Understanding Dissociative Disorders

A guide for family physicians and health care professionals

Marlene E Hunter

• Publisher: Crown House Publishing
• Year: 2009
• ISBN:
  9781845905804
• Topic: Psychologie
• Subtopic: Psychotherapeutische Beratung

Understanding Dissociative Disorders is for all physicians looking for ways to understand the idiosyncrasies of dissociative patients - their problematic ways of responding to medication, strange laboratory results and a multitude of physical and emotional symptoms. This book offers realistic, practical answers to questions you didn't even know to ask.

Chapter One

The “Thick-Chart” Patient

I was late getting to the office because of an emergency at the hospital, and the waiting room was full when I arrived. Generally my patients were pretty sanguine about waiting, because my receptionist would always explain the reason, but this day there was one glowering at me. Oh, no! I thought. Not her today! Mrs. J. was a frequent occupant of one of my waiting room chairs. She seemed to have an endless backlog of complaints, which usually started, “Oh, Doctor, last time I was here I forgot to mention …” and went on from there.

To be fair, she had legitimate complaints (as I described them to myself) because she had been in a nasty motor-vehicle accident two years before, suffering a miserable whiplash, and her husband had advanced emphysema and required a lot of her time and attention. Nevertheless, there were days when I felt my patience slipping as I listened to yet another list of complaints, most of which I could do nothing about—the pollution in the air, the full story of the accident, the fact that her children never lifted a hand to help her. All of these contributed to whatever the symptom of the day might be. Often the problem was poor sleep, or the latest medicine for pain didn’t help, or she thought she was getting another cold, which might perhaps turn into the flu. And she always took it as a personal insult if I was late.

What does “psychosomatic” really mean?

How often have you looked at your day sheet, on entering your office, and had a pang of tension or a groan of “Oh, no! Not her today!”

One of the many burdens that dissociative patients have to bear, is being labeled “psychosomatic”. Too often this results in acrimonious relations with their medical caregivers, a sense of great injustice and much anger in the patient, inappropriate referrals, polysurgery, too much and too many prescriptions (often useless or worse than useless), multiple and overlapping lab tests, and numerous other errors of commission or omission as we do our best to navigate the stormy waters.

But remember: “psychosomatic” just means mind-and-body, and everything is psychosomatic because we are not disconnected at the neck: anxiety is reflected in muscle tension; pain is reflected in emotional distress.

Our groans come from frustration—at not being able to decipher the root of the patient’s problems or his or her apparently disproportionate reaction to them.

The patient’s groans come from the other side of the same coin—“This person’s supposed to know what’s the matter with me! That’s her job! Why can’t she just get on with it and get me better? Instead of that, she sends me for all these tests and makes me spend all that money on useless medicine and then tells me that it’s all in my head!”

Teeth-clenching abounds.

As a matter of fact, the recognition of a thick chart, and one that seems to be getting thicker with every passing month, ought to alert us that something is obviously amiss here. Allow that little voice (groan) to whisper to you that here there might be an opportunity to do some serious delving and re-evaluating. Then sit down with the chart, pretend the patient belongs to someone else (“I wish!” you might hiss in response), take two and a half minutes to do some self-calming, and start going through it from the beginning.

Look for inconsistencies—in descriptions of the problem, in the consultation reports from your favorite witch doctor(s), in lab results, in other investigative procedures, in response to medication, in what seemed so terribly important (from the patient’s perspective) yesterday but seems to be forgotten or dismissed today.

Take particular note of any little messages you may have put on the chart. When I realized that I had another dissociative patient in my practice, I reread her whole chart and sat there, stunned, as I found (in my own inimitable handwriting) a note in the margin saying that “she seems like an entirely different person today”. Indeed, she did. She had done a home pregnancy test, which was positive, and a brand-new post-office box was opened—a new ego-state formed, one whose job it was to take care of that pregnancy.

There may be occasions when the patient forgets to come for the appointment, or turns up when no appointment has been made but she insists that it was. This is a classic behavior in highly dissociative patients and one that is particularly confusing to the uninitiated physician, especially when the patient is so demanding. How could she have forgotten an appointment? The answer, of course, is that some other ego-state made it. This may have been one of the protectors in the system who felt that something was amiss.

What to do?

If it is a case of a missed appointment, ask if it is still necessary. Remake it, if so; if the patient says “no”, make a careful note in the chart to record the event. If she still wants to come, rebook, but with the same notations in the chart. It is all right to comment that there must have been some miscommunication, when the patient is then sitting in your office. Watch for the reaction, using your best noncommittal physician’s facial expression and body language.

If it is a case of the patient’s turning up and insisting that an appointment was made, see if you can gently get the details of when that was supposed to have happened. Did the patient phone? What time of day? to whom did she speak? Explain that you are just trying to pin down how and where the miscommunication occurred. Again, make careful notes in the chart. Such notes might, in time, form a pattern.

Be aware of the reactions that are triggered in you by your patient’s behavior, demands, or unrealistic responses. Countertransference can be an invaluable guide to the root of any problem, and this is certainly true when we are working with dissociative patients. One of the clues that alerted me to the possibility of another dissociative patient in my own practice was the realization of my irritation at some of her behavior patterns: then the light went on, alerting me that perhaps she was like Jayere.

