Dsm V: Dissociative Subtype Of Ptsd?

[milbert]

I've been reading up on the DSM V revisions to PTSD, especially about the inclusion of a dissociative subtype of PTSD. I'm wondering what other people think of this? Do you identify with either an hyperarousal/intrusive or dissociative form of PTSD? Do you think changes to the DSM could help improve treatment of PTSD?

Here are a few quotes from one short article ([DLMURL]http://ajp.psychiatryonline.org/article.aspx?articleid=102343[/DLMURL]), although there are many others on this topic:

"Lanius et al. describe a form of PTSD that is primarily characterized by symptoms of dissociation in the wake of prolonged traumatic experiences (e.g., chronic childhood trauma or combat experiences) that primarily manifest as chronic numbing. This is in contrast to prominent symptoms of intrusion and hyperarousal in response to acute trauma. [...] Functional MRI studies have shown opposite responses in brain activity between these two groups in the medial prefrontal cortex, the anterior cingulate cortex, and the limbic system."

"Finally, Lanius et al.'s identification of the dissociative subtype of PTSD may offer a rational explanation for one of the major controversies in the field of trauma psychiatry. Many of the empirically based studies that examine clinical treatment of PTSD show that exposure therapy is an effective treatment. That is, treatments that use deliberate reexposure to trauma-related stimuli (e.g., trauma scripts) are thought to result in desensitization of the trauma response and to aid in integration of the traumatic events into ordinary experience. Lanius et al. note that some authors have speculated that overmodulated responses to trauma-related stimuli may prevent the necessary full engagement in exposure. However, there may also be a protective function for the dissociation of memories, affect, and meaning for persons with chronic traumatization. Bypassing this protective function may result in persons becoming overwhelmed by reliving the trauma and finding that once again that they cannot tolerate, make sense of, or cope with their experiences. Persons with complex PTSD seem to respond better to the phase-oriented treatments that were developed in the 1990s ([DLMURL="http://ajp.psychiatryonline.org/article.aspx?articleid=102343#ajp0310r8"]8[/DLMURL], [DLMURL="http://ajp.psychiatryonline.org/article.aspx?articleid=102343#ajp0310r9"]9[/DLMURL]), which focus on building better functioning in multiple domains prior to grappling directly with traumatic memories. The differences between the subtypes of PTSD may well account for the variations seen in disparate traumatized populations."

 

[Phoenix_Rising]

I haven't read the latest DMV but I will say that from the description there, both intrusive/hyperarousal and dissociative PTSD describe me perfectly.

It's pretty difficult for me to get into any traumas or therapy related to them (though I still believe I derived benefit from them) due to that overwhelm, and my tendency to dissociate when faced with anything triggering. My new T is the only one who has ever been able to help me to experience without becoming overwhelmed (though I do dissociate there as well at times) and she helps me to be grounded and bring my arousal level down too, which helps. I have only recently begun to realize how much I was dissociating just from not existing in and being aware of my own body. And I have far more dissociation than that.

But as a result, this is helping me more than anything has in a long time. Though I find it a lot harder to cope when I am not with her, during an appointment. So that is hard.

But before this I would know I was triggered but I couldn't tell you any more than that. I couldn't identify or experience emotions or what was going on in my body, other than that a lot was going on, and I knew what it felt like when I was triggered, so I'd be able to identify it that way. Or if it was a significant enough one, I'd dissociate even more than that, and I would know due to the severity of the dissociation.

So I think that yes, it does effect therapy and recovery, and make it harder to resolve and also take longer. And I think it is true about needing to develop "better functioning in multiple domains" as they put it, before engaging in trauma therapy--even then it is still difficult to remain present, and not get overwhelmed.

Phoenix_Rising

 

[maddog]

This is a most interesting line of thought and consideration for me.

Up until recently, I would definitely characterise my sub-type as the dissociative one, if we choose to distinguish the two for the sake of this discussion. Pervasive numbness and emotionlessness, together with accessibel yet almost entirely ignored/closed off, memories of my chronic childhood trauma, were the framework around which my entire functioning was built.

