Vedat Şar

Childhood Trauma, Dissociation, and Psychiatric Comorbidity in Patients With Conversion Disorder

OBJECTIVE The aim of this study was to evaluate dissociative disorder and overall psychiatric comorbidity in patients with conversion disorder. METHOD Thirty-eight consecutive patients previously diagnosed with conversion disorder were evaluated in two follow-up interviews. The Structured Clinical Interview for DSM-III-R, the Dissociation Questionnaire, the Somatoform Dissociation Questionnaire, and the Childhood Trauma Questionnaire were administered during the first follow-up interview. The Structured Clinical Interview for DSM-IV Dissociative Disorders was conducted in a separate evaluation. RESULTS At least one psychiatric diagnosis was found in 89.5% of the patients during the follow-up evaluation. Undifferentiated somatoform disorder, generalized anxiety disorder, dysthymic disorder, simple phobia, obsessive-compulsive disorder, major depression, and dissociative disorder not otherwise specified were the most prevalent psychiatric disorders. A dissociative disorder was seen in 47.4% of the patients. These patients had dysthymic disorder, major depression, somatization disorder, and borderline personality disorder more frequently than the remaining subjects. They also reported childhood emotional and sexual abuse, physical neglect, self-mutilative behavior, and suicide attempts more frequently. CONCLUSIONS Comorbid dissociative disorder should alert clinicians for a more chronic and severe psychopathology among patients with conversion disorder.

Prevalence of dissociative disorders among women in the general population

This study sought to determine the prevalence of dissociative disorders among women in the general population, as assessed in a representative sample of a city in central Turkey. The Dissociative Disorders Interview Schedule (DDIS), the Borderline Personality Disorder section of the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II), and the PTSD-Module of the Structured Clinical Interview for DSM-III-R (SCID) were administered to 628 women in 500 homes. The mean age of participants was 34.8 (S.D.=11.5, range: 18-65); 18.3% of participants (n=115) had a lifetime diagnosis of a dissociative disorder. Dissociative disorder not otherwise specified (DDNOS) was the most prevalent diagnosis (8.3%); 1.1% of the population was diagnosed as having dissociative identity disorder (DID). Participants with a dissociative disorder had borderline personality disorder, somatization disorder, major depression, PTSD, and history of suicide attempt more frequently than did participants without a dissociative disorder. Childhood sexual abuse, physical neglect, and emotional abuse were significant predictors of a dissociative disorder diagnosis. Only 28.7% of the dissociative participants had received psychiatric treatment previously. Because dissociative disorders are trauma-related, significant part of the adult clinical consequences of childhood trauma remains obscure in the minds of mental health professionals and of the overall community. Revisions in diagnostic criteria of dissociative disorders in the DSM-IV are recommended.

Frequency of Dissociative Disorders Among Psychiatric Outpatients in Turkey

The aim of this study was to determine the frequency of dissociative disorders among psychiatric outpatients in Turkey. One hundred fifty consecutive outpatients admitted to the psychiatry clinic of a university hospital were screened with the Dissociative Experiences Scale (DES). Twenty-three patients (15.3%) with a DES score greater than 30 and a comparison group selected from the same outpatient population who scored less than 10 on the scale were then interviewed with the Dissociative Disorders Interview Schedule (DDIS) in a blind fashion. According to the DDIS, 18 patients (12.0%) received a diagnosis of dissociative disorder; 83.3% (n = 15) of the dissociative patients reported neglect, 72.2% (n = 13) emotional abuse, 50.0% (n = 9) physical abuse, and 27.8% (n = 5) sexual abuse during childhood. Dissociative disorders are not rare among psychiatric outpatients. Self-rating instruments and structured interviews can be used successfully for screening dissociative disorders, which are usually underrecognized. Neglect was the most frequently reported type of childhood trauma, suggesting the importance of other childhood experiences in addition to sexual and/or physical abuse in the development of dissociative psychopathology.

