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Understanding Dissociative Disorders: A Guide for Family Physicians and Healthcare Workers by Marlene E., MD. Hunter (Crown House Publishing) is an essential primer for all professionals who are looking for ways to understand the idiosyncrasies of dissociative patients – their idiosyncratic ways of responding to medication, the inconclusive laboratory results, and a multitude of chronic physical and emotional symptoms that appear to defy diagnosis.
This volume outlines common presentations in the family physicians’ practice, and gives practical suggestions for working with this challenging group of patients within a medical setting. The author offers realistic, practical answers to a multitude of questions. Carefully organized for easy reference, this book discusses what can be done and what can’t be, where and how to ask for help, and what to say to the patient.

Somatoform Dissociation: Phenomena, Measurement, and Theoretical Issues by Ellert R. S. Nijenhuis (W. W. Norton & Company) The first comprehensive theory of somatoform dissociation. Expanding the definition of dissociation in psychiatry, Ellert R. S. Nijenhuis presents a summary of the somatoform components of dissociation—how sensory and motor functions are affected by dissociative disorders. Founded in the current view of mind-body integration, this book is essential reading for all mental health professionals engaged in the diagnosis, treatment, and study of dissociative disorders, PTSD, and other trauma-related psychiatric disorders.

Excerpt: Several objectives will be pursued. A primary goal is the development of a self-report questionnaire aiming to measure somatoform dissociative phenomena, the Somatoform Dissociation Questionnaire, SDQ. If Charcot (1887) and Janet (1893) were correct in their opinion that particular psychological and somatoform dissociative phenomena are characteristic of hysteria, then contemporary cases should also display them.

Several self-report questionnaires and interview schedules intending to measure psychological dissociation have recently been developed. The two best studied questionnaires are the Dissociative Experiences Scale, DES (Bernstein & Putnam, 1986) and the Dissociation Questionnaire, DIS-Q (Vanderlinden, Van Dyck, Vandereycken, & Vertommen, 1993). These instruments contain sub-scales that also constitute the main areas of investigation of the Structured Clinical Interview for DSM-III-R/-IV Dissociative Disorders, SCID-D (Steinberg, Cichetti, Buchanan, Hall, & Rounsaville, 1993): dissociative amnesia, depersonalization, derealization, identity confusion and identity fragmentation.

If the presence of a range of somatoform dissociative phenomena would likewise be characteristic of dissociative disorder patients, then it might be feasible to develop a somatoform dissociation questionnaire measuring the construct of somatoform dissociation using these patients. Beginning with 19th century clinical material and moving up to contemporary clinical observations of somatoform dissociative phenomena, it would be possible to study which – if any – of these symptoms are particularly characteristic of dissociative disorder patients, as well as discriminative between these patients and those with other psychiatric disorders.

It would also be possible to study whether a subset of the items of this questionnaire might serve as a screening instrument for the assessment of dissocia­tive disorder. Such a clinical tool might have certain advantages. Psychiatric patients generally seem more inclined to admit to somatoform symptoms than to psychological ones, which may delay rapid and proper assessment of their true condition. It apparently is the rule, rather than the exception, that they initially present themselves with somatoform symptoms in primary care (Brad-low, Coulter & Brooks, 1992; Bridges & Goldberg, 1985; Craig, Boardman, Mills, Daly Jones, & Drake, 1993). While in some cases the somatic complaints evidently are part of the clinical manifestation of a psychiatric disorder, such as an affective or an anxiety disorder (Kellner, 1992), in others the nature of the

symptoms remains unidentified (Kroenke, Arrington, & Mangelsdorff, 1990). Some psychiatric patients may be falsely suspected of malingering or presenting with a factitious disorder. Others erroneously are thought to suffer from physical disease. It has been reported that such was the case in 40% to 60% of patients with some type of somatoform psychiatric disorder (Ford & Folks, 1985; Goodyer, 1981; Lazare, 1981). Cases with unexplained somatic symptoms are frequent in general hospital outpatient clinics (Kellner, 1991; Kroenke et al., 1990; Mayou, 1993) and pain clinics (Keefe, Dinsmore, & Burnett, 1992). There are indications that a relatively small group uses disproportionate and very considerable amounts of consultations, laboratory investigations, costly surgical procedures and other forms of hospital care over long periods of time.

As many dissociative patients report, they (initially) seek frequent somatic care, and often reveal that they, their physicians, and medical specialists could not explain the varied and "strange" symptoms that come and go for seemingly inexplicable reasons. Boon and Draijer (1993) found that the patients with dissociative identity disorder (DID) they studied had received an average of 2.8 different diagnoses before being diagnosed as having DID, 37% received a neurological diagnosis in an earlier stage, and 82.9% reported a history of recurrent somatic complaints. Dissociative patients may also display denial of psychological dissociative phenomena (Putnam, 1989). Some fear being assessed as psychotic. Others are afraid of being disbelieved, ridiculed, or involuntary institutionalized (Cohen, Giller, & W., 1991).

In these instances, cases may not be detected by instruments that are designed to assess psychological dissociation, such as the DES and DIS-Q. It might prove true that these patients are more willing to acknowledge somatoform dissociative symptoms. Also, it could be that combined scores on psychological and somatoform dissociation questionnaires better predict caseness than do these scales separately. Finally, the development of instruments measuring psychological dissociation has resulted in increasing acknowledgement and recognition of the existence of dissociative phenomena and the dissociative disorders. This effect could perhaps also emerge with respect to somatoform dissociation in quarters of primary and secondary care.

