A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by community clinicians

A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by community clinicians
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  A Naturalistic Study of Dissociative Identity Disorder andDissociative Disorder Not Otherwise Specified Patients Treated byCommunity Clinicians Bethany Brand Towson University Catherine Classen University of Toronto Ruth Lanins University of Western Ontario Richard Loewenstein Sheppard Pratt Health Systems, Baltimore, MD Scott McNary Towson University Claire Pain University of Toronto Frank Putnam Cincinnati Children’s Hospital Medical CenterThe goals of this naturalistic, cross-sectional study were to describe the patient, therapist,and therapeutic conditions of an international sample of dissociative disorder (DD) patientstreated by community therapists and to determine if community treatment for DD appearsto be as effective as treatment for chronic PTSD and conditions comorbid with DD.Analyses found that across both patient (  N   280) and therapist (  N   292) reports, patientsin the later stages of treatment engaged in fewer self-injurious behaviors, had fewerhospitalizations, and showed higher levels of various measures of adaptive functioning(e.g., GAF) than those in the initial stage of treatment. Additionally, patients in the laterstages of treatment reported lower symptoms of dissociation, posttraumatic stress disorder,and distress than patients in the initial stage of treatment. The effect sizes for Stage 5 versusStage 1 differences in DD treatment were comparable to those published for chronic PTSDassociated with childhood trauma and depression comorbid with borderline personalitydisorder. Given the prevalence, severity, chronicity, and high health care costs associatedwith DD, these results suggest that extended treatment for DD may be beneficial and meritsfurther research. Keywords:  dissociation, dissociative disorders, dissociative identity disorder, trauma, treatment The prevalence of dissociative disorders(DD) in clinical settings ranges between5-20.7% among inpatients, (Friedl & Draijer,2000; Gast, Rodewald, Nickel, & Emrich, 2001;Ross, Anderson, Fleisher, & Norton, 1991; Tut-kun et al., 1998), 12-38% among outpatients(Foote, Smolin, Kaplan, Legatt, & Lipschitz,2006; Garcia, Rico, & Agra´z, 2006; Sar et al.,2003; Sar, Tutkun, Alyanak, Bakim, & Baral,2000), and 34.9% among patients presenting to Bethany Brand, Psychology Department, Towson University;Catherine Classen, Department of Psychiatry, University of To-ronto; Ruth Lanius, Department of Psychiatry, University of Western Ontario; Richard Loewenstein, Trauma Disorders Pro-gram, Sheppard Pratt Health Systems, Baltimore MD; Scott Mc-Nary,EducationalTechnologyandLiteracyDepartment,TowsonUniversity; Clare Pain, Department of Psychiatry, University of Toronto; Frank Putnam, Department of Pediatrics and Child Psy-chiatry, Mayerson Center for Safe and Healthy Children, Cincin-nati Children’s Hospital Medical Center.Portions of these data were presented at Bi-annual Inter-national Conference of the European Society for Trauma &Dissociation, Amsterdam, Netherlands, April 2008.The authors would like to warmly thank the patients andclinicians who volunteered to participate in this study. Theauthors also appreciate Steven Southwick’s, M.D., insight-ful suggestions about this article.Funding for this study came from an anonymous con-tribution made to Sheppard Pratt Health Systems’Trauma Disorders Program, a grant from the Constan-tinidas Family Foundation, and grants from Towson Uni-versity.Correspondence concerning this article should be ad-dressed to Bethany Brand, Psychology Department, TowsonUniversity, 8000 York Rd., Towson, MD 21252. Psychological Trauma: Theory, Research, Practice, and Policy © 2009 American Psychological Association2009, Vol. 1, No. 2, 153–171 1942-9681/09/$12.00 DOI: 10.1037/a0016210 153  a psychiatric emergency room (Sar et al., 2007).A nationwide random sample of experiencedclinicians found that 53% of patients treated inthe community for borderline personality disor-der (BPD) had a comorbid dissociative disorder(DD), including 11% meeting criteria for Dis-sociative Identity Disorder (DID; Zittel Conklin& Westen, 