Virginia Claudia Neacşu
Clinical Psychologist, C.M.D.T.A.
Abstract
We described a clinical case presenting with dissociative and PTSD-like symptoms and we attempted a diagnosis and some symptom explanations in the light of existing theories about trauma and dissociation.
Keywords: dissociation, posttraumatic stress syndrome, trauma theory
Theoretical Consideration concerning Trauma and Dissociation
DSM-IV defines dissociation as “…a disruption in the usually integrated functions of consciousness, memory, or perception of the environment” (DSM-IV, p. 693). DSM-IV-TR defines dissociation as “the splitting off of clusters of mental contents from conscious awareness, a mechanism central to hysterical conversion and dissociative disorders; the separation of an idea from its emotional significance and affect as seen in the inappropriate affect of schizophrenic patients”.
Cardeña (1994) has identified three broad categories of dissociation:
(1) Dissociation as non-integrated mental modules or systems.
(2) Dissociation as an alteration in consciousness involving a disconnection from the self or the world.
(3) Dissociation as a defense mechanism.
For Cardeña, true category 1 dissociative phenomena (such as dissociative amnesia and the conversion disorders) “are characterized by an apparent dysfunction in perception, memory, or action that a) cannot be reversed by an act of will; (b) occurs in the presence of preserved functioning of the apparently disrupted system; and (c) is reversible, at least in principle”. In contrast, “category 2 dissociation essentially encompasses depersonalization and derealization. The third category of dissociation refers more to the function of categories 1 and 2”.
Brown, distinguishes between Type 1 dissociation—encompassing Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder (DID), and the Conversion Disorders—and Type 2 dissociation, encompassing depersonalization/derealisation, peri-traumatic dissociation and out-of body experiences. Type 2 dissociation is described as “an altered state of consciousness characterized by a sense of separation (or detachment) from certain aspects of everyday experience, be it their body (as in out-of-body experiences), their sense of self (as in depersonalization), or the external world (as in derealization)”. (Holmes, 2005)
The concept of compartmentalization incorporates Cardeña’s (1994) category 1 and Brown’s type 1 dissociation. All compartmentalization phenomena are characterized by a deficit in the ability to deliberately control processes or actions that would normally be amenable to such control (Brown, 2004; Cardeña, 1994, cit in Holmes, 2005). The compartmentalized processes continue to operate normally (apart from their inaccessibility to volitional control), and are able to influence ongoing emotion, cognition and action. This definition incorporates conditions characterized by an inability to bring normally accessible information into conscious awareness (e.g. dissociative amnesia), which can also be regarded as a control problem.
PTSD subjects are considered to suffer from both types of dissociation, that is both detachment and compartmentalization. (Brewin, 2003; Foa, Molnar and Cashman, 1995 cit.in Holmes, 2005).