When you put these tidbits of information together, you may have a legitimate reason to consider that maybe, perhaps, possibly, that patient just might have a different diagnosis—one that answers a whole lot of confusing questions.

Do dissociative patients abuse the medical system?

Several years ago I was given an excellent paper to review on the apparent misuse of outpatient medical clinics by some families. The author hypothesized that these were dysfunctional families, with poor personal and social resources, whose various medical problems were more an expression of the psyche than the soma. In looking for connecting links, he found family disruption and often family violence, unsuccessful employment capabilities, little extended family support (although there might be a fairly large group of relatives), past and present problems with the law, and general lack of appreciation of these factors—on the parts of both the patients and the health care workers. Other similar research projects have been published with similar results. They will be discussed in Chapter Seventeen.

He decided to investigate the families for dissociative tendencies and found a remarkable correlation between the degree of unrecognized dissociative phenomena and the frequency with which such patients presented at the outpatient clinic. Indeed, it was a very predictable and reliable correlation—the more frequently the patient attended the clinic, the greater degree of family dysfunction and the greater the incidence of dissociative tendencies and behaviors in the patient. Unfortunately, to my knowledge this paper was never published, but I felt it worthy of comment.

If we extrapolate from this very nice piece of epidemiological research, we can begin to garner a little more understanding of mind–body communication: when the psyche is in a dysfunctional dissociative state, the body responds with its own separation from a sense of wellbeing and—both parts looking for answers when neither even knows the questions—the plethora of psychosomatic problems bubble up to the surface.

Presto! Our thick-chart patient.

Further research into the somatic aspect of dissociative disorders is being done in various parts of the world. Of particular note is the elegant work being done in The Netherlands by Ellert Nijenhuis and his colleagues. Two questionnaires have evolved from this research, which enjoy an exceptional correlation to a diagnosis of dissociative disorders—the Somatoform Dissociation Questionnaire-20 (SDQ-20) and the SDQ-5. They can be found at the back of his book, Somatoform Dissociation (1999).

As physicians, we look for answers to these somatic complaints because we want our patients to be, and feel, well. It is all too easy to make yet another referral, ask for one more set of lab tests, prescribe yet another miracle from the pharmaceutical corporations.

Thus we engage in a balancing act. Of course we want to make sure that we have not forgotten anything, omitted exploring some reasonable possibility, or dismissed a potentially dangerous (or even simply annoying) medical condition. So, all too often, we err on the side of overinvestigating. Beware. Too much is not necessarily better than too little.

I fell into this trap often, in the early years, when I was still such a novice in the dissociation field. I prescribed and prescribed, referred and referred. I am trusting my readers to know that I am not advocating any kind of neglect, but rather a healthy skepticism when the usual routes have all proven to reach such disappointing nonanswers.

Worse than that, we may actually do harm to our patients, especially with the polypharmacy. Many dissociative patients have extremely idiosyncratic responses to medication: some are able to tolerate huge doses with no effect whatsoever (or so it seems); others do well with tiny doses—sometimes only a quarter or even a tenth of the “normal” dose. I am thinking, for instance, of antidepressants. These may be used for depression and/or to relieve chronic pain such as fibromyalgia. Those of us who work with chronic-pain patients know that the usual dose of analgesics is often totally useless, yet, strangely, some conditions, such as fibromyalgia, may respond well to these tiny doses of tricyclics. Based on this, I began to offer some of my dissociative patients these very small doses of antidepressants, or of anxiolytics, with occasional rewarding results.

Furthermore, many of us feel that some medications are often contraindicated in dissociative patients. Hypnotics have no place in the therapeutic protocol, nor tranquilizers. Nor, I often used to think, antipsychotics. I have changed my mind somewhat about the antipsychotics used in very small doses. I will speak more about medication issues in Chapter Four. Of course, various medications may be used quite safely by physician therapists who are knowledgeable about dissociation, but it can be a quagmire for the unaware.

As a general rule of thumb, I think of these problems as “psychosomatic and somatopsychic issues in trauma and dissociation”. For example, I would list the following under the heading “Psychogenesis”:

• panic attacks
• flashbacks
• sleep disturbances
• derealization
• depersonalization
• vertigo

In the same way, I would list the following under “Somatogenesis”:

• body memories
• chronic pain syndromes
• headache
• gastrointestinal disorders
• genitourinary disorders
• air hunger
• eating disorders
• pseudoseizures

These are merely partial lists, of course, but they give an impression that can be useful to put things into a slightly different perspective. Many of these, and more, will be discussed throughout this book in the context of alerting the physician to dissociative expression.

“High-risk” populations

For those healthcare workers who work in underprivileged areas or with high-risk—in the economic and/or social sense—populations, it again behooves us to keep the possibility of a degree of dissociative disorder in the differential diagnosis. At present we have spearheaded a pilot project in the city where I live (Victoria, British Columbia) to evaluate the extent of dissociativity in the “street” population. This project has interested several levels: the tourism groups, both g...