Dissociative Disorders To The Patient example essay topic

It is very important to diagnose a case of dissociative identity disorder; if it is not diagnosed, it may lead to death. However, therapists have had many problems in diagnosing this type of disorder. This is due to two major factors. The first is that DID is seen as a very unusual disorder, and most cases of DID are mistaken for Schizophrenia. The second factor is that there is a lack of guidelines for the diagnosis of DID. Hence, even when DID is diagnosed it usually takes multiple weeks-or even months to recognize.

There are three categories of special techniques that are used to diagnose DID. The first category is screenings tools that are used to identify patients at risk for any dissociative disorder, not exclusively DID. The second category is structured interviews, and the third category is informal interviews. There are three screenings tools that are used to identify patients at risk for a dissociative disorder.

The first tool is the Dissociative Experiences Scale (DES). The DES is a twenty-eight question self-report that rates a patient's dissociative symptoms and experiences. The patient indicates his / her agreement with a question by circling a percentage from 0% to 100%. The sum of the twenty-eight scores is taken and averaged to determine whether or not the patient suffers from a dissociative disorder.

The DES is reported to have 80% sensitivity, and DID patients usually score above forty points. The two other screenings tools are the Dissociative Questionnaire and the Questionnaire of Experiences of Dissociation, and are both very similar to the DES. There are four types of structured interviews that can be used to diagnose DID. The first interview is the Dissociative Disorder Interview Schedule (DDIS). This interview is very time consuming (it can take anywhere from forty-five minutes to three hours) and is used more in research settings than clinical. There are one-hundred thirty-one items in the interview, most which ask about childhood sexual abuse.

The DDIS serves to diagnose dissociative disorders, somatization disorders, major depression, and borderline personality disorder. It is reported to have high sensitivity and a specificity for diagnosing DID. The second interview is the Structured Clinical Interview for DSM-IV Dissociative Disorders Revised (SCID-D-R). This interview is also very time consuming and is used more in research settings than clinical. In addition, it requires special training. The interview is highly sensitive to DID and is also able to detect all five dissociative disorders.

The third type of interview is the "symptom cluster method", which was formulated by Lowenstein. The symptom cluster method divides DID symptoms into six different phenomenological categories that should be watched for during an interview with a potential DID patient. The six categories are process symptoms or switching (symptoms that reflect transitions between alter personalities or interactions between alters), amnesia, auto hypnotic, post-traumatic, somatoform, and affective symptoms. The fourth type of interview is the hypnosis interview. However, this type of interview should be used only when a definite diagnosis has not been reached from another diagnostic measure and diagnosis is necessary, or in the case that diagnosis is a medical necessity.

This is because hypnosis alters a patient's state of consciousness, and hypnosis may yield symptoms that look like dissociative pathology even if a patient does not have DID. In the case that hypnosis must be used, it should be used only by a trained practitioner, and leading or suggestive questions should not be asked. The third category of special techniques, informal interviews, is probably the most common way to diagnose DID. This is partly due to the fact that most DID patients are diagnosed unexpectedly. A therapist will notice that a DID patient will display certain characteristics that fall under six broad factors. These are history of present illness, psychiatric history, medical history, family history, social and developmental history, and the results of a mental status exam.

When observing the patient's history of present illness, the therapist will probably be told about or observe suicide attempts, self-mutilation or self-destruction, and "desperate depression", also known as atypical affective symptoms. These symptoms include amnesia, fugue, auditory hallucinations, Schneiderian symptoms (made phenomenon, made impulses, feelings, volitional acts), PTSD symptoms (detachment, avoidance, re experiencing of trauma, nightmares), concurrent somatic and psychiatric symptoms, and hysteria. When reviewing the patient's psychiatric history, the therapist will most likely observe numerous previous diagnoses and treatment failures prior to the current disorder. These diagnoses will include PTSD, borderline personality disorder, eating disorders, psychotic disorders that are unresponsive to medications, somatoform disorder, substance or alcohol abuse, gender identity disorder, transsexualism or transvestism, Schizo affective disorder, Schizophrenia, and a history of sexual abuse. The patient will also probably have had numerous previous psychiatric hospitalizations.

The patient's medical history may contain headaches, numerous physical complaints of the sexual nature, unexplained pain (usually gynecological or gastrointestinal), fear of physical exams, or rejection of care. The patient almost always has a chaotic family situation, and is usually estranged from both parents and sometimes siblings. The patient's social and developmental history will usually contain repetitive sexual, psychological, and physical abuse from an early age. He or she usually has had a history of neglect and a greatly distorted childhood, being involved in cults as a young child. He / she displays from unusual sexual impulses and tends to act out. There are six different categories that fall under mental status exam.

