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14. Weiss RD, Mirin SM: The dual diagnosis alcoholic: Evaluation and treatment. Psychiatrhn 19:261-265, 1989. 15. Weiss RD, Collins DA. Substance abuse and psychiatric illness. Am J Addict 1 :93, 1992. 16. Weiss RD, Mirin SM, Frances RJ: The myth of the typical dual-diagnosis patient. Hosp Community Psychiatry 43:107, 1992.

26. DISSOCIATIVE DISORDERS INCLUDING DISSOCIATIVE IDENTITY DISORDER (FORMERLY MULTIPLE PERSONALITY DISORDER)
] o h J . Kluck, M.D.

1. What is dissociation?
Dissociation is a defense mechanism whereby some elements of the conscious experience are disconnected from other elements of the conscious experience.For instance, during a severe trauma, a person may dissociate the observing self from the experiencing self, as if they were watching another person experience the trauma. As such, the observing self may not experience fear, horror, or pain.

2. What are the dissociative disorders?


Dissociative disorders are a spectrum of disorders that rely heavily on dissociation as a means of self-protection from extreme emotions. This coping mechanism leads to significant distress or impairment in social, occupational, or other important areas of functioning.

3. What are the specific dissociative disorders, and how are they characterized? Dissociative amnesia (formerly psychogenic amnesia) is characterized by an inability to recall important personal information (usually of a traumatic or stressful nature), and the lack of
memory is too extensive to be explained by ordinary forgetfulness. Dissociative fugue (formerly psychogenic fugue) is characterized by sudden and unexpected travel away from home or ones customary place of work, accompanied by an inability to recall ones past and confusion about personal identity, or the assumption of a new identity. Dissociative identity disorder (formerly multiple personality disorder) is characterized by the presence of two or more distinct identities or personality states that recurrently take control of the individuals behavior and are accompanied by an inability to recall important personal information. Individuals with this disorder experience frequent gaps in memory-losing time for personal history, both recent and remote. Depersonalization disorder is characterized by a persistent or recurrent feeling of being detached from ones mental processes or body. It is accompanied by intact reality testing. Dissociative disorder not otherwise specified is characterized by predominant dissociative symptoms, but does not meet the criteria for one of the other dissociative disorders.

4. What are the associated features and disorders of each dissociative disorder?
Dissociative Disorder
Dissociative amnesia

Associated Features
Depressive symptoms, depersonalization, trance states, analgesia, and spontaneous age regression Depression, dysphoria, grief, shame, guilt, psychological stress, conflict, and suicidal and aggressive impulses

Associated Dis0rder.s
Conversion disorders, mood disorders, and/or personality disorders Mood disorders, posttraumatic stress disorder (PTSD), substance-related disorder
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Associated Features Associated Disorders

Dissociative Disorder
Dissociative identity disorder (DID)

Mood, substance-related, sexual, History of severe physical and sexual abuse during childhood; PTSD sympeating, sleep, personality disorders toms of nightmares, flashbacks, and increased startle responses; self-mutilation; suicidal and aggressive behavior. May be a repetitive pattern of physical and sexual abuse by significant others andor strangers.

