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Clandestine Psychopathology: Unrecognized Dissociative Karni Ginzburg, PhD,* Eli Somer, PhD,† Gali Tamarkin, MSW,† and Lilach Kramer, MSW† A large scale survey among mental health professionals in Abstract: Surveys among Israeli mental health professionals found that
Israel found that 63% of those interviewed had no experience almost half of them doubt the validity of dissociative disorders (DD) and either diagnosing or treating DD patients (Somer, 2000). These have no experience in either diagnosing or treating DD patients. These findings, ostensibly in line with arguments that both the diagnosis findings, in line with arguments that DDs are socially construed North and its manifestations are socially construed North American American phenomena, call for the need to investigate it in Israel. Eighty-one phenomena (see Spanos, 1994), call for the need to investigate psychiatric inpatients were screened for dissociative pathology. Participants the validity of DD in Israel. This study reports the results of categorized as having low levels of dissociation (n ϭ 26) and those demon- screening for DD among Israeli psychiatric inpatients.
strating high levels of dissociation (n ϭ 22) were asked to participate in aStructured Clinical Interview for the DSM—Dissociative Disorders—Re- vised. One-quarter of all participants were identified as having probabledissociative psychopathology. Based on the Structured Clinical Interview for Study Design
the DSM—Dissociative Disorders—Revised, estimates of DD range be- A two-stage methodological approach common to DD prev- tween 12 and 21%. None of the participants had any indication of a DD alence studies was employed (e.g., Tutkun et al., 1998). The first diagnosis in their medical records. Diagnosis of personality disorder and stage involved an initial screening of the target population by a psychiatric comorbidity were related to the likelihood of a DD diagnosis and self-report questionnaire. In the second stage, a structured clinical interview was conducted with available individuals who scored Key Words: Dissociative disorders, psychiatric inpatients, childhood
above a cutoff point considered indicative of probable dissociative pathology. For comparison purposes, we also included a group of (J Nerv Ment Dis 2010;198: 378 –381) participants who scored below a cutoff point indicating the probableabsence of DD. Another advantage of the current study relates to thescreening instrument employed. Many previous studies used theDissociative Experiences Scale (Bernstein and Putnam, 1986) for Despitetheaccumulationofsupportiveevidence,thediagnosis screening purposes, which in addition to the assessment of patho- of dissociative disorders (DD) is still controversial. Surveys logical dissociation, also assesses manifestations of normative dis- among mental health professionals revealed that almost half of sociation, such as absorption and imaginative involvement. In the them regard DD as dubiously valid, or invalid, disorders (Leo- current study, we used an extensive screening tool that focuses nard et al., 2005). Thus, it is not surprising there are indications exclusively on dissociative pathology.
that DDs are underdiagnosed in psychiatric care. That is, al- Participants and Data Collection
though systematic screening among psychiatric patients revealed Ninety-six psychiatric inpatients who did not have an ap- that a considerable proportion of patients, ranging between 4 and pointed legal guardian, hospitalized for at least 1 week in acute 29%, meet the diagnostic criteria for DD (e.g., Foote et al., 2006; wards of 2 psychiatric hospitals, were approached by the research Gast et al., 2001), most of those who were diagnosed by the staff. Eighty-one (84%) patients consented to participate in the study research staff with DD (79%– 84%) did not have a dissociative (stage 1). In the second stage, inpatients who were categorized as diagnosis recorded in their clinical files (Foote et al., 2006; having low levels of dissociation ͓Multidimensional Inventory of Dissociation—Hebrew Version (H-MID) scores Յ10; n ϭ 26͔ and There is only scarce evidence regarding the actual diag- those demonstrating high levels of dissociation (H-MID scores Ն30; noses received by undetected DD patients. There are indications n ϭ 22) were invited to participate in a Structured Clinical Interview that many may have received multiple diagnoses (Tutkun et al., for the DSM—Dissociative Disorders—Revised (H-SCID-D-R) in- 1998), possibly reflecting either real comorbidity or clinicians’ terview. Some of these patients were discharged by the time of the uncertainty. The few studies that traced the clinical records of second stage, whereas others refused to be interviewed. Twenty- DD patients indicated that affective disorders were the most three participants (10 low dissociators and 13 high dissociators) prevalent disorder diagnosed by their therapists (Tutkun et al., were eventually interviewed in the second stage. A series of com- 1998). However, the validity of the diagnosis of affective disor- parisons indicated that stage 2 participants and dropouts did not der turned out to be questionable in light of reports of relatively differ in age, gender, level of education, history of childhood low levels of dissociation among individuals with affective maltreatment, onset age of the mental health disorder, or number of Fifty-nine percent of the participants were men. Participants’ age ranged between 18 and 65 years ͓mean (M) ϭ 34.18, standarddeviation (SD) *School of Social Work, Tel Aviv University, Tel Aviv, Israel; and †School of ϭ 11.3͔. Most were single (61.7%), the rest were Social Work, University of Haifa, Haifa, Israel.
