Textbook of Psychiatry/Dissociative Disorders/Treatment

In treating patients with Dissociative Disorders, a variety of theoretical approaches are reported to be effective including cognitive behavioral therapy, hypnosis, psychopharmacological treatment, psychodynamic therapy, phenomenological treatment, contextual treatment, cognitive analytic therapy, feminist-informed treatment, and adjunctive treatment with Eye Movement Desensitization and Reprocessing (Brand et al. 2009). However, a review of the current literature examining the treatments for Dissociative Disorders illustrates a serious lack of well-designed studies on the treatment of Dissociative Disorders and a scarcity of controlled outcome research for Dissociative Disorder patients (Brand et al. 2009). A majority of the current information available regarding treatment recommendations for Dissociative Disorder is based off clinical and empirical evidence from case studies and case series. Although there are multiple approaches for treating Dissociative Disorders, the common element of these treatments addresses the dissociative pathology and exploring prior traumatic events. Treatment of Dissociative Disorders is associated with improvements in symptoms of dissociation, depression, general distress, anxiety and PTSD, as well as decreased use of medications and improved work and social functioning (Brand et al. 2009). Duration of treatment varies depending on the particular Dissociative Disorder being treated, with Dissociative Amnesia and Dissociative Fugue recovering more quickly and having a better outcome as compared to Dissociative Identity Disorder and Depersonalization Disorder. However, a significant proportion of patients’ improvement during initial treatment may not remain stable over time, indicating the need for additional follow up for contingent intervention in the case of recurrent dissociative symptoms or other psychopathological states (Jans et al. 2008).

Psychotherapy
Overall, the most common form of treatment for the Dissociative Disorders is psychotherapy, which generally focuses on the dissociative psychopathology and associated trauma or stressor. Many different types of psychotherapy have been used in the treatment of Dissociative Disorders, including psychodynamic, cognitive behavioral, supportive, hypnotherapeutic, free association and drug assisted. Dissociative Disorder patients often present with challenging symptomatology and one must be flexible in the approach and technique applied (Turkus and Kahler, 2006). It is crucial to recognize the devastating effects that the past trauma or stressor has had on the patient’s life and their current state of dysfunction (Turkus and Kahler, 2006). Applying skill-building interventions at the beginning stages of treatment helps stabilize the patient and ameliorate the disabling dissociative symptoms, allowing treatment to progress and help patients to cope with painful affect and recollections of the traumatic experience (Turkus and Kahler, 2006). As psychotherapeutic techniques are applied in treatment, it is important to remember not to overwhelm the patient by forcing the intervention or insisting on following a preset time length for the treatment process as each patient’s progress may vary. Patients with Dissociative Amnesia and Dissociative Fugue generally recover more quickly, especially when the dissociative event is of short duration, and their symptoms may even resolve spontaneously when the individual is removed from the precipitating trauma or stressor. However, longer-lasting episodes become more difficult to treat and may be intractable (Stern et al. 2008). Clinicians should try to restore patients’ memories to consciousness as soon as possible; otherwise, the repressed memory may form a nucleus in the unconscious mind around which future dissociative episodes may develop (Sadock and Sadock, 2007). Treatment of Dissociative Amnesia is aimed at the restoration of missing memories while treatment of Dissociative Fugue is focused on the recovery of memory for identity and events preceding the fugue. Cognitive and psychodynamic are the most common psychotherapy techniques applied in treatment of Dissociative Amnesia and Dissociative Fugue; however, hypnotherapy and pharmacologically facilitated interviews are frequently necessary adjunctive techniques to assist with memory recovery (Sadock and Sadock, 2007).

