EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE AMERICAN PSYCHIATRIC ASSOCIATION
HONOLULU--Growing recognition of a distinct dissociative subtype of posttraumatic stress disorder is reflected in diagnostic changes proposed for the next edition of the Diagnostic and Statistical Manual of Mental Disorders, Dr. David Spiegel said.
In the meantime, recent evidence suggests that the psychotherapy often prescribed for patients with the hyperarousal subtype of PTSD might be insufficient for those with predominantly dissociative symptoms, Dr. Spiegel said at the meeting.
"The idea is to have a dissociative subtype for PTSD," Dr. Spiegel said. "This is an important addition to PTSD in the DSM-5."
A combination of supportive care and prolonged exposure therapy might be the optimal approach. "This is pretty clear evidence that for those who are high in dissociative symptoms, prolonged exposure alone is not as effective as a more cognitive and supportive psychotherapy," Dr. Spiegel said. With hyperarousal PTSD, exposure-based therapy is designed to teach patients to regulate their own emotional arousals. They are systematically exposed to various traumatic memories, see them from a different point of view (cognitive restructuring), and decondition the fear-based reactions. "It's focused on fear as a primary affect and the amygdala fear system as an aroused system."
In contrast, "for the dissociative subtype, we recommend phase-oriented treatment," Dr. Spiegel said. "You want to identify the dissociative symptomatology, stabilize the patient, discuss and clarify the meaning of the dissociative symptoms, explore stressors that might lead to dissociative episodes, and reduce the risk of revictimization, which is a major problem," Dr. Spiegel said. People with dissociative PTSD tend to detach themselves from fear and risk so well that they are at risk of experiencing another dangerous situation, he said.
"You teach people (in more detail) mood regulation and abilities to self-soothe, the ability to access dissociative material in a controlled manner, and to identify attachment schemas," Dr. Spiegel said. For example, a "traumatic transference" can arise whereby the patient identifies the therapist with whoever or whatever inflicted the trauma. "Invariably, they will be expecting you to reinjure them rather than to help them. Dealing with those transference issues is a crucial part of psychotherapy, especially [for] those with dissociative-type trauma."
People with the dissociative subtype also are more likely to have a history of early life trauma (including physical or sexual abuse), compared with those who have hyperarousal PTSD, so they will be more sensitive to traumatic transference issues, Dr. …