Psychological Interventions for Dissociative disorders

Abstract

INTRODUCTION Dissociative disorders as described by ICD 10 include a range of disorders and combine what are conversion disorders (assumed under somatoform disorders in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and the cluster of dissociative disorders. The mutual idea shared by these disorders is a partial or complete loss of usual integration between memories, cognizance of identity, and immediate sensations and voluntary control of body movements. Conversion occurs when there are clinical symptoms representing alteration of functioning of motor or sensory systems and which do not follow a pattern of a known neurological or medical disease. Dissociation is a mechanism that allows the mind to compartmentalize certain memories or thoughts from normal consciousness. These split-off mental contents are available and may return to consciousness either by an event or spontaneously. Broadly, dissociative disorders may be viewed as shown in Table 1.Table 1: Types of dissociative disordersCommon dissociative disorders in the Indian setting have been dissociative motor disorders and dissociative convulsions. Dissociative stupor and possession states were next most frequent with multiple personality disorders being rather infrequent. Depression and borderline personality disorder often coexist. Role of culture in presentation The expression of disease is affected by culture, and there are distinct differences which need to be understood while planning management, particularly in the Indian context [Table 2].Table 2: Cultural presentation of dissociative disordersETIOLOGY To plan management, understanding some elements of etiology is important. Broadly, it may be viewed as a reaction to an external trauma or secondary to a personality attribute which incline the patient to dissociate [Table 3].Table 3: Three principles for treatment of dissociation in a contextual approachPsychotherapy is the cornerstone of treatment for dissociative disorders and hence choosing the right therapist is of paramount importance. The following section enumerates the characteristics of a therapist ideally suited to engage in therapy for dissociative disorders. The therapist must be cognizant with the clinical features and the psychodynamic aspects of dissociative disorders and be able to accurately diagnose it. An early and appropriate treatment plan can only be framed after a proper diagnosis which is often hampered by the lack of awareness among clinicians about the dissociative process, the effects of psychological trauma, and by misconceptions about the varied clinical symptoms. Furthermore, the usual diagnostic interviews and mental status examinations taught during training often do not explore about dissociative processes and psychological trauma, and the onus is on the therapist to inquire specifically about features suggestive of dissociation A formal training in psychotherapy is desirable before the therapist attempts to undertake therapy for dissociative disorders. Patients with dissociative disorders may need to be approached from a psychodynamic perspective to gain a better understanding of the role of past trauma in the manifestation of their current symptoms and unless the therapist is well versed in the nuances of psychodynamic approach and trained formally in psychotherapy, only crisis intervention and supportive therapy will be done, which will partially ameliorate the patient's symptoms. Ideally, an experienced therapist should be able to incorporate eclectic therapeutic techniques, psychoeducation and skills development flexibly within an overall psychodynamic framework and undertake therapy. The therapist should be able to detect any psychotic breakdown while the patient is undergoing therapy and intervene accordingly. Persons with dissociative disorders frequently suffer from other comorbidities such as affective disorders, anxiety disorders, and substance abuse. The therapist should ideally also be trained to detect any such condition which may hinder the progress of therapy As therapy progresses, the therapist explores the patient's unconscious conflicts which may be a cause of maladaptive functioning. Also, resistance emerges and the therapist may experience counter transference. The therapist should be experienced enough to recognize counter transference which can provide valuable information about the original trauma by its re-enactment within the therapeutic context and to manage it sensitively so that trust in the therapeutic alliance is maintained Culturally patterned dissociative symptoms have been well documented globally. In a country like India where there is immense socio cultural variability it is of particular importance as the dissociative symptoms can vary in presentation across regions and cultures. The occurrence of dissociative motor disorders, dissociative convulsions, and dissociative stupor and possession states are common in the Indian scenario while dissociative identity disorders were less frequently reported than western studies. In some situations, dissociation may be a culturally sanctioned way of disclaiming