Frequency of dissociative identity disorder in the general population in Turkey

This study attempted to determine the prevalence of dissociative identity disorder in the general population. The Dissociative Experiences Scale (DES) was administered to 994 subjects in 500 homes who constituted a representative sample of the population of Sivas City, Turkey. The mean DES score was 6.7+/-6.1 (mean +/- SD). Of the 62 respondents who scored above 17 on the DES, 32 (51.6%) could be contacted during the second phase of the study. They were matched for age and gender with a group of respondents who scored below 10 on the scale, and the Dissociative Disorders Interview Schedule (DDIS) was then administered to both groups. Seventeen subjects (1.7%) received a diagnosis of dissociative disorder according to the structured interview. In the third phase, eight of 17 subjects who had a dissociative disorder on the structured interview could be contacted for a clinical evaluation. They were matched with a nondissociative control group and interviewed by a clinician blind to the structured interview diagnosis. Four of eight subjects were diagnosed clinically with dissociative identity disorder, yielding a minimum prevalence of 0.4%. Dissociative identity disorder is not rare in the general population. Self-rating instruments and structured interviews can be used successfully for screening these cases. Our data, derived from a population with no public awareness about dissociative identity disorder and no exposure to systematic psychotherapy, suggest that dissociative identity disorder cannot be considered simply an iatrogenic artifact, a culture-bound syndrome, or a phenomenon induced by media influences.

Comparison of dissociative identity disorder with other diagnostic groups using a structured interview in Turkey

Twenty patients with dissociative identity disorder (DID), 20 with schizophrenic disorder, 20 with panic disorder, and 20 with complex partial epilepsy were evaluated with the Dissociative Disorders Interview Schedule (DDIS) and the Dissociative Experiences Scale (DES). Subjects with dissociative identity disorder were more frequently diagnosed as having somatization disorder, past or concurrent major depressive episode, borderline personality disorder, depersonalization disorder, and dissociative amnesia than other groups. They reported Schneiderian symptoms and extrasensory perceptions more frequently. In their anamnesis suicide attempts, trance states, sleepwalking, and childhood traumas were more frequent than those in comparison groups. The secondary features of dissociative identity disorder and the DES score differentiated these patients from comparison groups significantly. DID has a set of clinical features different from that of schizophrenic disorder, panic disorder and complex partial epilepsy. The differences are similar to those yielded previously in studies from North America.

Dissociative identity disorder: An empirical overview:

Objective: Despite its long and auspicious place in the history of psychiatry, dissociative identity disorder (DID) has been associated with controversy. This paper aims to examine the empirical data related to DID and outline the contextual challenges to its scientific investigation. Methods: The overview is limited to DID-specific research in which one or more of the following conditions are met: (i) a sample of participants with DID was systematically investigated, (ii) psychometrically-sound measures were utilised, (iii) comparisons were made with other samples, (iv) DID was differentiated from other disorders, including other dissociative disorders, (v) extraneous variables were controlled or (vi) DID diagnosis was confirmed. Following an examination of challenges to research, data are organised around the validity and phenomenology of DID, its aetiology and epidemiology, the neurobiological and cognitive correlates of the disorder, and finally its treatment. Results: DID was found to be a complex yet valid disorder across a range of markers. It can be accurately discriminated from other disorders, especially when structured diagnostic interviews assess identity alterations and amnesia. DID is aetiologically associated with a complex combination of developmental and cultural factors, including severe childhood relational trauma. The prevalence of DID appears highest in emergency psychiatric settings and affects approximately 1% of the general population. Psychobiological studies are beginning to identify clear correlates of DID associated with diverse brain areas and cognitive functions. They are also providing an understanding of the potential metacognitive origins of amnesia. Phase-oriented empirically-guided treatments are emerging for DID. Conclusions: The empirical literature on DID is accumulating, although some areas remain under-investigated. Existing data show DID as a complex, valid and not uncommon disorder, associated with developmental and cultural variables, that is amenable to psychotherapeutic intervention.

The many faces of dissociation: opportunities for innovative research in psychiatry.