These categories are appearance, behaviors, affect and mood, thought process and content, perceptions, and cognition. The patient's appearance will not appear unusual during the first interview, but over the course of many sessions, the therapist will observe a significantly different style in clothes, hair, makeup, glasses, posture, and jewelry. The patient will also display signs of injury. There may also be variances in the patient's behavior. The therapist may observe intra-interview amnesia, spontaneous regression, strange behavior despite the apparent rapport between the patient and therapist, the use of "we", spontaneous voice or accent changes, sudden involuntary movements, changes in facial muscles, changes in handedness (whether the patient uses his / her right or left hand), marked changes in creative abilities or styles, and handwriting changes. The patient may also display dramatic shifts in anxiety or mood.

The patient may have an abnormal self-concept, abnormal body concept, an obsessive imagination, and marked phobias. He / she may also suffer from negative hallucinations, Schneiderian symptoms, illusions, flashbacks, re vivifications, depersonalization, de realization, and marked detachment. The patient may also suffer from psychogenic amnesia and abstraction despite an apparent psychosis. The therapist may also suspect DID if probing questions are answered in a puzzling or out of character manner. He / she should proceed to ask the patient if another "personality" is present. A negative response may indicate denial instead of the absence of DID.

If the response is positive, the therapist should understand that this revelation could be de-stabilizing and frightening to the patient, and should give the patient time to cope without trying to proceed with the interview too quickly. If, during the course of an interview, or after many interviews, the therapist observes a poly symptomatic presentation, he / she will probably choose to ask questions about the presence of other "personalities". This presence will settle the diagnosis of DID (however, alters are more likely to emerge unexpectedly when a patient is in crisis, or if the diagnosis has been made previously). Questions can be asked relatively directly.

There are three common examples of question to be asked of a suspected DID patient: Have you ever been told by others that you seem like a different person? Have you ever referred to yourself by different names? Have you ever acted in a completely different manner? There is only one effective approach to treat dissociative identity disorder. This approach is outpatient therapy sessions.

There are currently no medications for DID patients. There are a few alternative approaches to treat DID, but these are usually used in conjunction with outpatient therapy sessions. There is usually a negative result when these alternative approaches are not used in conjunction with outpatient therapy sessions. Treatment of DID is long-term, intense, and painful. However, if the patient receives and completes the correct treatment, his / her condition will be completely cured, and he / she will be able to lead healthy and normal life.

There are four goals of therapy which interweave with each other. They are to stabilize symptoms of DID, to control dysfunctional behavior, to restore normal, everyday functioning, and to improve relationships. Proper conduct of a therapist for a DID patient is especially crucial, because DID patients are extremely vulnerable. Physical contact between the therapist and the patient is not recommended because it can be misinterpreted. However, holding a patient's hand during an abreaction may help ease the pain. The therapist must discuss with the patient if he / she wishes to seek out massage / bodily therapy.

Sexual contact between a therapist and a patient is never appropriate. The frequency of therapy sessions depends on the particular therapist and the particular patient. The number of sessions per week should reflect how stable the patient is and how well he / she is able to function on his / her own. However, for an average therapist who is treating the average DID patient, two sessions of therapy per week is recommended. The therapist may consider it necessary to hold marathon sessions, and in this case they should be pre-scheduled as such and should have a pre-determined structure and schedule.

Although extra sessions are sometimes needed, if a patient schedules a particularly large number, the therapist needs to reexamine the regularly scheduled amount of sessions and verify that that number is sufficient for the particular patient. The therapist should also ensure that the increased amount of sessions is not detracting from the patient's ability to return to normal functioning and living. Three to five years is accepted as the minimum length of treatment for a DID patient, although more complex cases may sometimes take six years. There are four phases of therapy. The initial phase of therapy is the assessment and planning phase. This phase involves contacting the alter personalities and developing a plan of treatment.

The middle phase is the working phase. It involves establishing communication between the alters, breaking down amnesic barriers, sharing memories, and abreaction. The late phase involves the evaluation of progress made in the middle phase of therapy. There is also a further reworking of memories and preparation for and integration of alter personalities. The postintegration phase involves resolution of major abuse issues and memories.

The patient must learn to develop and apply new coping skills and adjust to new feelings and memories (from the alter personalities). This phase also involves grieving the loss of the alter personalities. In the initial phase of therapy, the therapist must help the patient to contact the alter personalities and develop a plan of treatment. To do so, the therapist must establish safety and trust with the patient. The therapist must develop a treatment alliance, and ensure that the patient agrees on the goals and will make a commitment to the treatment.

