Learning Objectives
- Clarify why treatment for dissociative disorders is limited.
- Describe treatment options for dissociative identity disorder.
- Describe treatment options for dissociative amnesia.
- Describe treatment options for depersonalization/derealization disorder.
Treatment for dissociative disorders is limited for a few reasons. First, with respect to dissociative amnesia, many individuals recover on their own without any intervention. Occasionally treatment is sought out after recovery due to the traumatic nature of memory loss. Second, the rarity of these disorders has offered limited opportunities for research on both the development and effectiveness of treatment methods. Due to the differences between dissociative disorders, treatment options will be discussed specific to each disorder.
Dissociative Identity Disorder
The ultimate treatment goal for dissociative identity disorder is the integration of subpersonalities to the point of final fusion (Chu et al., 2011). Integration refers to the ongoing process of merging subpersonalities into one personality. Psychoeducation is paramount for integration, as the individual must understand their disorder, as well as acknowledge their subpersonalities. As mentioned above, many individuals have a one-way amnesic relationship with the subpersonalities, meaning they are not aware of one another. Therefore, the clinician must first make the individual aware of the various subpersonalities that present across different situations.
Achieving integration requires several steps. First, the clinician needs to build a relationship and strong rapport with the primary personality. From there, the clinician can begin to encourage communication and coordination between the subpersonalities gradually. Making the subpersonalities aware of one another, as well as addressing their conflicts, is an essential component of the integration of subpersonalities, and the core of dissociative identity disorder treatment (Chu et al., 2011).
Once the individual is aware of their personalities, treatment can continue with the goal of fusion. Fusion occurs when two or more alternate identities join (Chu et al., 2011). When this happens, there is a complete loss of separateness. Depending on the number of subpersonalities, this process can take quite a while. Once all subpersonalities are fused and the individual identifies themselves as one unified self, it is believed the patient has reached final fusion.
It should be noted that final fusion is difficult to obtain. As you can imagine, some patients do not find final fusion a desirable outcome, particularly those with harrowing histories; chronic, severe stressors; advanced age; and comorbid medical and psychiatric disorders, to name a few. For individuals where final fusion is not the treatment goal, the clinician may work toward resolution or sufficient integration and coordination of subpersonalities that allows the individual to function independently (Chu et al., 2011). Unfortunately, individuals that do not achieve final fusion are at greater risk for relapse of symptoms, particularly those with whose dissociative identity disorder appears to stem from traumatic experiences.
Once an individual reaches final fusion, ongoing treatment is essential to maintain this status. In general, treatment focuses on social and positive coping skills. These skills are particularly helpful for individuals with a history of traumatic events, as it can help them process these events, as well as help prevent future relapses.
Dissociative Amnesia
As previously mentioned, many individuals regain memory without the need for treatment; however, there is a small population that does require additional treatment. While there is no evidenced-based treatment for dissociative amnesia, both hypnosis and phasic therapy have been shown to produce some positive effects in patients with dissociative amnesia.
6.5.2.1. Hypnosis. One theory of dissociative amnesia is that it is a form of self-hypnosis and that individuals hypnotize themselves to forget information or events that are unpleasant (Dell, 2010). Because of this theory, one type of treatment that has routinely been implemented for individuals with dissociative amnesia is hypnosis. Through hypnosis, the clinician can help the individual contain, modulate, and reduce the intensity of the amnesia symptoms, thus allowing them to process the traumatic or unpleasant events underlying the amnesia episode (Maldonadao & Spiegel, 2014). To do this, the clinician will encourage the patient to think of memories just before the amnesic episode as though it was the present time. The clinician will then slowly walk them through the events during the amnesic period to reorient the individual to experience these events. This technique is essentially a way to encourage a controlled recall of dissociated memories, something that is particularly helpful when the memories include traumatic experiences (Maldonadao & Spiegel, 2014).
Another form of “hypnosis” is the use of barbiturates, also known as “truth serums,” to help relax the individual and free their inhibitions. Although not always effective, the theory is that these drugs reduce the anxiety surrounding the unpleasant events enough to allow the individual to recall and process these memories in a safe environment (Ahern et al., 2000).
Depersonalization/Derealization Disorder
Depersonalization/derealization disorder symptoms generally occur for an extensive period before the individual seeks out treatment. Because of this, there is some evidence to support that the diagnosis alone is effective in reducing symptom intensity, as it also relieves the individual’s anxiety surrounding the baffling nature of the symptoms (Medford, Sierra, Baker, & David, 2005).
Due to the high comorbidity of depersonalization/derealization disorder with anxiety and depression, the goal of treatment is often alleviating these secondary mental health symptoms related to the depersonalization/derealization symptoms. While there has been some evidence to suggest treatment with an SSRI is effective in improving mood, the evidence for a combined treatment method of psychopharmacological and psychological treatment is even more compelling (Medford, Sierra, Baker, & David, 2005). The psychological treatment of preference is cognitive-behavioral therapy as it addresses the negative attributions and appraisals contributing to the depersonalization/derealization symptoms (Medford, Sierra, Baker, & David, 2005). By challenging these catastrophic attributions in response to stressful situations, the individual can reduce overall anxiety levels, which consequently reduces depersonalization/ derealization symptoms.
Key Takeaways
You should have learned the following in this section:
- Treatment for dissociative identity disorder involves the integration of subpersonalities to the point of final fusion and takes several steps to achieve.
- For some patients, this is not possible as they do not find final fusion to be a desirable outcome.
- Instead, the clinician will work to achieve resolution or sufficient integration and coordination of the subpersonalities to allow the person to function independently.
- For dissociative amnesia, hypnosis and phasic therapy are used, as well as barbiturates known as “truth serums.”
- Finally, diagnosis alone is sometimes enough to reduce the intensity of symptoms related to depersonalization/derealization disorder and due to the high comorbidity with anxiety and depression, alleviation of these secondary symptoms is often the goal of treatment.
Review Questions
- What is the treatment goal for dissociative identity disorder? How is it achieved?
- What are the treatment options for dissociative amnesia and depersonalization/depersonalization disorder?
Module Recap
In this module, we discussed the dissociative disorders of Dissociative Identity Disorder, Dissociative Amnesia, and Depersonalization/Derealization Disorder in terms of their clinical presentation, epidemiology, comorbidity, etiology, and treatment approaches.
