The DSM5 and Dissociation
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).