The therapist must discuss the diagnosis with the patient, explaining his / her dissociative process. He / she must also explain all dissociative disorders to the patient and provide reading materials or resources. He / she must map the patient's personality system, and ensure that the patient understands that the goal of the treatment is direct contact with and integration of the alters. The last part of this stage is to develop an agreement between the therapist and patient regarding the length of treatment, consequences of self-destructive or violent behavior, and any other treatment expectations. The middle phase of therapy is the working phase. The patient must establish communication between the alter personalities break down amnesic barriers (allowing the host personality to remember when other alters in control).

He / she must reveal abuse and traumatic memories that were dissociated with alter personalities. This results in abreacting the abuse memories, a physical and emotional re-experiencing of the abusive events. The patient must also explore and cope with thoughts, memories, and feelings regarding the abuse. The therapist must ensure that he / she adjusts the treatment approaches when working with a younger alter personality or when working with particularly aggressive alters. To aid in this particularly difficult middle phase, therapist may choose to use a number of techniques with the patient to aid in therapy.

For example, to encourage integration among the alters, he / she may choose take a vote among all the alters regarding some aspect of the host's life. He / she may choose to use creative elements (metaphors, rituals, imagery, dreams) to recover memories in a safer way. Hypnosis can also be used to contact alters, integrate personalities, recover memories, or reduce symptoms. Age progression or regression can be used to increase or decrease the age of an alter personality. Writing exercises can be used to encourage communication between alters, audiovisual recordings of sessions can be used to convince a patient of the existence of other alters.

It can also serve to allow alters to become better acquainted. Expressive arts (music, drawing, movement) and medications can be used to relieve depression or anxiety. If therapy is not progressing well, the therapist may choose to use physical restraint against the patient in order to avoid injury to him / herself or anyone else. The therapist may also choose to hospitalize the patient to allow him / her to safely work through a crisis. Group therapy, social services, AA groups, vocational counselors, and social support groups may also be called in. Sometimes spouses, friends, and relatives of the patient are asked to become involved in the patient's life and treatment.

The late phase of treatment involves evaluating the progress made in the middle phase of therapy and final integration of the alters. The therapist must set limits on the pace of therapy, the behavior of the patient, and the rate at which painful memories are uncovered. Finally, the alters must be joined into a single personality. This is usually done by hypnosis. The postintegration phase involves coping with major abuse memories, new feelings and memories, and grieving the loss of alter personalities.

The patient must learn to deal with conflict without dissociating. He / she must increase his / her confidence and self esteem and explore his / her future plans for life. Although there are alternative treatments for DID, they generally have not proved successful when used alone. Some of these treatments have proved detrimental even when used in conjunction with outpatient therapy sessions. These treatments include inpatient treatment, group therapy, therapist telephone availability, physical restraint, and hypnotherapy. Inpatient therapy should be used only when the specific goal is returning the patient to a functional state.

The therapist must be able to determine which factors have destabilized or threaten to destabilize the patient, what must be done to alleviate these factors, and should help the patient attempt to acquire skills to cope with destabilizing factors. Inpatient therapy should not be used in place of outpatient therapy sessions. Group therapy is generally not advised as a treatment for DID, even in conjunction with outpatient therapy sessions. However, the patient may need to be assured that he / she is not coping with the disorder alone. The patient may feel positive results when the leader sets clear expectations within the group.

However, patients usually tend to act out during these sessions, and there are not enough therapists to help each patient cope with his / her abreaction. This usually has a negative impact on the rest of the group. Although limited telephone availability access from the patient to the therapist is advisable for emergencies, providing unlimited telephone access has not proved beneficial. Regular calls by the therapist to check up on the patient are not advised either. Some therapists may feel that physical restraint is necessary when violent alter personalities become physically aggressive or self-destructive and it becomes impossible for the therapist to work with all the personalities in therapy.

However, other therapists feel that resolving issues verbally with the alter is more beneficial, and allows all the alters to be contacted during therapy. The amount of physical restraint used hinges on the discretion of each particular therapist. Hypnotherapy is generally a positive tool. It helps patients manage crisis by overcoming sudden flashbacks and reorienting themselves to actual reality. It helps to strengthen the ego, helps patients remain stable between sessions, serves as a safe outlet for expressing feelings, and aids in skill building. It also relieves traumatic memories, helps to increase communication between alters and between alters and the therapist, and aids in memory retrieval.

However, hypnotherapy should be used in conjunction with other approaches in treating DID.