Donald Meichenbaum stated four groups of risk factors, which predict who will develop PTSD after experiencing a negative event. The first category encompasses stimulus characteristics-intensity, duration and its proximity to the subject (to experience/to witness or hear about the event). A second category includes the response characteristics: its nature (anxiety, terror, dissociation) and the temporal distance between the occurrence of the event and the onset of the pathological symptoms- the longer it takes for the symptoms to occur, after the event, the higher the likelihood of developing PTSD. The likelihood for PTSD also increases if, along with the specific response, there are comorbid features: anxiety, depression, suicidal ideation and irritability. The third risk factor are premorbid features in terms of socialization patterns, especially intergenerational victimization-if the parents have also been victimized, the child is more likely to develop PTSD. The forth, often overlooked risk factor is the reinsertion environment after the negative event, a supportive/non-supportive environment. (Meichenbaum, Volpe, 1998)
L. Terr (1991) described two types of traumatic events. Events that are abrupt, short-term (a few minutes and as long as a few hours) can be referred to as Type I traumatic events. This category encompasses natural and accidental disasters and deliberately caused human-made disasters (rape, robbery, severe physical abuse). Type II trauma represents the ongoing or repeated exposure to traumatic events (chronic victimization by child sexual abuse, domestic violence). “Research indicates that… individuals who directly or vicariously experience such events show similar profiles of psychopathology including chronic PTSD”. (Volpe, 1996)
Case Description
Patient L.P., 20 years of age, college student, presented to a psychiatric consultation in December 2007, and to the psychological service two weeks later. The main complaints were dissociative crises, during which she travels various places outside her apartment, apparently in an attempt to escape being hit or hurt in some way. She preserves consciousness for her identity and chronological age, but her behavior and verbal expression are extremely regressed: she uses numerous diminutives, she designates herself by the nickname, and she is temporally and spatially disoriented- behaving as if her dead grandmother were still alive and waiting for her. The episodes last 30 minutes to about one hour. In the past, during some of these episodes, she manifested self-harming behavior and her mood varied from one episode to another–intense fear/sadness/irritability/numbness. Outside the episodes she had a sad mood, diminished interest for previous enjoyed activities and anergia. She declared previous suicidal ideation, which she communicated to some members of her family, but did not proceed with her intention. As the psychiatric and psychological interview revealed, she had no delirious ideation, hallucinations, inter-episodic disorganized behavior or negative symptoms.
She has never used drugs and is less than a regular alcohol consumer. She declares having suffered a single head trauma, when her stepfather pushed her and she hit her head falling. She didn’t lost consciousness then and clearly remembers that event. Neurological examination revealed no pathological changes in the EEG and CT didn’t evidentiate any structural cerebral modifications.
Case History
The dissociative episodes were first noticed, most probably, by her boyfriend the summer of 2006 and, they may have been present before 2006, she or her father/boyfriend can’t state the exact date of onset. Apparently her mother noticed some moments of “spacing out” but they were not as dramatic as the present complaints. In November 2004 she witnesses her grandmother’s having a stroke (VCA) and becoming comatose, she tried to save her, giving her HTN medication and tried to call several ambulances. Eventually, after three days hospitalization, her grandmother died. She remembers clearly the facts and her emotional states during those moments. Around her baccalaureat examinations period, her mood became constantly depressed, she was anhedonic and easily fatigued. The symptoms accentuated gradually until she passed her faculty exams. Between the two examinations, she studied continuously. She applied and took an examination for six faculties.
The patient’s biological parents divorced when she was 4. They each remarried and she has four stepsisters, two from each parent’s new family. At the moment, she lives with her boyfriend in her grandmother’s house. She has been trusted in her mothers care and lived with her and her stepfather until recently. He was an excessive drinker and physically abused her mother; sometimes she would hit him back. The patient has also been hurt several times when she tried to defend her mother. She asked the patient to introduce her stepfather as her biological parent in social circumstances and motivated the preserving of the abusive relationship as an attempt to offer the patient the benefits of a complete family and of her stepfather’s financial status. The patient describer her mother as prone to emotional outbursts and domineering.
During the first two weeks since referral, the dissociative episodes occurred every other day, then daily to decrease in frequency at the end of the third week, after she was administrated Eglonyl. Her mood already improved within the first two weeks since referral, after receiving Carbamazepine and Prozac. Her anxious disposition and exaggerated startle response to minor stimuli non-trauma associated persist, she declares a decrease in memory and attention performance, reflected in her grades level and intrusive memories of her grandmother death. At the beginning of the third week, the results on the (RAVLT), Rey Auditory Verbal Learning Test, were within normal limits, for the II to VI series, with a slight deficiency on the performance after the first presentation. She was also able to successfully finish one of her academic projects, which she worried she wouldn’t realize if the crises continued.