5. What is the differential diagnosis of dissociative disorders? Dissociative Disorder Possible Similar Diagnosis Distinguishing Features Presence of a medical condition that Dissociative amnesia* Amnestic disorder due to a general could explain the condition medical condition Usually retrograde memory loss Amnestic disorder due to a brain associated with a head trauma, as injury compared with anterograde memory with dissociative amnesia Motor abnormalities and EEG abnormalities Seizure disorders A broad spectrum of brain dysfunction Delirium and dementia Substance-induced, persistent A significant history of ongoing subamnesic disorder stance use associated with persistent memory loss A recent history of heavy substance use Substance intoxication associated with memory loss Malingering Dissociative amnesia disorder patients usually score high on hypnotizability and dissociative capacity Direct physiological consequence of Objective evidence of such a medical Dissociative fugue** condition a specific general medical condition (e.g.. head injury) Aura, motor abnormalities, stereotyped Complex partial seizures (CPS) behavior, perceptual alterations, a postictal state, and abnormal findings on serial EEGs Direct physiological effects of a A significant history of ongoing subsubstance stance use Grandiose ideas and other manic symptoms Travel during a manic episode Wandering episode in a schizophrenic Signs and symptoms of schizophrenia person Conduct is bizarre without secondary gain Malingering Direct physiologicalconsequence of Objective evidence of such a medical Dissociativeidentity disorder (DID)' a specific general medical condition condition (e.g., seizure disorder) Complex partial seizures Aura, motor abnormalities, stereotyped behavior, perceptual alterations, a postictal state, and abnormal findings on serial EEGs Malingering Obvious secondary gain Factitious disorder A pattern of help-seeking or dependent behavior Direct physiological effects of a A significant history of ongoing substance substance use
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Table notes:

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* Dissociative amnesia is not diagnosed if it occurs exclusively during any of the following: dissociative fugue,
dissociative identity disorder, depersonalization disorder, posttraumatic stress disorder, acute stress disorder, or somatization disorder. ** Dissociative fugue is not diagnosed if it occurs exclusively during the course of dissociative identity disorder, depersonalizationdisorder, posttraumatic stress disorder, acute stress disorder, or somatization disorder. 7 Controversy exists concerning the differential diagnosis of DID as compared to a variety of other mental disorders, such as schizophrenia and other psychotic disorders, bipolar disorder, anxiety disorders, somatization disorders, and personality disorders.

6. Why has the prevalence of DID increased dramatically in recent years? This issue is the source of great controversy. Some believe that mental health professionals are now aware of the diagnosis; therefore, previously undiagnosed cases are now being recognized. Others believe that some mental health professionals are overinvested in finding this disorder; thus, it is over-diagnosed in a population of people that are naturally suggestible.
7. Why is it difficult to diagnose DID? Many practitioners do not actively search for symptoms of DID in their patients. Many DID patients do not present with florid symptoms. Most DID patients present with moderate to severe depressive symptoms. Most DID patients usually do not present with complaints of amnesia (lost time) unless asked directly. Even when asked, they may deny amnesia because of embarrassment. Alternate personalities (referred to as alters) may not present themselves in the initial stages of treatment.

8. What is the etiology of DID? The etiology of DID is complex and controversial, and not supported with strong empirical evidence. Currently, there are two main proposed pathways to the formation of DID. The traditional theory is that DID arises because of severe, chronic inescapable childhood trauma (physical andor sexual). The child dissociates or splits off the experience from consciousness to protect the self from awareness of the event and the very intense feelings associated with it. More recently, several authors have suggested that, in the face of severe trauma, the child must maintain an attachment or bond with the perpetrator. The child cannot predict, control, or escape the situation, leading to feelings and thoughts of helplessness and powerlessness. The biological imperative states that the child must be and stay attached to the perpetrator to stay alive. While the abuse dictates that the child break away, it would be impossible to do so. The childs solution is to dissociate into two parts: an unaware attachment part, and an unattached experiencing part. Theoretically, with repeated trauma over many years, more splits in the self occur to maintain order, continuity, and organization. Some of these split-off additional selves, which may or may not become named, are experienced as separate individuals with separate consciousnesses.

9. What is the nature of traumatic memories of childhood abuse? This is an area of major controversy. Since the early 1900s, psychological theorists (e.g., Janet and Freud) suggested that people developed psychogenic amnesia for severe childhood abuse. However, in recent years, many scholars have questioned if it is possible to forget or repress memories of overwhelming trauma, and then later recall them. Part of the conflict is related to the fact that, until recently, the concepts of memory have been largely theoretical, with little real supportive data. Despite the fact that mental health professionals have depended on these concepts, the issues of whether there is an unconscious mind and if repression is possible have never been conclusively resolved. Patients who have a history of severe childhood abuse commonly are very hypnotizable and suggestible, and often have an inordinate desire to please their therapists. Such patients can be quite sensitive to the reactions of the therapist, and may be easily influenced by the therapists interests and belief systems. Thus, if a therapist is overzealous in finding and treating victims of severe childhood abuse, this urge can be transmitted to the patient, who may attempt to accommodate the therapist by developing memories of events that did not happen; i.e., the so-called pseudomemories.