2005), although new research sug-gests that the overlap between these disorders ismisleading because the disorders are distin-guishable on many personality features (Brand,Armstrong, Loewenstein, & McNary, in press).A study with similar methodology found that upto 8.6% of the patients being treated for panicdisorder were diagnosed with comorbid DD(Morrison, Bradley, & Westen, 2003). Thesedata suggest that DDs are common among psy-chiatric samples in North American and West-ern and Eastern Europe.Patients with dissociative disorders havecomplex presentations with high levels of co-morbid psychiatric difficulties, including com-plex posttraumatic stress disorders (Courtois &Ford, 2009; Ford, 2009); treatment resistant de-pression and anxiety (Johnson, Cohen, Kasen,& Brook, 2006; Putnam, Guroff, Silberman,Barban, & Post, 1986); personality disordersand relational problems, including borderlinepersonality disorder (Dell, 1998; Ellason, Ross,& Fuchs, 1996; Johnson et al., 2006; ZittelConklin & Westen, 2005); active substanceabuse (Dunn, Paolo, Ryan, & van Fleet, 1993;Karadag et al., 2005; Ross et al., 1992); eatingdisorders (Johnson et al., 2006); self destruc-tiveness and suicidality (Foote, Smolin, Neft, &Lipschitz, 2008; Putnam et al., 1986). Due totheir acute polysymptomatology, patients withdissociative disorders typically take multiplepsychiatric medications (Loewenstein, 1991)and are almost always excluded from research,even in treatment outcome studies of chronicchildhood abuse (Cloitre, Koenen, Cohen, &Han, 2002; McDonagh et al., 2005; van derKolk & Courtois, 2005). As a result, informa-tion about treatment outcomes with dissociativedisorder patients is limited.At present, treatment outcome research onDID patients is limited to case studies (e.g.,Kellett, 2005; Sar, Ozturk, & Kundakci, 2002),clinical series studies (e.g., Coons, 1986; Kluft,1984, 1988), and acute stabilization followinginpatient treatment (Ross & Ellason, 2001; Ross& Haley, 2004). Clinical case studies and caseseries suggest that many DID patients improvewith treatment, with up to two thirds of themeventually integrating personality states and be-coming less symptomatic after years of treat-ment (Brand, Classen, McNary, & Zaveri, inpress). Of the few quantitative studies that havebeen conducted, the longest study was of DIDpatients followed for two years after dischargefrom a specialized inpatient trauma and disso-ciation program (Ellason & Ross, 1997). Atfollow up, the patients met criteria for signifi-cantly fewer comorbid axis I and II disordersand used less psychotropic medication. Addi-tionally, they demonstrated significantly de-creased symptoms of depression, dissociation,amnesia, somatic symptoms, substance abuse,and Schneiderian first-rank symptoms (Ellason& Ross, 1995). Twenty-two percent had inte-grated their dissociated personality self-states(henceforward referred to as “self-states”).While this study’s findings are encouraging, itdid not have a control group and had a lowretention rate (i.e., 46%). Decreases in depres-sion, PTSD, global distress, and dissociationhave been found following inpatient treatmentin other studies of shorter follow-up duration(Ellason & Ross, 1997, 2004; Ross & Ellason,2001; Ross & Haley, 2004).Results from these preliminary studies sug-gest that many DD patients appear to respond totreatment with decreases in dissociation, de-pression, and PTSD, as well as decreases inself-destructiveness and comorbid axis I and IIdisorders (for a review, see Brand, Classen, etal., in press). However, these studies have meth-odological weaknesses, including a reliance onsmall samples, single therapists, and/or treat-ment sites. Additionally, most of the studieshave used inpatient samples that may confoundtreatment effects with regression to the meanphenomena. The research has been primarilyconducted with U.S. patients and expert thera-pists. Thus, the efficacy of outpatient treatmentprovided by community therapists is unknown.Rigorous research is needed using large sam-ples, patients from within, as well as outside theUnited States, and a wider range of therapists toprovide data indicating whether treatment helpsthis severely impaired population. If so, to whatdegree is it effective? Comparing effect sizesfrom DD