In treating patients with Dissociative Identity Disorder, extended psychotherapy remains the treatment of choice, although approaches vary widely and remain controversial (Stern et al. 2008). Successful psychotherapy requires the clinician to be comfortable with a range of psychotherapeutic interventions (psychoanalysis, psychodynamic therapy, cognitive therapy, behavioral therapy, hypnotherapy, etc.) and be willing to actively work to structure the treatment (Sadock and Sadock, 2007). Comfort with family treatment and systems theory is helpful in working with a patient who subjectively experiences himself or herself as a complex system of selves with alliances, family-like relationships and intragroup conflicts (Sadock and Sadock, 2007). Some clinicians approach treatment by delineating and mapping the alternate identities, inviting each to participate in the treatment, and facilitating communication between the various identities in an attempt to understand past episodes of trauma as experienced by each identity (Stern et al. 2008). Other clinicians focus on the function of the dissociative process in the here-and-now of the patient’s life and the ongoing treatment (Stern et al. 2008). They help patients become aware of using dissociation to manage feelings and thoughts within themselves and to manage the closeness and distance within relationships (Stern et al. 2008). All approaches seek to increase affect tolerance and to integrate the dissociated states within the patient (Stern et al. 2008). Patients with Dissociative Disorder who integrated their dissociated self states were found to have reduced symptomatology compared with those who did not integrate (Brand et al. 2009).

Treatment of Depersonalization Disorder is difficult and patients are often refractory to interventions (Stern et al. 2008). A variety of psychotherapeutic techniques can be used to treat Depersonalization Disorder, although none of these have established efficacy (Simeon, 2004). Treatment of accompanying psychiatric conditions (such as depression or anxiety) may help and, as with other dissociative disorders, exploration of prior traumatic events may prove useful (Stern et al. 2008; Simeon, 2004).

Pharmacotherapy
Overall, the use of pharmacotherapy in the treatment of Dissociative Disorders is limited and controversial, as most medications (such as antidepressants and anxiolytics) are initiated to alleviate comorbid anxiety and mood symptoms, but do not treat the dissociative psychopathology. Currently, no pharmacological treatment has been found to reduce dissociation, per se (Stern, Rosenbaum et al. 2008). Although antidepressant medications are useful in the reduction of depression and stabilization of mood, one must be cautious in using benzodiazepines to reduce anxiety as they can also exacerbate dissociation (Sadock and Sadock, 2007; Stern, Rosenbaum et al. 2008). Presently, no specific pharmacotherapy exists for the treatment of Dissociative Amnesia and Dissociative Fugue other than pharmacologically facilitated interviews. A variety of agents have been used for this purpose, including sodium amobarbital, thiopental, benzodiazepines and amphetamines (Sadock and Sadock, 2007). This procedure is generally used for more acute cases, but can be occasionally useful in refractory cases of chronic dissociative amnesia when patients are unresponsive to other interventions (Sadock and Sadock, 2007). The material uncovered in a pharmacologically facilitated interview needs to be processed by the patient in his or her usual conscious state. In treating patients with Dissociative Identity Disorder using pharmacotherapy, there are reports of some success with selective serotonin reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, ?-blockers, clonidine, anticonvulsants, and benzodiazepines in reducing intrusive symptoms, hyperarousal, anxiety and mood instability (Sadock and Sadock, 2007; Stern, Rosenbaum et al. 2008). Atypical antipsychotics have also been used for mood stabilization, overwhelming anxiety and intrusive PTSD symptoms in patients with Dissociative Identity Disorder, as they may be more effective and better tolerated than typical antipsychotics. Although not routinely used, other possible suggestions for pharmacologically treating Dissociative Identity Disorder include the use of prazosin in reducing nightmares, carbamazepine to reduce aggression, and naltrexone for amelioration of recurrent self-injurious behaviors (Sadock and Sadock, 2007).

With regards to pharmacotherapy for Depersonalization Disorder, no medication has been shown to be efficacious to date, although research has been limited, and thus no definitive medication treatment guidelines exist (Simeon, 2004). Previous studies had suggested a possible role for serotonin reuptake inhibitors in treating primary Depersonalization Disorder, but unfortunately a more recently completed placebo-controlled trial, failed to show benefit with fluoxetine in 54 patients with Depersonalization Disorder (Simeon, 2004). As with the other Dissociative Disorders, treatment of comorbid anxiety and mood instability with antidepressants and anxiolytics may be useful.

Combined Treatment
Although psychotherapy is the most common and efficacious treatment approach for treating the Dissociative Disorders, it is not uncommon to combine psychotherapeutic technique and pharmacological management in clinical practice. Reducing the patients’ comorbid anxiety and mood instability with antidepressants and anxiolytics may help stabilize the patient overall and allow psychotherapy to progress, as well as help patients cope with painful affect and recollections of the traumatic experience as they arise.