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In working with someone who might have DID, avoid leading questions and responses that could even subtly reveal an investment in finding histories of severe childhood abuse. 10. Summarize recent ideas concerning normal memory. Normal memory is mediated by the hippocampus and the frontal lobe. Explicit (declarative) versus implicit (non-declarative)memory Explicit memory is the recollection of past events with conscious or intentional effort, and has both visual and verbal components. Implicit memory is the development of various behaviors based on past experience of which one has no recall. This includes conditioned responses. Sensory versus short-term versus long-term memory Sensory memory systems record and store stimuli of the five sensory systems. Short-term memories are the active contents of the mind. They are the result of a persons analysis of an experienced event, which is different from a recording of the actual event. What goes into short-term memory is largely voluntary, but unwanted associated events also can be stored with the voluntary memories, Short-term memory, also called working memory, is what one uses to process the immediate present. Long-term memory storage is vast and mostly voluntary. Like short-term memory, unwanted associated memories can accompany voluntary memories. Long-term memories may be transferred from short-term memory, but passing through short-term memory is probably not necessary. Rehearsing a memory in short-term memory does help, up to a point, to transfer a memory into long-term memory. Forgetting may be influenced by decay, the loss of intensity of a memory over time, and by associative interference (the storage of a similar memory to the event forgotten). Normal memory is malleable. Memories are reliably inuccurute. Memory is not like a video camera, recording events or scenes and then storing them in a vast video library. Memory is a dynamic process. Each time one recalls an event, the memory changes. Current events influence and change memories. Bias and belief systems can also color memories. Memories are greatly influenced by the intensity of affect experienced at the time of the event. Memories are influenced by the context of the retrieval; i.e., suggestion and giving approval for a response can influence the response. Memory for ordinary events may be a combination of the actual event, similar events, and the individuals own enrichment (fantasy). Memories can be recovered for events that never happened; i.e., pseudomemories or false memories. This can include iatrogenic memories, created with the help of a therapist asking leading questions or making unwarranted suggestions to the patient. Other important figures also can induce false memories through similar processes.
11. Summarize recent ideas concerning traumatic memory. Traumatic memory is largely mediated by the amygdala. Individual responses to trauma are dependent on several factors: premorbid temperament, interpersonal resiliency factors, and the presence or absence of preexisting or concurrent psychopathology. Traumatic memories generally are not influenced by the storage of other similar, associated events ; i.e ., interference. Traumatic memories do not wune in inrensity over the passage of time; i.e., decay. The memory (of a trauma) is just as vivid today as it was 20 years ago when it happened.) A traumatic memory may be recalled at any time if triggered by a reminder. The memories are mostly sensory and emotional and the subject may not be able to put words to them. This is very different from explicit memory. Trauma victims often cannot make up a story of what happened to them.

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Individuals may be amnesic for parts of a traumatic event, and memories of other aspects may become intensely fixed in the mind. Dissociation is believed to play a role in amnesia for a traumatic event. J. Freyd has theorized that the victim of ongoing childhood abuse by a caregiver must become amnesic regarding the abuse, because the child is so dependent on the caregiver for life-sustaining functions. Freyd has coined the term betrayal trauma, and posits that these victims cannot allow themselves to remember the traumas until later in life when they are better able to take care of themselves. She calls this an evolutionary adaptive function. Delayed recall of very severe traumas has been and remains highly controversial between academic memory researchers and clinicians.