She has an intense reaction to stimuli associated with the trauma (ambulance sound)- self-blame, helplessness, numbness and/or severe anxiety and dispneea, and avoids them. Apart from the anxious disposition and general heightened reactivity, the intense psychological and physiological reaction is selective-it appears only at the ambulance sound, but not at the sound of fire engine or police sirens. During the dissociative states, she phones her father or her boyfriend, towards whom she has a remarkable affective dependency.
Diagnosis and Assessment
For orientative purposes we evaluated the patient with IES (Impact of Event Scale, Horowitz et al., 1979). Instead of describing the worst event experienced the week prior to psychological assessment, she was instructed to complete the scale relating her response choices to the most stressful event she has experienced until the assessment. She cited two such events: the moments spent in the ambulance, trying to get her grandmother to the hospital in time and one of the numerous physical conflicts between her mother and stepfather which she witnessed and during which her mother’s life was endangered. The evaluation yielded a total score of 34 points, with 17 points for each of the two subscales-avoidance and intrusion. There are no Romanian norms for the scale, but studies suggest a 26 total score as a cutoff, above which a moderate or severe impact is indicated. The 1979 version of IES doesn’t evaluate the hyper arousal dimension of PTSD. The stroke her grandmother suffered and the moments until receiving adequate care were experienced with fear and helplessness. She witnessed the cited conflict with fear, anger and helplessness. The resulting symptoms interfere with her daily functioning and have imparing effects on her short and long-term plans, as she listed them. We can presume the presence of PTSD symptoms on axis I, chronic, possibly with delayed onset. She does meet the A and B criteria for PTSD, but only 2 symptoms from the B and form the C PTSD criteria.
Differential diagnosis: Dissociative amnesia- she does have multiple episodes of inability to recall important personal information, usually of a stressful nature, too extensive to be explained by ordinary forgetfulness. (e.g. arguments with her boyfriend). However, she also qualifies for PTSD criteria.
Dissociative fugue, dissociative identity disorder- although in some of the dissociative states she attempts to leave her apartment; she preserves awareness about her identity and age and does not assume another identity. She displays immature verbal expression and interests both during and outside the dissociative states-her clothing and accessories are typical for a teenager, she sleeps with a stuffed animal and she uses diminutives to designate herself and her significant others. During the dissociative crises she is able to perform simple arithmetics and does not give approximate answers, as in Ganser’s syndrome.
Concerning axis II conditions, we signal some type B cluster personality traits: a pervasive and early pattern of: a)frantic efforts to avoid real or imagined abandonment (e.g. she reacts with intense distress when she is refused help and has difficulties in tolerating her boyfriend’s absence during the day, when they both attend faculty courses); b) recurrent suicidal threats (outside the dissociative episodes); c) discomfort in situations in which she is not the center of attention; d) the requirement of excessive admiration and expectations of favorable treatment or automatic compliance with her demands.
Differential diagnosis: Dependent personality disorder –the patient firmly promotes her decisions both current and important, to members of her family and other authority figures (teachers/trainers), and when she perceives a lack of instrumental support, she actively (and angrily) demands it, although she is aware of the possibility of a conflict. She feels able to adequately function in many areas and does not comply with demands that seem inconvenient to her in order to avoid support withdrawal.
Discussion
The dissociative states that the patient displayed qualify for Cardeña’s both first and second categories of dissociation. They manifest themselves as an apparent dysfunction in memory and action, they cannot be reversed by an act of will, and they occur in the presence of preserved functioning of the apparently disrupted system (memory) and are reversible. According to Brown, during this patient’s dissociative states, both compartmentalization and detachment are present. She is not able to deliberately control processes or actions that would normally be amenable to such control -actions and memory. She declares her real age (20), but fails to integrate this piece of information with the information concerning her grandmother death which occurred when the patient was 17. Usually, in this patient compartmentalization is present when the trigger is of an interpersonal nature. When the stimulus is an inanimate element of the traumatic situation (i.e. ambulance siren), the main type of dissociation is a kind of detachment (she concentrates on her inner’s anxiety experiences and is indifferent to other s attempts to initiate interaction). According to Terr’s theory, which stresses the type and duration of the traumatic events, one can say that the patient has been exposed both to type I and II trauma. Describing the traumatic events selected for the IES, she mentioned that, although she wanted to save her mother’s life, she felt embarrassed and unable to stand up against her stepfather, since, by doing so, she would have disobeyed her mother’s requests, which were to consider and respect him as her real father (in exchange of the financial advantages he would offer them). Therefore, the patient had to choose between two mutually exclusive rules, having a major impact on her disposition since they were stated by the same significant other: “You must help me, you owe it to me” and “You must respect your stepfather”. It might have been this contradiction which put her in a helplessness position. Also, not being able to help her grandmother get to the hospital sooner (while waiting for the ambulance to arrive, she tried to call a taxi, but didn’t have enough money available to pay for it) might have had the same effect on her.