It has been claimed that the progress of psychiatry has lagged behind that of other medical disciplines over the last few decades. This may suggest the need for innovative thinking and research in psychiatry, which should consider neglected areas as topics of interest in light of the potential progress which might be made in this regard. This review is concerned with one such field of psychiatry: dissociation and dissociative disorders. Dissociation is the ultimate form of human response to chronic developmental stress, because patients with dissociative disorders report the highest frequency of childhood abuse and/or neglect among all psychiatric disorders. The cardinal feature of dissociation is a disruption in one or more mental functions. Dissociative amnesia, depersonalization, derealization, identity confusion, and identity alterations are core phenomena of dissociative psychopathology which constitute a single dimension characterized by a spectrum of severity. While dissociative identity disorder (DID) is the most pervasive condition of all dissociative disorders, partial representations of this spectrum may be diagnosed as dissociative amnesia (with or without fugue), depersonalization disorder, and other specified dissociative disorders such as subthreshold DID, dissociative trance disorder, acute dissociative disorders, and identity disturbances due to exposure to oppression. In addition to constituting disorders in their own right, dissociation may accompany almost every psychiatric disorder and operate as a confounding factor in general psychiatry, including neurobiological and psycho-pharmacological research. While an anti- dissociative drug does not yet exist, appropriate psychotherapy leads to considerable improvement for many patients with dissociative disorders.

Psychotherapy of an adolescent with dissociative identity disorder: Change in Rorschach patterns

Abstract A female adolescent with dissociative identity disorder was assessed using structured interviews and the Rorschach test before and after one year of individual psychotherapy. In addition to improvement in several comorbid psychiatric disorders, according to the structured evaluation, criteria for neither dissociative identity disorder nor borderline personality disorder were met at the second evaluation. The main differences on the Rorschach assessments before and after integration were in the development of form-dominated color and human movement responses and a diminution in the externally focused coping style. The differences were interpreted as improvement in aggressiveness, impulsivity, anxiety, and better identification with social environment. This case study suggests that the Rorschach test can be used to evaluate the change of patients with dissociative identity disorder in psychotherapy.

Reliability and Validity of the Turkish Version of the Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID-D): A Preliminary Study

A total of 34 consecutive patients with dissociative identity disorder or dissociative disorder not otherwise specified were evaluated using the Turkish version of the Structured Clinical Interview for DSM–IV Dissociative Disorders (SCID-D). They were compared with a matched control group composed of 34 patients who had a nondissociative psychiatric disorder. Interrater reliability was evaluated by 3 clinicians who assessed videotaped interviews conducted with 5 dissociative and 5 nondissociative patients. All subjects who were previously diagnosed by clinicians as having a dissociative disorder were identified as positive, and all subjects who were previously diagnosed as not having a dissociative disorder were identified as negative. The scores of the main symptom clusters and the total score of the SCID-D differentiated dissociative patients from the nondissociative group. There were strong correlations between the SCID-D and the Dissociative Experiences Scale total and subscale scores. These results are promising for the validity and reliability of the Turkish version of the SCID-D. However, as the present study was conducted on a predominantly female sample with very severe dissociation, these findings should not be generalized to male patients, to dissociative disorders other than dissociative identity disorder, or to broader clinical or nonclinical populations.

Trauma and dissociation in context: personal life, social process, and public health.

To what extent are individuals and societies ready to face and to accept truth? Criticizing the “university discourse,” which he considered biased, Lacan (1966) stated wisely: “For centuries, knowledge has been pursued as a defense against truth.” He even doubted the existence of true “science” until he discovered the “hysterical (dissociative) discourse” which he saw as truly “scientific.” While maintaining the primacy of subjective division, the hysterical (dissociative) person calls “knowledge” into question rather than explaining everything with the knowledge he or she already has (Fink, 1998). Thus, historically, dissociative patients have undeniably initiated medical, psychiatric, and psychoanalytic discoveries while proving to clinicians and researchers the inadequacies of their presumed knowledge and know-how.