12. List factors associated with traumatic amnesia. Age: the younger one is at the time of the trauma, then the greater the vulnerability. Dose: the more severe and the longer the duration of the trauma, the greater the vulnerability. Preexisting vulnerability Head injury
According to several studies of childhood sexual abuse, women report the following: About 25-30% have total amnesia for the event(s) About 3540% remember some of the event(s). About 3 W O % say they always remembered the abuse.

13. How can these new understandings concerning memory apply clinically to a person with a dissociative disorder? Normal memories are quite corruptible and must be understood in the context of the patients life. Traumatic memories, which are largely sensual and emotional, can be very accurate and intense, but the patient may not be able to put them into words. Thus, traditional talk therapies may not be effective. False memories can he induced. Thus, the therapist must remain neutral and avoid asking leading questions or making unwarranted suggestions. For example, Do you think you could have been satanically ritually abused? I have seen similar cases like yours. Your father may have sexually assaulted you.

14. What are the goals of treatment of a DID patient? The treatment can be thought of as being divided into three phases: early, middle, and late-stage treatment. The goals of early-stage treatment include: * Helping patients improve self-care. As children they were forced into the position of taking
care of an adults needs, and did not receive appropriate care themselves. Thus, they did not learn to take care of themselves. Establishing a better sense of safety by helping them to reduce their suicidal ideation and behaviors, as well as other self-destructive and self-defeating coping strategies. Reducing symptoms of PTSD, dissociation, anxiety, and depression. Medications may be very helpful. Acknowledging that trauma played a central role in the development of their current symptomatology and dysfunction. Education about their disorder and its treatment is essential. Helping patients to realize that they are one person with different parts and aspects to themselves, and not different people or personalities. Improving functioning in their everyday life, such as at work, in school, and in relationships. Teaching, training, and helping to practice better coping mechanisms to assist them in managing their PTSD and dissociative symptoms. Helping them to improve their relationships and shore up their support systems. Identifying the key alters: their roles, strengths and weaknesses, and needs. Helping the patient to develop as much co-consciousness as possible (i.e., each identity has an awareness of the other identities).

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Insisting that patient (host or executor) must be responsible for all of the alters behaviors all of the time. Until this is achieved, this task must remain a top priority. Helping the patient understand that all of the alters are important parts of the self, and attempts should be made to meet the needs of each one, even the bad ones. Helping the patient and the alters learn to work cooperatively for the best interest of them all.

15. How are the goals of early-stage DID treatment achieved? The approach to achieving these goals is largely directive in nature, using cognitive and behavioral techniques. Uncovering repressed traumatic memories, processing traumatic memories and nightmares, and experiencing abreactions of traumatic memories is counter-productive in this stage, and usually leads to profound regression and dysfunction. Depending on the ego strength of the individual, the first phase of treatment may require months to years. Many patients will either be satistied with this level of improvement or incapable of going much farther.

16. What are the goals of mid-stage treatment for a DID patient? The goals of mid-stage treatment include: Talking about the traumas, if the patient is able to put words to the traumatic experiences. Understanding the meaning of what happened, and correcting cognitive distortions are more important than the veracity of the memories per se. For instance, being beaten by a parent may mean to the patient, I was to blame for the beating, I am bad, I am worthless, I am not loveable, etc. The patient needs to construct as integrated a memory as possible of what happened to them and what it meant in reality, while experiencing the associated feelings. He or she needs to realize that the traumas happened a long time ago, were survived, and are not happening now. Patients need to realize that their mistreatment by their caretakers was not their (the patients) fault. Then they need to put into perspective that the traumas did not destroy their self-worth. Using nonverbal techniques, if the patient cannot put words to their traumatic experiences. These techniques include eye movement, desensitization and restructuring (EMDR) techniques, deconditioning to the feelings associated with the traumas, and somatic therapies. Through the relationship with the therapist, patients need to learn that they must and can bear the associated pain. It is only through the controlled and coordinated experiencing of these intense trauma-related affects that the patient can decrease the intensity of their fear and pain. The therapist may then help the patient to find words to describe these experiences and to make meaning out of them. Nonverbal techniques also can be very helpful to patients who can describe their traumas in words. Having a secure, trusting, safe relationshipwith a therapist. It is only through the relationship with the therapist that the patient can face memories in a controlled and coordinated manner. Reassessing former understanding of how the real world operates. Before therapy, the patients perceptions were fraught with misconceptions and distortions about themselves and the world. This can include issues regarding identity, competence, trust, power and control, autonomy, and value systems. Fusing (disappearance) of alternate personalities. Some patients fully integrate until there is only one personality. Others are pleased to reduce the number of alters, who have learned to function together cooperatively. 17. How are the goals of mid-stage treatment achieved? The treatment during the mid-phase is extremely complex, and should not be attempted by neophyte therapists, or even experienced therapists, if they have not had specific training and supervision of several DID patients. This phase of treatment can take 1-3 years.
18. What are the goals of late-stage treatment for a DID patient? The goals of late-stage treatment include: Coalesce a new sense of self, based on the patients real strengths and weaknesses. Forgive, let go of, and grieve the past. The patient will never have the parents or the childhood that was wanted, and for this they must grieve.