And then suddenly, as in over the past few months, it's as though that entire framework has turned on its head and instead been replaced with the intrusiveness/hyperarousal subtype. While the numbness and dissociation still reemerge at random intervals, they are now the exception and not the rule.

Odd and perplexing to consider that while my prior state was consistent with the so-called typical manifestation of complex childhood trauma, it's as though the trauma has suddenly taken on an acute quality (in terms of how I am living and reexperiencing it), coinciding with the domination of the subtype more associated with acute trauma.

Sorry... um, did that sentence make sense? Geez, I wonder which subtype is characterised by cognitive and intellectual impairment and scrambulation!!!

I also find it interesting that the suggestion is that the hard core intensive exposure therapies are less suitable for the chronic trauma sufferer, or at least that they require considerable prior work in improving other domains of functioning. This actually fits almost exactly with my own experience. T and I dived into imaginal exposure therapy fairly soon after I had begun the first disclosures of my traumas and while the symptom pattern was still very much unfolding. I found the process to be awkward, highly distressing (and not in a healthy way), impossible to engage with and ultimately of little to no value.

In hindsight, we both realised we'd gone there too soon and without having addressed a number of other day-to-day life functioning issues, with the result that it was almost a year later before we returned to the imaginal exposure, this time with much more impactful results. I am choosing to believe that the long term outcome will be a positive one, though in truth I think I'm still too submerged in the process to be able to assess the outcomes at this stage.

But I say all of that to say that the intensive exposure therapies are certainly not the first port of call for a chronic trauma situation in my own personal experience, and perhaps due to the infinite number of trauma events and the complex interplay of developmental and personality variables and factors that both influence and are influenced by chronic childhood trauma, it may always be questionable as to whether or not the full benefits of an approach such as imaginal exposure can be realised in the case of chronic trauma.

Or perhaps I should just stop trying to articulate myself until I'm a bit more coherent...

Maddog

 

[sea]

This makes like no sense diagnostically like, at all. Everybody "relates to both" because both sets of symptoms are pretty much...PTSD. You can be PTSD within a normal range of dissociation or you can be PTSD and dissociative disorder which are already in the DSM? .......... wat?

When they talk about the therapy module for "dissociative PTSD" (lol like WTF??? It makes like NO sense, lmao) they're basically just talking about the therapy module for complex trauma lol you make sure the patient is stable before going into intensey stuff. IDK it just sounds really like extraneous and irrelevant diagnostically to me.

 

[Meadowsweet]

In terms of finding the best treatment, in the UK we have NICE (National Institute for Clinical Excellence) guidelines. These note that more than one disorder may be diagnosed. They go on to define certain disorders that need to be brought under control before trauma therapy can begin and other disorders that may improve with trauma related therapy. It seems more logical to highlight additional disorders, as this allows the combination to alter over time and the treatment to be adjusted accordingly. If a person is diagnosed with a sub-division of a disorder, it could cause confusion if their significant symptoms change. .

From a personal perspective, I spent some years completely emotionless and lived a normal (cold and numb) life undiagnosed. Now I experience dissociation and hyperarousal. For a long time hyperarousal was the dominant feature, because I was in a lot of denial and minimalised my experiences, and believed more strongly that my fear was of something about to happen. As I've removed myself from situations where I feel in danger, there is less stimulus for hyperarousal. But, the diagnosis of PTSD brings forth the reality that my worst fears have already happened, I've failed to stop them - the difficulty in accepting that, or the sudden realisations of facts brings about much more noticable dissociative symptoms.

 

[markymark]

Being fairly newly diagnosed with both PTSD and DID I can only comment on observations from my therapy and psychiratrist sessions.

It seems they are treating my wild mood swings (successfully) with medication and talk therapy (with the help of my wife) to identify the several alters I have been living with. Some alters are young and child-like, some are old and wise, and some are flat out reckless.

All I know so far is that I have been out of control most of my life. Moving my family 21 times in 20 years often not even realizing it until we were moved in. Definitely paranoia. These alters seem to hold the complete memories of the stressors I experienced. I have been able to recall in the last week detailed images of one event and it horrified me. I am guarded and alert more than ever before. It's a 3 D movie playing over and over in my mind.

