Dissociation).


Evan said:

I think the major benefit of a diagnosis (often overlooked) is for the client.

A friend of mine suffers with very severe depression. One night they freaked out in a new way. They were very worried that they didn't know what was going on. Their shrink was able to tell them that what happened was a 'dissociative panic attack'. That this was known and understood by others was hugely reassuring to my friend. I think this is the major benefit to diagnosis.

As to therapy. The diagnosis probably gives some ideas about where to start and what to try first up - but I think most decent therapists probably adjust what they do to the client. So I'm not sure that it is all that much use in actual treatment of people. I think this would make a very interesting study - but I don't expect to see it funded anytime soon. (Rather than patient compliance with therapists' directions it would be therapist compliance with diagnosis.)

Paul Author Profile Page replied to Evan:

Hi Evan, Thanks! Yes, I agree that people are comforted when they know that what they experience has a name. I think every not well understood human condition, mental or physical, will do well by being better understood. So, I'm glad to see imaging studies starting to come out. In terms of therapy, I am not sure the new studies will help with that. But they do help with validating that there are neurological bases for clinical experiences. That is huge. I think there is an equally huge difference in terms of treatment that happens when therapist and client come to appreciate that they are dealing with multiple personalities, or even being somewhere else on the dissociative spectrum, than something else. There is a validation there that gives space and allows parts to heal and for the patient to work towards being more whole.

Grace said:

Bravo to Dr. David Spiegel and the supporters of having DID not only included but expanded in the DSM! One battle at a time. Complex PTSD will come eventually.

Am also grateful for new technology that validates not only the "disorder" but the healing of the brain with the healing of DID. Technology is wonderful.

Excellent news.

Paul Author Profile Page replied to Grace:

Hi Grace. I would not count on complex PTSD becoming entrenched in the DSM. As I said in the post, I think there are very good reasons to leave it out. This is not to diminish it, just that it would be superfluous and add confusion to an area that needs more clarity.

Nansie said:

Hey Paul! I know my diagnosis 1.5 years ago was hard to accept but once I did things became clearer to me... past and present. Plus I can look back and gain newer insights and understandings to what was going on. This has been really helpful to me.

On the flip side though... I wouldn't feel comfortable sharing this info with many people. It's the labeling piece that concerns me. I have noticed at times that when health care people know these kinds of diagnoses about a patient they start acting differently and almost patronizing or they don't take you as seriously.

I always found the DSM interesting in the way that so called "normal" people, although well intentioned, are creating boxes, catagories for illnesses they have limited knowledge on? I would like to see recovered folks have more input on this stuff.... I don't really have any answers but I get nervous from all the people that tried to remove DID altogether. This sounds like some new acknowledgement and validation for us but we'll see.

Paul Author Profile Page replied to Nansie:

Hi Nansie. I understand your discomfort sharing the diagnosis with other treaters. Though, the way I see it, if my primary care doctor had the reaction you talk about, I would find another. If he has reservations about it, he has not made them known to me. He has always asked about how I am doing mentally, how my treatment is going. A good doctor would be able to separate that out. Of course, I have had many years of experiences in emergency rooms, way back when, and encountered this "different treatment." It's not good. But the more this is kept in the dark, the lower chances that dissociative disorders will be accepted by the medical community. I think the DSM is absolutely necessary. It's far from perfect, but I think there is a lot of clinical experience brought to bear on all aspects of creating what's in the DSM. Evan may well be completely right. The greater impact of labeling things may be from the point of view of the patient. There is probably nothing worse than to not know what you are dealing with.

Ivory said:

I am a label hater. Admittedly.

I also understand the need for common labels to properly define symptoms/diagnosis across scientific scholarship. Also, I am happy that there seems to be something of a positive curve in the DSM. I have had a QEEG done and yes, I have a constant pulsating burst of electrical energy in my prefrontal lobes. I know that trauma, any degree of it, is the perception of the victim. For instance, what wouldn't traumatize one, will destroy another emotionally. I hope they consider that and not try to "fix" the degree of trauma so they can pack it all nicely in their tupperware book. Oh, what I wrote just sounds catty, I'm sorry.

Paul Author Profile Page replied to Ivory:

Thanks Ivory. Yes, labels have good aspects and not so good aspects. I agree. I would hope that the goals in terms of what to fix should be driven by the patient.

in my country you need "labels" to get help.
no "label" = no help.
sometimes doctors have to give a diagnosis which don't fit to the symptoms but there is no other way for getting help :(
sad but true. things become worse in our land, especially for mental health illnesses :(

Paul Author Profile Page replied to LostShadowChild:

Hi LSC. I think this is more or less true everywhere if you are getting financial support from insurances or public. At least I think it must be true.

castorgirl said:

I struggle with diagnoses. I like the label because it can help me put my experiences into context and allow me to connect with others who have similar experiences. Yet, I struggle with them, because the DD's aren't widely understood or accepted where I live. So I see diagnoses as a necessary double edged sword... at least until we find a better language and way to describe psychiatry.

I appreciate the grouping of diagnoses, as described by Spiegel. If nothing else, it might help demystify the DD's.

The new grouping may also mean a change in the coding for the DD's. At the moment, the DD's are in the 300's, putting them close in numbering to the Factitious Disorders. Even though they have different headings, because of the FMS debates, it's always annoyed me that they're basically next to each other.

Thanks for the lead on Lanius...

Take care,

Paul Author Profile Page replied to castorgirl:

CG, I am glad to know that struggling with all of this is common. Language is so important. We live in a world where we can only learn about things and understand them more if we can use words to describe things. Of course, that's never perfect. But I think we have to try.

Michael said:

Complex PTSD in my opinion would include all traumas and would lead to a understanding that all trauma does not have the same effect.

The understanding of DID in my opinion is to limited and is biased toward sexual abuse by an individual excluding the effects of other types of trauma.

Complex DID would include poly multiples which are not just like a multiples only more parts, it is a different dynamic.

Paul Author Profile Page replied to Michael:

I don't know Michael. I think many appreciate that life is way more complex than can be captured in a manual. DID in the DSM makes no reference, as far as I can tell, to specific types of traumas.

castorgirl said:

Have you seen the documentary "How mad are you?" Interesting experiment, where five people with a history of mental health issues, and five people without, stay in a house for a week. During the week they are observed and given a range of psychological tests. At the end of the week, three observing mental health professionals had to try and guess which were the five with the mental health issues, and their diagnoses. It was interesting how behaviour which was normal for these people, suddenly took on new meaning.

The Rosenhan experiments were also mentioned.

Paul Author Profile Page replied to castorgirl:

Sorry, CG. My reply got deleted in trying to fix the blank notification problem (which is fixed). No, I haven't seen that documentary. I read about the Rosenhan experiments. I'm fascinated by the Stanford prison experiments from the 70s.

Paul Author Profile Page said:

This is perhaps relevant to this thread (which I know is now a bit dated). People may want to check out this site:

Tylas Raine said:

"They are proposing that there be a stress and trauma spectrum section which will include PTSD and the dissociative disorders."

From someone who suffers from PTSD and DID and can feel how this works, there is no other way to categorize it.

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