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Make and maintain healthier relationships. Terminate therapy and grieve the loss of the therapist. At the end of therapy, the patient should not be encumbered with memories and feelings from past traumas, allowing them to live in the here and now. They should be able to give up their preoccupation with their symptoms, and focus on the challenges of the outside world. BIBLIOGRAPHY 1. Appelbaum PS, Uyehara LA, Elin MR: Trauma and Memory: Clinical and Legal Controversies. New York, Oxford University Press, 1997. 2. Bjork EL, Bjork RA: Memory Handbook of Perception and Cognition, 2nd ed. San Diego, Academic Press, 1996. 3. Chu JA: Rebuilding Shattered Lives: The Responsible Treatment of Complex Posttraumatic and Dissociative Disorders. New York, John Wiley & Sons, Inc., 1998. 4. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th ed. Washington, DC, American Psychiatric Association, 1994. 5. Kluft RP, Fine CG: Clinical Perspectives on Multiple Personality Disorder. Washington, DC, 1993. 6. Pope KS, Brown LS: Recovered Memories of Abuse: Assessment, Therapy, Forensics. Washington, DC, American Psychological Association, 1996. 7. Putnam F W :Diagnosis and Treatment of Multiple Personality Disorders. New York, Guilford Press, 1989. 8. Ross CA: Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of Multiple Personality. 2nd ed. New York, John Wiley & Sons, Inc., 1997.

27. SEXUAL DISORDERS AND SEXUALITY


Harold P. Martin, M . D
1. Name the three categories of sexual disorders.
Paraphilias Gender identity disorders Sexual dysfunction

2. What are paraphilias? Paraphilia is defined by DSM-IV as a disorder in which a person experiences recurrent, intense sexually arousing fantasies, urges, or behavior involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or ones partner, or ( 3 ) children or non-consenting adults. Patients may not be able to become sexually aroused unless involved with a paraphilia or may have an obsessive need to engage in the paraphiliac fantasy or behavior. According to DSM-IV, impairment in social or occupational functioning or significant emotional distress is necessary for a diagnosis. However, even if patients are comfortable with their paraphilia and have no apparent impairment of job or social life, the diagnosis can be made if the paraphiliacal behavior is obligatory for sexual arousal or recurrent, persistent, and obsessive. Behaviors may result in social or legal ramifications (e.g., pedophilia, exhibitionism). Indeed, for many paraphiliacs, the only emotional distress is the fear of discovery, legal punishment, or disapproval by persons they care about. Types of paraphilias include: Exhibitionism: sexual arousal from exposing ones genitals to strangers. Fetishism: use of nonliving objects-usually clothes-that the patient may hold, rub, smell, for sexual arousal. Transvestic fetishism: cross-dressing, which usually is seen in heterosexual men, who find cross-dressing sexually arousing. Pedophilia: fantasies, urges, or behaviors involving sexual activity with children. Voyeurism: observing unsuspecting persons unclothed or involved in sex.