certain experiences or it may arise in religious context and may be perceived to be beneficial and the therapist should be sensitized about their occurrence to prevent unwarranted pathologization (Eli Somer, 2006). The therapist should be experienced enough to be aware of and pick up the same. To summarize, there has to be an amalgamation of theoretical expertise, specific therapeutic knowledge and human skills encompassing a broader context on the part of the therapist for the development of an ideal therapeutic alliance. ROLE OF THERAPY IN DISSOCIATIVE DISORDERS Management of dissociative disorders begins with an accurate diagnosis, ruling out other causes for the presentation, assessing for comorbidities and predisposing trauma and personality factors. Acute conversion disorders aim at alleviating the symptom and use reassurance, narcoanalysis, and behavior therapy techniques. The aim of therapy should be immediate alleviation of symptoms as the patients ego state is not available for any other exploration. And the primary goal of this stage is also to make the patient feel safe, where he/she feels safe enough to let go of the symptoms For chronic cases, exploratory insight oriented therapy is suggested. Whilst medication has a role in treating the co-morbidities and anxieties, psychotherapy plays a large role in the eventual integration and conflict resolution. Caution is to be applied when there is associated psychosis. If there is psychosis one should NOT attempt any form of insight oriented therapy as it will cause further breakdown. When conducting therapy the therapist should continuously be alert and monitor for any psychotic symptoms, if there is a doubt then we should err on the side of caution and temporarily stop therapy and alert the psychiatrist. The goal of therapy is to reduce dissociation and integrate the functioning of the mind. Whilst many therapies are advocated empirical evidence is lacking. INITIAL ASSESSMENT AND DETERMINATION OF TREATMENT SETTING After the initial assessment of a patient with dissociative disorder, the clinician has to determine the treatment setting-whether the patient can be treated on outpatient basis or if hospitalization is warranted. In the initial phases of treatment, establishing the patients’ safety is of paramount importance and a thorough assessment regarding safety issues (particularly the risk of harm to self or others) should be made before determining the treatment setting [Table 4].Table 4: Comparative overview of outpatient and inpatient therapyTherapy in the outpatient setting is vulnerable to disruption due to external factors like influence of family or significant others and stressors in the social context, in the acute stage or imminent threat of harm to self or others. Hence, it is important to factor in such potential disruptions during the initial assessment period to minimize the impact of pathogenic interpersonal patterns on the progress of therapy. However, in the long run, outpatient treatment is preferred. Inpatient treatment has to be considered in the scenarios as shown in Table 5.Table 5: Indications for inpatient therapyIn certain cases of dissociative disorder with complex psychopathology, an entire treatment team maybe required, comprising of clinicians, therapists, family therapists, specialists in eye movement desensitization and reprocessing etc. In such cases, it is important that the entire team should function in a well co-ordinated and concerted manner but with clear delineation of responsibilities to restore integrated functioning of the patient. ROLE OF GROUP THERAPY The role of traditional group therapy in the treatment of dissociative disorders is limited. In particular, patients with dissociative identity disorder have difficulty in participating in generic therapy groups where participants are encouraged to discuss their traumatic experiences and may even have worsening of symptoms if they are unable to tolerate the distress engendered in the process. However, select groups focused on psycho-education, problem solving and specific skills development can be a valuable adjunct to individual psychotherapy. Conversion disorder This term is another name for dissociative disorders. As per ICD 10, they are a host of dissociative disorders with partial or complete loss of the normal integration between memories of the past, awareness of identity, immediate sensations and control of bodily movement. As per Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, conversion disorders also called the Functional Neurological Symptom Disorder is a type of Somatic Symptom and related disorder is characterized by alteration in voluntary motor or sensory symptom characterized by similar features as described above. The assessment and management of this disorder is similar to as mentioned in the dissociative disorders. THE DIFFERENT THERAPEUTIC INTERVENTIONS AVAILABLE IN THE MANAGEMENT OF DISSOCIATIVE DISORDERS A broad overview of the treatment of dissociative disorders is outlined in Figure 1. Based on the type of dissociative disorder, the choice is shown in Figure 2.Figure 1: Overview of approach to treatment of dissociative