I've learned these alters I have created are just coping mechanisms and probably has saved my life. Most of the time, while Under duress or stress, the alter most equipped to deal with it is the one who steps in. I rarely have any recall of the switch.

I'm only new at learning new ways to be aware of this and ultimately learnt to be me.

 

[Abrasky]

I think it is helpful to identify dissacotiative forms of PTSD. Then they can help target treatment better to individuals. I know exposure therapy and putting myself in situations where I was triggered only 'flooded' me and made my symptoms worse. I was on a high dose antideppressants when I needed them. It was better just admit when treatment is not working so I could get on with finding a treatment that did work. Getting memories back. Do what works not what the doctors think is popular. I just stopped triggering myself too much and got real treatment, now 13 years later I'm not frightened of going outside at all and have friends and haven't needed to take antideppressants for 4 years.
I also have wild mood swings, and they have become really wild while getting out the core memories of the trauma that caused it in the first place. About 22-36 alter personality moods. Other people see them as moods, but my psychologist recognised them as personality moods, it's a very strong level of dissacotiation like spacing out a lot.
My personalities also contain the memories of the trauma's I experienced. The personalities disappear when all the memories and emotional pain they hold reintergrate into my real personality. When I'm at the end, I have flooding, where everything floods at once. Personality flooding of 22 personalities and their memories is quite an experience, and if I never experience it again I will be quite happy!
My psychologist said the 22 personalities 'flooding' is a very horrible experiences. It was the worst thing I have been through in 13 years of councelling. She said it was all the memories coming from the long term memory into the short term memory. It would take years to keep those memories there and store them right to stop the flooding.

 

[anthony]

That is 2010 information, which in the scheme of the DSM V, is outdated already.

The criterion for PTSD and trauma sub-types have changed radically since that article, for example, they took several diagnoses out of anxiety related category and created a new category for trauma and stressor disorders... being PTSD's new home. They have changed the criterion several times now... and I still believe it will change slightly still before final release.

 

[markymark]

One of my alters has revealed itself to be one of my past survival instructors when I was in military training. He goes by the name Sidney Baker. Often, I go for a 8 to 10 mile walk and don't know I do it until my wife send out the search party and they shake me out of it. What is remarkable is I'm not in the best of physical shape and still able to hike long distances at my age of 44.

I've had to install a gps permanent locator on my car because often I get in the car and end up somewhere I don't recognize. I've lost my car several times, often finding it miles away of where I ended up on foot. It's embarrassing especially when I arrive to work late because of is and make up some lame excuse why I'm late. I can't tell my supervisors this!

I'm desperate for answers from theses alters and know they hold certain memories I need to recall to heal. I'm horrified when they write in my journal with handwriting not mine, or words and sentence structures I would never use.

 

[markymark]

I was terrified to take any from of medication due to the pills and vaccinations I received and how they made me feel. But finally I agreed to take medication. It's no magic bullet, but I'm able to sit through therapy now without jumping through my skin. Always thought medication was just a sign of weekness through the eyes my "hardened self" shell I created. It has helped me become a more tolerable person, but I pray I don't have to take this medication for ever.

 

[Srain]

Just starting with my tdoc I could never have started exposure therapy while still highly depersonalized or dissociated, something in me would have snapped and I would have gotten up and walked out. It's a matter of trust.

I imagine it stems from the last therapist I had for any great length of time that allowed to "expose me" only this ended being the den of lions and let them eat me while I dissociated myself into oblivion. Trust is a huge issue.

 

[sea]

It would be like saying you need to diagnose a "Bronchitis" subtype of the common cold just because coughing is a symptom of both bronchitis and the cold. Dissociation is a symptom of PTSD. It's also a disorder in and of itself. Just like chronic cough and coughing are two different things. When the dissociative symptoms are markedly increased from the average dissociative symptoms of PTSD, dissociative disorder is diagnosed. There is no dissociative PTSD. The idea is completely erroneous. You either dissociate normally as a result of trauma which is an inherent part of the diagnosis of PTSD, or, you have a dissociative disorder.