treatment studies to those from studiesof chronic PTSD or disorders that are comorbidwith DD would help evaluate the efficacy of DD 154 BRAND ET AL.  treatment by providing a context for the mag-nitudes of treatment responses.Designing treatment outcome studies for pa-tients who have many comorbid conditions ischallenging. Although regarded as the most rig-orous design for evaluating treatment research,some researchers have expressed concern aboutsome of the limitations of randomized con-trolled trial (RCT) studies that are relevant tothe study of DD (Borkovec & Costonguay,1998; Bradley, Greene, Russ, Dutra, & Westen,2005; Morrison et al., 2003; Westen, Novotny,& Thompson-Brenner, 2004) and complex trau-matic stress disorders (van der Kolk & Courtois,2005). These authors’ concerns include thatRCTs typically have so many exclusion criteriathat they are of limited generalizability because,rather than treating the typical community pa-tient who suffers from multiple disorders andpoly symptomatology, they focus on single“pure” disorders that are easier to treat. Consis-tent with this concern, a recent meta-analysis of RCTs for PTSD (Bradley et al., 2005) foundthat 62% of the studies excluded patients withcurrent drug or alcohol use and 46% excludedpatients at risk for suicide, leading the authorsto question the generalizability results. Bradleyand colleagues urged the field to investigatetreatment for “poly symptomatic patients withrepeated childhood traumas” (p. 222). In linewith Bradley et al.’s findings, of the four studiesof chronic PTSD in which at least one quarter of the sample reported childhood abuse, two spe-cifically excluded DID (Cloitre et al., 2002McDonagh et al., 2005) and the other two al-most certainly excluded DD patients due toexcluding patients with suicidal ideation orthose taking psychiatric medications (Cohen &Hien, 2006; Cottraux et al., 2008).Similarly, the American Psychological Asso-ciation’s Presidential Task Force on Evidence-Based Practice recommended that treatment re-searchers need to expand their focus to includeinterventions that are delivered in naturalisticsettings because such studies possess strongecological validity and generalize to patientswith multiple symptoms and syndromes (Amer-ican Psychological Association’s PresidentialTask Force on Evidence-Based Practice, 2006).This recommendation is particularly relevant topoly symptomatic and highly comorbid DD pa-tients. Correlational data from naturalistic stud-ies provide a methodology that complementsthe potential limitations of brief, randomizedstudies (Westen et al., 2004). While correla-tional data cannot lead to conclusions aboutcausality, they can generate hypotheses aboutpotential moderators and possible treatmentstrategies that can be examined in future con-trolled experimental settings.In consideration of the limitations of the ex-isting research on treatment outcome of DD andthe limitations of RCT methodology, a study of treatment provided to DD community patientsis needed. The present study was designed forthis purpose and is limited to the cross-sectionalresults of an ongoing longitudinal pilot study of treatment outcome for DD patients. It relied onpractice network methodology, in which partic-ipants are community therapists who recruit apatient participant from among their caseload.Therapists were recruited via emails sent toprofessional organizations, telephone calls andemails to therapists who had graduated from theDD Psychotherapy Training Program of the In-ternational Society for the Study of Trauma &Dissociation (ISSTD; note that ISSTD was for-merly known as the International Society for theStudy of Dissociation or ISSD), and telephonecalls and emails to therapists listed in  Psychol-ogy Today’s  therapist directory. Practice net-work methodology has the advantage of in-creased generalizability to patients treated in thecommunity while having the disadvantage of not being able to establish causality (e.g., Bork-ovec, Echemendia, Ragusea, & Ruiz, 2001; Zit-tel Conklin & Westen, 2005).Westen and colleagues have been strong pro-ponents for this methodology because of theincreased generalizability of the findings, andhave used this it to determine clinically relevantfindings about treatment for patients with