either married (12.3%) or separated/divorced (25.9%). Half the Send reprint requests to Karni Ginzburg, PhD, School of Social Work, Tel Aviv sample had 12 years of education (51.9%), 28.4% had fewer years University, Tel Aviv, 69978, Israel. E-mail: [email protected].
of education, and the rest (19.8%) completed Ͼ12 years of educa- Copyright 2010 by Lippincott Williams & Wilkins tion. Most of the inpatients were unemployed during data collection ISSN: 0022-3018/10/19805-0378DOI: 10.1097/NMD.0b013e3181da4d65 The Journal of Nervous and Mental Disease • Volume 198, Number 5, May 2010 The Journal of Nervous and Mental Disease • Volume 198, Number 5, May 2010 One half of the sample (55.6%) carried a diagnosis of schizo- disorder, 1 was identified as DID, and 8 patients were assessed as phrenia, and the records of one-third (34.5%) indicated an affective suffering from dissociative disorder not otherwise specified. None of disorder. Fourteen percent of the patients were diagnosed as having the low dissociators was diagnosed as having DD. Thus, there was a personality disorder, with or without a comorbid disorder. Eighty- a considerable agreement between H-SCID-D-R diagnoses and five percent had a single psychiatric disorder, and the rest (14.8%) H-MID categorization (␹2 ϭ 13.6, p Ͻ 0.001, ␾ ϭ 0.77). Similarly, carried 2 or more concurrent diagnoses. During data collection, a strong association was found between the severity of dissociative patients had been hospitalized for an average of 4.61 weeks (SD ϭ pathology as was estimated by the H-MID, and H-SCID-D-R (r ϭ 4.12). Mean number of previous hospital admissions was 4.34 The study was undertaken after institutional Helsinki com- Dissociative Symptoms and Psychiatric History
mittees approved the research design. Informed consent was ob- Examination of the patients’ psychiatric records revealed that tained from all participants before data collection.
none of the 10 diagnosed DD patients had been previously identified Instruments
as suffering from any dissociative psychopathology. The most prev- Biographical variables: Data regarding gender, age, marital alent disorder in the sample’s psychiatric records was affective status, number of years of education, and occupation were gathered disorder (6), followed by personality disorder (5), schizophrenia (3), through self-report questionnaires. Data on psychiatric diagnosis, adjustment disorder (1), and substance abuse disorder (1). Four of number of admissions, and length of current hospitalization were the DD patients carried a single psychiatric diagnosis whereas the records of the 6 newly diagnosed DDs indicated a concurrent Childhood maltreatment was assessed by The Child Trauma diagnosis of Ͼ1 psychiatric disorder.
Questionnaire (Bernstein et al., 1994). This self-report measure Severity of dissociative symptomatology as measured by the assesses childhood maltreatment history, manifested as emotional H-MID was not associated with existing psychiatric diagnosis. More abuse or neglect, physical abuse or neglect, and sexual abuse.
specifically, inpatients diagnosed with schizophrenia did not differ The Child Trauma Questionnaire has been demonstrated to in their mean H-MID score from those with affective disorders have strong psychometric properties in both clinical and community t(71) ϭ 1.8, n.s͔. Severity of dissociative symptoms was, however, samples (Bernstein et al., 1994). Alfa Cronbach in the current associated with an existing psychiatric diagnosis of a personality sample was 0.84, demonstrating good internal consistency.
disorder. That is, inpatients carrying a diagnosis of personality Dissociative symptoms were assessed by the H-MID. This disorder (with or without another comorbid diagnosis) scored higher self-report inventory, developed by Dell (2006), was translated into on the H-MID (M ϭ 39.07, SD ϭ 13.75) compared with those who Hebrew and validated by Somer and Dell (2005).
were not seen as personality disordered ͓M ϭ 17.47, SD ϭ 16.54; The inventory is comprised of 168 dissociation items and 50 t(79) ϭ 4.11, p Ͻ 0.05͔.
validity items. Respondents are asked to indicate how often they Severity of dissociative symptomatology was also associated experience each symptom when not under the influence of alcohol or with the number of comorbid psychiatric diagnoses assigned to the drugs. Total score ranges between 0 and 100. A score of 30 and patient. That is, patients whose records specified 2 or more concur- above is considered a cutoff mark indicative of probable dissociative ring psychiatric diagnoses had higher levels of pathological disso- psychopathology, whereas a score of 10 and below is considered an ciation (M ϭ 45.18, SD ϭ 16.45) than those who had received a indication of a low level of dissociation (P.F. Dell, personal com- single psychiatric diagnosis ͓M ϭ 15.3, SD ϭ 13.06; t(79) ϭ 7.4, Previous studies demonstrated strong psychometric properties Finally, neither number of previous psychiatric hospitaliza- (Dell, 2006; Somer and Dell, 2005). Alfa Cronbach in the current tions nor onset age of the mental health disorder was associated with sample was 0.99, indicating excellent internal consistency.
severity of dissociative symptoms (r ϭ 0.06, n.s.; r ϭ Ϫ0.05, n.s., The Structured Clinical Interview for DSM-IV Dissociative Disorders—Hebrew version (H-SCID-D-R), developed by Stein-berg et al. (1990), was translated to Hebrew by Somer et al. (2001).