disordersFigure 2: Choice of therapy based on type of disorderIn order to decide the form of therapy needed in dissociative states, it is important to understand the possible genesis of dissociation [Figure 3].Figure 3: Possible genesis of dissociationA few techniques which may be practised while managing the patient are as follows. Psychoeducation Psychoeducation is an inevitable aspect in the management of dissociative disorder. Psychoeducation should focus on normalizing and acknowledging patient's symptoms and relating them with dysfunction in daily life. It also enables an understanding in the patient and family members about the intellectual strengths and the key role of coping skills in therapy. Psycho-education must focus on the biological and neural basis of the involved feature and as a result shift focus away from victimization. Another aspect, knowing what is wrong with them enables them to give some meaning to symptoms and help them feel safe and under control. The therapist must explain in simple terms and must be easy to understand exercising caution to avoid making them sound manipulative. Grounding skills Grounding helps the patient detach from emotional pain, regain focus from the intense emotional sensation. Often patients experience symptoms in relation to the trauma that are associated with past events in their life. They get consumed by emotion and don’t have the immediate tools to manage them. This subsequently overwhelms them, which may cause the need to dissociate. Grounding helps to shift their attention from the negative emotions to the external world and also enables them to anchor to the present moment. They are taught coping responses like washing hands, describe their immediate external environment, describe the texture of the sofa, identify 10 colours in the room etc., These techniques allow them to detach from strong emotions and establish contact with the present moment in the immediate external world through sensory and cognitive awareness. This will help manage overwhelming anxiety and limit the panic. Cognitive awareness Patient is asked to answer cognitively oriented questions like: Where am I? What is today? What is the date? What is the month and year? How old am I? What season is this? Sensory awareness This technique involves using the senses to anchor to the present moment. For example; feel the back of the chair and describe its texture, count all the red items in this rooms, identify 5 sounds around you, name two things you can smell right now, place a cool cloth on your face and describe how it feels, have a cup of tea and focus on its warmth, etc., [Table 6].Table 6: Sensory awareness strategiesDISTRESS TOLERANCE Distress Tolerance skills teaches the patients to tolerate painful emotions and uncomfortable feelings without resorting to impulsive and unhealthy behavior like substance abuse, self-harm, dissociation etc., It does not aim to solve the core issue and to bring about long term conflict resolution. The aim of distress tolerance is to increase the patient's capacity to bare the painful emotion when the situation cannot be changed immediately. First the patient is taught the role of emotions in life and the consequences of resisting them. They are then taught how to identify and label an emotion; after which they are a taught various tools to handle the emotion. It is observed that once the patient learns this emotional first-aid, they start to feel relatively confident and safe in the face of an emotion because now they have tools to manage them. Various distraction and other related DBT skills are taught under DT: Self-soothing: where the patient can identify and engage in activities that employ their senses, that sooth them TIPP: This acronym stands for temperature, intense exercise, paced breathing and paired muscle relaxation. This helps to reduce extreme emotional arousal quickly ACCEPTS: Acronym stands for activities, contribution, comparison, emotions, push aways, thoughts, and sensations IMPROVE: This acronym stands for imagery, meaning, prayer, relaxation, one thing in the moment, vacation, encouragement Cost-benefit analysis: They are asked to reflect on the pros and cons of their behavior Containment imagery: These are skills that help in regaining control over intense emotions Mindfulness Radical acceptance: Patient is taught to accept undesirable circumstances that cannot be changed. Decreasing resistance to what-is, will reduce the distress associated with it. This concept teaches them that how to manage an unchanging painful situation is a matter of choice. They have a choice to accept something that is not going to change and move on or choose to resist it and deal with the consequent pain and dysfunction [Figure 4]. Figure 4: Radical acceptanceFor example, when a patient ABC diagnosed with a chronic illness, understands from the doctors about the chronicity and restriction it will pose in his life. He goes through various thoughts, “Why me,” This is not fair,” “how can this be my life ahead” and many such thoughts which reflect the inability or difficulty in accepting a situation. 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