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9 Articles in Volume 17, Issue #9
Can Physiological Profiles Affect Pain Treatment?
Editorial: Moving Forward from Trump's Opioid Declaration
How Might Pain Practitioners Best Offer Patients Relief Without Pharmacology?
Letters to the Editor: An opportunity to learn what is on the minds of your colleagues and patients
Lumbar Lordosis and Back Pain
Oxytocin, an Opioid Alternative, Ready for Regular Clinical Use to Manage Chronic Pain
Pain, Sleep & Suicide: The Core Role of Interventional Care
Spiritual Factors Impacting a Patient’s Ability to Cope with Uncertainty (Part 3)
The Inter-Connection between Smoking and Opioid Misuse

Can Physiological Profiles Affect Pain Treatment?

The presentation of dissociative or alter identities in a practice setting may change how a practitioner approaches treatment.

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?

Prevalence & Pain Levels in Dissociative Patient Profiles

Phillip/Jasmine’s case may not be an unusual one. The 12-month prevalence of DID among adults in a United States community is 1.5%; for dissociative amnesia, it’s 1.8%; and the lifetime prevalence of depersonalization/derealization disorder is approximately 2%.5,6 The prevalence of dissociative disorders in clinical settings ranges between 5% and 20.7% among inpatients; 12-38% among outpatients; and 34.9% among patients presenting to a psychiatric emergency room.7-9 Research examining the incidence of chronic pain among individuals with dissociative disorder is scarce.

In an extensive review of 52 previously reported cases of DID, headaches were the most frequent somatic complaint (more than 60%).10 Another study found that somatic symptoms, such as headaches, joint pain, back pain, pelvic pain, and pain in the extremities, were more common in patients with dissociative disorders than in control groups.11

Further research suggested subjects reporting more dissociative experiences had higher pain thresholds.12 Reports indicate that different personalities could “take over” at times of more severe pain.13 For example, patients with dissociative disorders frequently report amnesia after self-injury.14 It is possible that a patient may learn to voluntarily induce an altered state of consciousness, or “switch” identities, whereby different personalities assume executive control.15 These alters might present with different ages, genders, characteristics, or levels of autobiographical awareness. Some might be aware of, or be “co-conscious with,” other parts of the personality.

The predominant or primary personality in Dissociative Identity Disorder cases is therefore often designated as the “host personality.”13 One study documented a difference in pain perception, location, and estimates of secondary functional impairment among four different personalities in the same patient.13 In the case of Phillip/Jasmine, the patient, Phillip, would be considered the host personality, and Jasmine would be identified as the alter.

Current DSM-5 Diagnoses

Dissociative Identity Disorder is often difficult to detect due to the hidden nature of the dissociative symptoms, the coexistence of other mental health disorders, and feelings of disconnection that can be difficult for the patient to verbalize.16 Before the development of specialized diagnostic tests, patients suffering from dissociative disorders were often misdiagnosed, thereby preventing the start of effective treatment. Findings indicate that previous diagnoses (eg, bipolar, depression, anxiety, psychotic, substance use) were common in patients presenting with DID, and it was not uncommon for a decade or more to pass before a correct assessment of DID was made.16

Over the past 25 years, however, there has been an increase in scientific research on the diagnosis and treatment of dissociative disorders. Screening tools such as the Dissociative Experience Scale and the Somatoform Dissociation Questionnaire, as well as diagnostic tools, such as the Structured Clinical Interview for Dissociative Disorders, the “gold standard,” have helped advance identification and treatment.17 While screening tests may not diagnose a specific dissociative disorder, tools may help identify patients with dissociative symptoms who need to be further evaluated. Thus, it is recommended that providers seek out a specialized evaluation with a trained mental health professional.

Treatment Plans

Patients with dissociative disorders often have complex presentations, including high levels of comorbid psychiatric difficulties, and often use multiple psychotropic medications. These complicated conditions are almost always excluded from research, resulting in limited information about treatment outcomes.18

The standard of care for dissociative disorders is specialized psychotherapy, which focuses on understanding the dissociative symptoms and developing constructive ways of coping with stress. The dissociation may be acting as a creative survival mechanism in the face of overwhelming trauma, whereby the mind shields itself by segregating the experience, or “splitting” it off into its constituent parts, rather than experiencing it as what would be an unendurable “whole.”19 Medications, such as antidepressants, anticonvulsants, or tranquilizers, may be used as an adjunct to psychotherapy to help control mental health symptoms associated with the disorders, but no medications have been reported to specifically treat dissociative disorders.

Although DID is the most severe of the dissociative disorders, it responds well to long-term psychotherapy intended to help the patient merge his/her multiple personalities into one personality.20 The trauma of the past should be explored and resolved with proper emotional expression. The consensus of experts is that phase-oriented treatment is most effective: 1) Establishing safety, (ie, stabilization, symptoms reduction); 2) working through and integrating traumatic memories; and 3) integration and rehabilitation.21 Hospitalization may be required if behavior becomes bizarre or destructive. Patients in later stages of treatment have been found to engage in fewer self-injurious behaviors and fewer hospitalizations and showed higher levels of adaptive coping than those in the initial stages.18 Additionally, patients in the later stages of treatment tend to report lower symptoms of dissociation and distress than patients in initial treatment stages.18

When treating for dissociative amnesia, including dissociative fugue, psychotherapy often involves hypnosis, which may help a patient remember and work through trauma. Other forms of therapy include creative art therapy, which may help with thought expression; cognitive behavioral therapy (CBT), which may help identify unhealthy and negative beliefs/behaviors; and medications.22 Patients with dissociative disorders are most frequently found to be highly hypnotizable in comparison to patients diagnosed with other mental health disorders.23

Treatment for depersonalization disorder can be very difficult. However, the condition may improve with a thorough therapeutic exploration of the trauma in the individual’s past and the use of eye movement desensitization and reprocessing (EMDR). This therapy is designed to alleviate the distress associated with traumatic memories, and combines the CBT techniques of re-learning thought patterns with visual stimulation exercises to access traumatic memories and replace the associated negative beliefs with positive ones.20 However, the use of EMDR remains controversial and it is suggested that other treatments for trauma, such as prolonged exposure or cognitive processing therapy, be utilized instead.24 Thus, it is recommended that providers seek out a specialized treatment with a trained mental health professional.

Revisiting Phillip’s Case

The therapeutic approach recommended by the author to the pain clinic team was to build a relationship with the patient prior to initiating any invasive treatments, and to discuss concerns openly with Phillip/Jasmine and his partner. Providers were encouraged to acknowledge Jasmine as being an alter, engage with all parts of Phillip’s personality in a non-prejudicial, affirming way, and to discuss the risks to the patient and to the provider associated with more invasive treatments with all identities when present.25

It was also recommended that a multidisciplinary approach to pain management be instituted with collaboration from the primary psychologist to ensure the appropriate evaluation and treatment care plan were developed with the appropriate alter(s).

Last updated on: November 9, 2017
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