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Can Physiological Profiles Affect Pain Treatment?

The presentation of dissociative or alter identities in a practice setting may change how a practitioner approaches treatment.
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According to the American Psychological Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5),1 dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior, which can potentially disrupt every area of psychological functioning.

Dissociative disorders include dissociative identity, dissociative amnesia, depersonalization/derealization, as well as other specified and unspecified dissociative disorders. The manner in which a practitioner interacts with a patient presenting with a dissociative disorder can affect patient education, treatment follow-through, and outcomes. Pain practitioners in particular should be aware of the unique attributes of these disorders and how they can affect pain levels.

Defining Dissociative Disorders

Several changes have been made to the criteria for diagnosing dissociative disorders in DSM-5.1 Dissociative identity disorder (DID, previously termed “multiple personality disorder”) has been expanded to include certain possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder. Criteria for DID also now states that transitions in identity may be observable by others or self-reported, and that the individual may have recurrent gaps in recall for everyday events, not just for traumatic experiences.1 The DSM-IV diagnosis of dissociative fugue is now listed as a specifier of dissociative amnesia rather than a separate diagnosis. Derealization is included in the name and symptom structure of what previously was called depersonalization disorder in DSM-IV.1

Individuals with DID experience recurrent, inexplicable intrusions into their conscious functioning and sense of self, alterations in sense of self, unexpected changes of perception, and intermittent functional neurological symptoms.1

Only 6% of patients with DID present with multiple or dissociated identities publicly and in an obvious manner.2 Unlike depictions in sensationalized films, such as Sybil and Split, the majority of people with DID do not have dramatic shifts in personality and only persons very close to them are typically aware of the personality changes.1 Unfortunately, such depictions have led some individuals to think DID is not a real disorder.

Dissociative amnesia is defined as an inability to recall autobiographical information beyond normal forgetfulness; the condition may also involve bewildered wandering or a fugue. Depersonalization/derealization disorder is characterized by clinically significant persistent or recurrent depersonalization (ie, detachment from the mind, self, or body) and/or derealization (ie, detachment from the surroundings).

Of particular importance for pain practitioners is stress, which may influence the patient’s mental state. Stress often produces transient exacerbation of dissociative symptoms that may make them more evident.1 In fact, dissociative disorders are frequently found in the aftermath of severe trauma, including persistent psychological, physical, or sexual abuse during childhood.3

In addition, dissociative symptoms may occur in other disorders such as post-traumatic stress disorder (PTSD) or borderline personality disorder. Thus, APA’s dissociative disorders chapter is placed next to the trauma- and stressor-related disorders in DSM-5, reflecting the close relationship between these diagnostic classes.1

The Case of Phillip/Jasmine

Phillip is a 55-year-old, Caucasian male who lives in a major metropolitan city with his wife of more than 20 years. He was referred to the pain clinic to help lessen his arthritic pain and improve his function because, in his words, “there is not enough medication to help with the pains.” His primary care provider had prescribed both opioid and non-opioid medications. Phillip has also been diagnosed with underlying medical conditions, including bipolar disorder, headaches, abdominal pain, calculus of the kidney, diabetes, and osteoarthritis, which may exacerbate his pain.

Due to his diagnosed dissociative disorder, Philip met regularly with a psychologist. His therapy had reached the recollection phase and he was beginning to understand the state of his co-consciousness (ie, the presence of alters). By definition, “alters” are not separate identities, but rather parts of a single individual that are not yet functioning together in a smooth, coordinated, and flexible way.4

Phillip came to one of his pain clinic appointments dressed as “Jasmine,” a distinct personality state, or alter, who presented herself because “she is reasonable, and Phillip tends to express himself more angry.” (Jasmine said she agreed to come despite the pain complaints coming from Phillip.) She expressed being concerned about her body image and questioned whether she was transgender. Phillip, when present in therapy, recalled Jasmine being shy; as a result, she would sometimes withdraw, leaving Phillip in situations in which he didn’t know where he was or why he was there.

Personality fusion (ie, when both identities share consciousness and negotiate everything) had not been fully achieved in the patient. The pain physician posed a question to the pain team: Can the alter switch during a session? If so, how might the transition affect the patient and the provider? In this case, for instance, could safety be called into question considering Phillip’s self-diagnosed anger?

Last updated on: November 9, 2017
Continue Reading:
Pain, Sleep & Suicide: The Core Role of Interventional Care
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