eatingdisorders, depression, anxiety disorders, andBPD (Morrison et al., 2003; Thompson-Brenner& Westen, 2005a, 2005b; Wilkinson-Ryan &Westen, 2000; Zittel Conklin & Westen, 2005).For example, research using this methodologyhas found that patients treated in the communitytypically present with multiple, rather than sin-gle psychiatric disorders, and that these co-occurring disorders substantially lengthen treat-ment (Morrison et al., 2003). The present studyadapted Westen’s methodology and therapistquestionnaire for use with DD patients (ZittelConklin & Westen, 2005). Multiple studieshave shown that clinicians’ observations can be 155TREATMENT OF DISSOCIATIVE DISORDERS  highly reliable and valid, particularly when theyuse standardized measures (Dutra, Campbell, &Westen, 2004; Thompson-Brenner & Westen2005a, 2005b; Westen & Muderrisoglu, 2003;Zittel Conklin & Westen, 2005).The first goal of the current study was todetermine if patients in later stages of treatmentshow higher levels of adaptive functioning andlower levels of symptoms than DD patients inthe early stages of treatment. Specifically, pa-tients in the early stages of treatment were ex-pected to have higher levels of dissociation,distress, and PTSD, self harm, suicide attempts,and hospitalizations, as well as lower levels of adaptive functioning (e.g., GAF) compared toDD patients in the later stages of treatment. Thesecond goal of the study was to determine if outpatient treatment for DD appears to be aseffective in reducing symptoms of dissociation,distress, PTSD, self harm, suicide attempts, andhospitalizations, as well as increasing adaptivefunctioning as has been found for treatment forconditions that are often comorbid with DD,including chronic PTSD and borderline person-ality disorder. Method Participants Participants were 292 therapists and 280 pa-tients. The therapists were recruited from mem-bership registers of the International Society forthe Study of Trauma & Dissociation (ISSTD),the ISSTD’s list of therapists who had gradu-ated from its DD Psychotherapy Training Pro-gram (DDPTP), and listservs for mental healthprofessionals, including those focused on psy-choanalysis, dialectical behavioral therapy, andtrauma-focused therapy. Initial email invitationssent to therapists described the study as a treat-ment outcome study of DD treatment in whichthey were invited to participate. We broadenedour recruitment methods by a) making tele-phone calls to graduates of the DDPTP to invitethem to participate; b) encouraging these pro-fessionals to forward the email invitation tocolleagues who were treating DD and might beinterested; and c) attempting to recruit thera-pists who were less well trained in treating DDby calling approximately 100 therapists fromMaryland and Pennsylvania who listed them-selves as general therapists in the electronicdirectory of   Psychology Today . The latter re-cruitment effort did not result in any additionalparticipants. Unfortunately, our response ratecannot be determined because it is unknownwhat percentage of the recruitment emails werereceived and read by the intended recipients. Atthe time of recruitment, ISSTD had approxi-mately 1300 members and approximately 700individuals had graduated from its psychother-apy training program. However, email ad-dresses were available for only approximately100 of the most recent training program gradu-ates; unfortunately, email addresses had notbeen requested from earlier graduating classesof the ISSTD therapist training program, result-ing in not being able to reach them by email.Dozens of emails invitations sent to members of the ISSTD and its training program bouncedback. Additionally, approximately 20 therapistswrote to indicate that they were not currentlytreating any dissociative patients.Inclusion criteria required that the therapistbe currently engaged in providing ongoingtreatment of at least 3-months duration to oneadult patient diagnosed with DID or DDNOS.Exclusion criteria for therapists were not havinga current adult in treatment diagnosed with ei-ther DID or DDNOS and not being able to readEnglish. We asked clinicians to invite a singleDD patient from his or her caseload to partici-pate. We did not provide therapists with anyguidelines about how to select a patient otherthan