Biographical Data and Dissociative Symptoms
The SCID-D is reported to have a high discriminant validity and Linear regression was conducted to examine the unique and inter-rated reliability (␬ ϭ 0.88; Steinberg et al., 1990) and is cumulative contribution of patients’ biographical data (gender, age, considered a gold standard for the assessment of DDs. This inter- and childhood maltreatment), current psychiatric comorbidity (hav- view assesses DDs, according to DSM-IV-TR criteria and provides ing at least 2 concurring diagnoses), and the interactions of child- severity ranking of the identified dissociative pathology. The third hood maltreatment with age, gender, and psychiatric comorbidity to and fourth authors, licensed clinicians and graduate students, re- the variance of pathological dissociation. Z scores were computed ceived 5 hours of training and ongoing supervision by the second author (E.S.) on the administration and scoring of the H-SCID-D-R.
The regression model explained 40% of the variance of dissociative psychopathology ͓F(7,80) ϭ 7.71, p Ͻ 0.001͔. Child- hood maltreatment (␤ ϭ 0.31; p Ͻ 0.01), psychiatric comorbidity(␤ ϭ 0.40, p Ͻ 0.01), and the interaction between age and childhood Dissociative Symptoms and Psychopathology
maltreatment (␤ ϭ Ϫ0.30, p Ͻ 0.01) made a significant contribution Twenty-two participants (27.2%) scored at, or above, an to the explained variance of dissociative psychopathology. An in- H-MID cutoff mark indicative of probable dissociative psychopa- verse relationship between childhood abuse and dissociative psy- thology. Forty-one percent (n ϭ 33, 40.7%) were classified as chopathology was identified: the more severe the childhood mal- having a moderate level of pathological dissociation, and approxi- treatment, the higher the reported dissociative psychopathology, and mately one-third (n ϭ 26, 32.1%) scored at the lower end of the inpatients identified as suffering from a single psychiatric disorder endorsed lower levels of dissociative symptomatology than those Of the 13 high dissociators who were interviewed in the second stage, 10 (77%) were diagnosed with the H-SCID-D-R, as To explore the specific nature of the interaction, a median suffering from a DD: 1 was diagnosed as having a depersonalization split analysis was conducted for age (median ϭ 32), and respondents 2010 Lippincott Williams & Wilkins The Journal of Nervous and Mental Disease • Volume 198, Number 5, May 2010 were categorized into 2 age groups (32 years old or younger, and Tutkun et al., 1998). The weaker effect of childhood maltreatment older than 32 years). Pearson correlations indicated a significant among older patients may be a possible result of decreasing disso- correlation between childhood maltreatment and dissociative psy- ciative experiences with age (Maaranen et al., 2008) and some chopathology among the younger (r ϭ 0.58, p Ͻ 0.001) but not post-traumatic adaptation that may have occurred over time.
among the older participants (r ϭ 0.19, n.s.).
The findings of this study should be considered in light of its limitations. The most salient weak point is the modest sample sizeand rate of participant attrition. Although response rate was satisfy- DISCUSSION
ing in the first assessment, due to hospital discharge only half of the About one-quarter of the participants were identified with a subsample that was screened to participate in the second assessment probable dissociative psychopathology. H-SCID-D-R with available was allocated and consented to participate. Although participants eligible patients identified 12% of the entire inpatient sample as and dropouts did not differ in their demographic characteristics, having a DD. Based on the high agreement between H-SCID-D-R exposure to childhood maltreatment, or psychiatric history, the diagnoses and the H-MID categorization, it is plausible to assume possibility of selective attrition cannot be completely ruled out.
that rates of DD in the complete sample were actually higher, The findings of the study imply that dissociative disordered probably closer to 21%. The fact that these incidence rates are patients hospitalized for psychiatric care might not be accurately similar to those reported in other studies (e.g., Foote et al., 2006, diagnosed and consequently might not receive optimal care. There is Mueller et al., 2007), supports the validity of the DD and is evidence that most DD patients spend Ͼ3 years in the psychiatric inconsistent with arguments that DDs reflect socially construed system and one-third of these see 6 or more clinicians before a DD North American phenomena (see Spanos, 1994).
diagnosis is made (Leonard et al., 2005). In light of the adverse Similar to previous reports (Foote et al., 2006; Mueller et al., consequences of misdiagnosis, in general, and among the chroni- 2007), none of the psychiatric inpatients diagnosed as DD had a cally traumatized, in particular, the findings of the current study prior indication for this diagnosis in their clinical records. Despite stress the critical need for quality DD diagnostic training among the growing body of evidence supporting the validity of DDs, these patients continue to be under- or misdiagnosed, under- or mistreated,and insufficiently respected (Spiegel, 2006). Various causes mayexplain this troubling reality. First, the inability of many DD patients REFERENCES
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