According to Meichenbaum’s theory, the patient presents with at least three risk factors for PTSD: she both experienced the event (her grandmother’s CVA) and witnessed it (the physical conflict between her parents), she experienced them with intense anxiety, one of her parent was also subjected to victimization (continuous domestic abuse) and the reinsertion environment (after both negative events) was not supportive.
She declared that, until recently, she trusted her mother with all her problems and concerns (at her mother’s requests), but she realized that these were used as reasons to reproach, whenever her mother was upset and were attributed to deficiencies in her daughter character. The image she has about he mother is ambivalent-“I had an image about her as an irreproachable person. Now is a mixture of feelings- I care about her but I’m also afraid of her”.
It is possible that this inconsistency between her mother’s promises and her actual behavior might have caused the patient’s tendency to regard people as basically disloyal or dishonest. This tendency becomes transparent during some dissociative states, when she vacillates between relying on her boyfriend for protection and being afraid of him, both during the same episode. She was promised preferential treatment as a result of her stepfather’s status, instead she felt isolated by her peers. She revealed that she had an ally and confident in her grandmother who treated her well. The loss of this attachment figure might have had a significant impact on her and could account for the intrusive thoughts and images and, also, for the patient tendency to seek nurturance in her, during the dissociative episodes.
Since she showed am improvement in her daily functioning and a decrease in the intensity and frequency of the main presenting complains she remains under psychiatric care with periodical assessment recommendations and was referred to a trauma intervention trained psychotherapist.
References
Holmes E.A., Brown R.J., Mansell W., Fearon R.P., Hunter E.C.M., Frasquilho F., David Oakley, (2005). “Are there two qualitatively distinct forms of dissociation? A review and some clinical implications”, Clinical Psychology Review 25 (2005) 1–23, retrieved from http://www.ucl.ac.uk/hypnosis/articles/Holmes2005.pdf., (19.04.2007)
Meichenbaum D., Ph.D., Volpe J.S, (1998). “Trauma Response Profile”, http://www.aaets.org/article39.htm, retrieved 20.04.2007
Volpe J.S., (1996). “Effects of Domestic Violence on Children and Adolescents: An Overview” retrieved (26.03.2007) from http://www.aaets.org/article8.htm
2000, Manual de Diagnostic si Statistica a Tulburarilor Mentale, Ed. a patra, 1994 A.P.A.
2000, A.P.A. Diagnostic and statistical manual of mental disorders – fourth edition, text revision. Washington, DC: Author. retrieved (20.04.2007) from http://arts.monash.edu.au/behaviour/dissociation/whatisdiss.pdf
http://www.swin.edu.au/victims/resources/assessment/ptsd/ies.html
Biographical Note
Virginia Claudia Neacşu is a Clinical Psychologist, C.M.D.T.A. “Academician Ştefan Milcu”, Bucharest. She graduated from University of Bucharest, Faculty of Psychology and Education Sciences, MA Cognitive Behavioural Therapy and she currently practices psychotherapy under supervision – CBT – CT, being also trained in SFBT and narrative therapy.