to specify that the only exclusion criteriafor patients were being younger than 18 and notbeing able to read English. To make our resultsmost generalizable to community samples of DD patients, we did not exclude any patientsregardless of substance use, eating disorders,active suicidality, psychosis, recent hospitaliza-tion or hospitalization during the study, or anyother type of acuity or comorbidity, all of whichare typical exclusion variables in treatment out-come studies.To maximize the ease of participating andreduce loss of therapist data through postalmail, therapists completed their measures on aninteractive, password-protected website. Thismethodology and the therapist survey wereadapted from one used in a naturalistic nation-wide community study of BPD that found nosystematic differences between therapists’ re-sponses gathered via a web-based survey com-pared to those gathered via a paper and pencil 156 BRAND ET AL.  survey (Zittel Conklin & Westen, 2005). Toprotect patient confidentiality and recruit awider range of participants, including those whodid not have access to the Internet, the patientmeasures were sent via postal mail to the ther-apists’ work addresses. The therapists gave thepacket of measures to the patients who com-pleted them outside of session without theirtherapist seeing their answers. Self-addressedstamped envelopes were provided for patientsin the United States. All surveys were identifiedby code numbers so that matched pairs of pa-tient and therapist data could be linked. Neithertherapists nor patients were compensated forparticipating. The study received IRB approvalfrom Towson University and Sheppard PrattHealth System and all participants provided in-formed consent prior to participation.Of the 292 therapists, 74% ( n    220) prac-ticed in the US, 8% ( n  25) in Canada, and theremaining 18% ( n    67) from 17 countriesoutside North America (including  n    8 fromthe United Kingdom,  n    7 from the Nether-lands,  n  4 each from Germany and Australia, n  3 from Sweden,  n  2 each from Scotland,Belgium, New Zealand, and Spain, and  n    1each from Argentina, Norway, Brazil, Finland,Taiwan, Singapore, Israel, Slovakia, and SouthAfrica). Thus, we had participants from everycontinent except Antarctica. Therapists withinNorth America were from 37 states and 5 Ca-nadian provinces. See Table 1 for therapistcharacteristics. Therapists provided data on asingle DD patient whom they invited to partic-ipate. Among the patients diagnosed with any of the 5 DDs in their caseloads, therapists identi-fied DID patients as the most frequent dissocia-tive disorder ( n  277; 98%) they were treating,with an average of 4.1 ( SD  4.6) DID patientsper therapist at the time of participation. Manyof these therapists reported a considerableamount of experience treating patients with DDalthough 34.4% reported treating three or fewerDID patients throughout their career. We ex-cluded 24 therapists who did not complete morethan half of the survey or who had computerproblems (e.g., consistent pattern of stuck com-puter keys).Therapists provided background informationon their patients. See Table 2 for patient demo-graphics. Two therapists’ identified patient pre-ferred not to participate, two therapists pre-ferred to not ask a patient to participate, and 32patients who agreed to participate did not returndata. The patients were well educated, with only4% having less than a high school education( n    12), 17% having graduated from highschool ( n  47), and 78% having some collegeeducation ( n  217). Therapists reported a highdegree of axis I comorbidity, with PTSD in 89% Table 1 Therapist Characteristics % ( n )  M SD  Min Max Therapist Gender (N    292) Female 75 (223)Male 23 (69) Therapist Orientation (N    292) Cognitive behavioral 17 (49)Psychodynamic 49 (144)Family systems 3 (8)Humanistic/experiential 8 (25)Other 22 (66) Treatment Setting (N    276) Private practice 73 (216)Outpatient clinic 17 (49)Hospital inpatient/partial 2 (6)School 0.3 (1)Other 1 (4) Therapist Experience (N    285) Years in practice 100 (285) 21.8 9.6 3 44Years treating DD 99.6 (284) 12.8 7.6 0 41DID patients integrated 98.9 (282) 3.9 9.1 0 75157TREATMENT OF DISSOCIATIVE DISORDERS
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