 

Part I (Chapters II to VII) concerns the development and psychometric charac­teristics of two versions of the Somatoform Dissociation Questionnaire. Chapter II highlights a range of somatoform dissociative phenomena as encountered in 19th century patients with hysteria, and focuses on what Janet observed to be the markers of hysteria: mental stigmata and mental accidents. As hysteria promi­nently encompassed the current dissociative disorders, it was logical to study whether somatoform dissociative symptoms would also be prominent in a con-temporary patient with DID. These and similar clinical observations inspired the formulation of a large pool of items that constituted the initial version of the SDQ.

Chapter III provides data on the relative prevalence of each of these somatoform phenomena with dissociative patients and psychiatric patients with other

DSM-IV diagnoses. More essentially, it describes the development and psychometric characteristics of the SDQ-20, a self-reporting questionnaire designed to measure the construct of somatoform dissociation. If dissociative disorders indeed affect the whole organism, as 19th century French pioneers such as Briquet and Janet claimed, then concomitant presence of somatoform and psychological dissociative symptoms should be found. To evaluate this hypothesis, the concurrence is analyzed between both phenomenological areas, as measured by the DIS-Q and the SDQ-20.

In this study, as well as in the studies on somatoform dissociation described in other chapters of this book, the SCID-D (Steinberg, 1993; Steinberg et al., 1993) is used as the "golden standard" to assess DSM-IV dissociative disorders (APA, 1994). As the SCID-D is unlikely to be a perfect instrument, some false positives and false negatives could be selected. In some cases it can be difficult to disentangle factitious dissociative disorder and cases of malingering from true dissociative disorder, or to diagnose dissociative disorder when the patient is denying his or her dissociative symptoms (Boon & Draijer, 1995). However, based on the excellent reliability and validity of the SCID-D, we assume that in the vast majority of cases, careful use of this instrument yields true positives and true negatives.

Beginning with the SDQ-20, an analysis is performed to determine whether a subset of items optimally predicted caseness of dissociative disorder. The development and psychometric characteristics of the resulting dissociative disorder screening instrument, the SDQ-5, are presented in chapter IV. Chapter V presents an SDQ-20 and SDQ-5 cross-validation study.

In Chapter VI the severity of somatoform dissociation in various diagnostic groups is examined. Amongst others, it involves a test of the hypothesis that among patients with DSM-IV somatoform disorders, which include somatization disorder and conversion disorder, somatoform dissociation is a prominent symptom. Some critics have argued that dissociation instruments do not assess severity of dissociation, but rather severity of general psychopathology. In order to assess whether this criticism applies to the SDQ-20, Chapter VI presents an assessment of whether this instrument discriminates between various DSM-IV diagnostic categories over and above differences in general psychoneuroticism. This chapter essentially involves assessment of the criterion-related and discrimi­native validity of the SDQ-20. In addition, this study includes an assessment of the proportions of patients from these various groups which obtain SDQ-5 and DES scores exceeding the cutoff values of these scales in the screening for dissociative disorders.

Chapter VII is dedicated to the hypothesis of Merskey (1992) that dissociative disorders are actually misdiagnosed bipolar mood disorders, or bipolar disorder iatrogenetically shaped to present as "dissociative disorder." The chapter includes two letters of ours to the Editor of the British Journal of Psychiatry, and describes Merskey's response to our first letter.

 

Several theories of dissociation state that in many cases dissociation is induced by exposure to traumatic events, and represents a way of coping with over-

whelming events which may have certain advantages when threat is ongoing, but which, in the longer run, may become a pathological adaptation. Part II (Chapters VIII to XI) is dedicated to the theme of trauma, (somatoform) dissociation, and defense. Chapter VIII focuses on the hypothesized relationship of self-reported trauma with somatoform and psychological dissociation, and involves patients with dissociative disorders and patients with other DSM-IV diagnoses.

There is evidence suggesting that dissociation involves extreme state-depen­dency (Putnam, 1997) and that traumatic events exert harmful and disintegrating influences relative to their intensity, duration, repetition (Draijer & Boon, 1993; Janet, 1909), as well as the age of the victim at onset (Boon & Draijer, 1993). Extreme state-dependency is also characteristic of animal defense to predatory threat and injury. This defensive system consists of a series of discrete substates which are tuned to meet various stages of predatory imminence and injury. Starting from these observations, in chapter IX a model is presented which maintains severe and chronic childhood trauma, in particular, may induce basic, evolutionary developed, defensive substates which are adapted to meet particular stages of threat and attack. In this view, particular somatoform dissociative state-dependent responses would be similar to animal defensive state-dependent responses. In Chapter X several hypotheses derived from this model are empirically evaluated.

One of the SDQ-20 items evaluates (medically unexplained) genital pain occurring apart from sexual intercourse. In some cases, this pain may relate to (sexual) trauma, and possibly to presence of dissociative disorder as well. Since a substantial number of psychiatric patients first present for medical care with somatic symptoms (see above), it seemed worthwhile to study to what extent patients presenting in a gynecology outpatient department of a general hospital with chronic pelvic pain report somatoform and psychological dissociative phenomena, and trauma. It also seemed important to investigate to ability of the SDQ-5 to select cases of dissociative disorder among this population. This study is the subject matter of Chapter XI. 

Chapter XII provides a summary, discussion and indications for future research. The appendices present the English and Dutch versions of the SDQ-20, the SDQ-5, and the Traumatic Experiences Checklist (TEC; Nijenhuis, Van der Hart & Vanderlinden, 1994). A Dutch version of chapter XII is included as well.

 

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