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Guidelines for Treating Dissociative Identity Disorder in ...

This article was downloaded by: [ ]On: 21 October 2011, At: 09:20 Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UKJournal of Trauma & DissociationPublication details, including instructions for authors andsubscription information: for Treating DissociativeIdentity Disorder in Adults, ThirdRevisionInternational Society for the Study of Trauma and DissociationAvailable online: 03 Mar 2011To cite this article: International Society for the Study of Trauma and Dissociation (2011): Guidelinesfor Treating Dissociative Identity Disorder in Adults, Third Revision, Journal of Trauma & Dissociation,12:2, 115-187To link to this article: SCROLL DOWN FOR ARTICLEFull terms and conditions of use: article may be used for research, teaching, and private study purposes.

116 International Society for the Study of Trauma and Dissociation revision was undertaken by a new task force3 in 2009 and 2010 after input from an open-ended survey of the membership. The current revision of the Guidelines focuses specifically on the treatment of dissociative identity disorder (DID) and those forms of disso-

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Transcription of Guidelines for Treating Dissociative Identity Disorder in ...

1 This article was downloaded by: [ ]On: 21 October 2011, At: 09:20 Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UKJournal of Trauma & DissociationPublication details, including instructions for authors andsubscription information: for Treating DissociativeIdentity Disorder in Adults, ThirdRevisionInternational Society for the Study of Trauma and DissociationAvailable online: 03 Mar 2011To cite this article: International Society for the Study of Trauma and Dissociation (2011): Guidelinesfor Treating Dissociative Identity Disorder in Adults, Third Revision, Journal of Trauma & Dissociation,12:2, 115-187To link to this article: SCROLL DOWN FOR ARTICLEFull terms and conditions of use: article may be used for research, teaching, and private study purposes.

2 Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly publisher does not give any warranty express or implied or make any representationthat the contents will be complete or accurate or up to date. The accuracy of anyinstructions, formulae, and drug doses should be independently verified with primarysources. The publisher shall not be liable for any loss, actions, claims, proceedings,demand, or costs or damages whatsoever or howsoever caused arising directly orindirectly in connection with or arising out of the use of this of Trauma & Dissociation, 12:115 187, 2011 Copyright International Society for the Studyof Trauma and DissociationISSN: 1529-9732 print/1529-9740 onlineDOI: for Treating Dissociative IdentityDisorder in Adults, Third RevisionINTERNATIONAL SOCIETY FOR THE STUDYOF TRAUMA AND DISSOCIATIONFOREWORDThe International Society for the Study of Dissociation (ISSD), the formername of the International Society for the Study of Trauma and Dissociation(ISSTD), adopted theGuidelines for Treating Dissociative Identity Disorder (Multiple Personality Disorder ) in Adultsin 1994.

3 However, theGuidelinesmust be responsive to developments in the field and require ongoing first revision of theGuidelineswas proposed by the ISSD s Standardsof Practice Committee1and was adopted by the ISSD Executive Councilin 1997 after substantial comment from the ISSD membership. The secondrevision of theGuidelineswas requested and approved in 2005 based on theexpertise of a task force of expert clinicians and currentReceived 10 April 2010; accepted 12 June 2011 by the International Society for the Study of Trauma and Dissociation(ISSTD), 8400 Westpark Drive, Second Floor, McLean, VA 22102. TheGuidelinesmay bereproduced without the written permission of the ISSTD as long as this copyright notice isincluded along with the address of the ISSTD. Violators are subject to prosecution underfederal copyright correct citation for this revision of theGuidelinesis as follows: International Societyfor the Study of Trauma and Dissociation.

4 (2011). [Chu, J. A., Dell, P. F., Van der Hart, O.,Carde a, E., Barach, P. M., Somer, E., Loewenstein, R. J., Brand, B., Golston, J. C., Courtois,C. A., Bowman, E. S., Classen, C., Dorahy, M., Sar,V.,Gelinas, ,Fine, ,Paulsen,S., Kluft, R. P., Dalenberg, C. J., Jacobson-Levy, M., Nijenhuis, E. R. S., Boon, S., Chefetz, , Middleton, W., Ross, C. A., Howell, E., Goodwin, G., Coons, P. M., Frankel, A. S., Steele,K., Gold, S. N., Gast, U., Young, L. M., & Twombly, J.]. Guidelines for Treating dissociativeidentity Disorder in adults, third of Trauma & Dissociation, 12,115 correspondence to International Society for the Study of Trauma andDissociation, 8400 Westpark Drive, Second Floor, McLean, VA 22102. E-mail: by [ ] at 09:20 21 October 2011 116 International Society for the Study of Trauma and Dissociationrevision was undertaken by a new task force3in 2009 and 2010 after inputfrom an open-ended survey of the current revision of theGuidelinesfocuses specifically on thetreatment of Dissociative Identity Disorder (DID) and those forms of disso-ciative Disorder not otherwise specified (DDNOS) that are similar to is intended as a practical guide to the management of adult patientsand represents a synthesis of current scientific knowledge and informedclinical practice.

5 There is a separateGuidelines for the Evaluation andTreatment of Dissociative Symptoms in Children and Adolescents(ISSD,2004) available through the ISSTD and published in theJournal of Trauma& Dissociation. The American Psychiatric Association (2004) has publishedPractice Guidelines for the Treatment of Patients with Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD), which may be relevant tothe treatment of the past 30 years, the diagnosis, assessment, and treatment of dis-sociative disorders have been enhanced by increased clinical recognitionof Dissociative conditions, the publication of numerous research and schol-arly works on the subject, and the development of specialized diagnosticinstruments. Peer-reviewed publications concerning Dissociative disordershave appeared in the international literature from clinicians and investiga-tors in at least 26 countries, including the United States, Canada, PuertoRico, Argentina, The Netherlands, Norway, Switzerland, Northern Ireland,Great Britain, France, Germany, Italy, France, Sweden, Spain, Turkey, Israel,Oman, Iran, India, Australia, New Zealand, the Philippines, Uganda, China,and Japan.

6 These publications include clinical case series and case reports;psychophysiological, neurobiological, and neuroimaging research; discus-sion of the development of diagnostic instruments; descriptions of openclinical trials and treatment outcome studies; and descriptions of treatment,treatment modalities, and treatment dilemmas. They consistently provideevidence that DID is a valid cross-cultural diagnosis that has validity compa-rable to or exceeding that of other accepted psychiatric diagnoses (Gleaves,May, & Carde a, 2001). However, they also note that pathological alterationsof Identity and/or consciousness may present in other cultures as spirit pos-session and other culture-bound syndromes (Carde a, Van Duijl, Weiner, &Terhune, 2009).Key findings and generally accepted principles that reflect current sci-entific knowledge and clinical experience specific to the diagnosis and treat-ment of DID and similar forms of DDNOS are presented in should be understood that information in theGuidelinessupplements,but does not replace, generally accepted principles of psychotherapy andDownloaded by [ ] at 09:20 21 October 2011 Journal of Trauma & Dissociation, 12:115 187, 2011117psychopharmacology.

7 Treatment for DID should adhere to the basic princi-ples of psychotherapy and psychiatric medical management, and therapistsshould use specialized techniques only as needed to address specificdissociative recommendations in theGuidelinesare not intended to beconstrued as or to serve as a standard of clinical care. The practice rec-ommendations reflect the state of the art in this field at the present not designed to include all proper methods of care or toexclude other acceptable treatment interventions. Moreover, adhering to theGuidelineswill not necessarily result in a successful treatment outcome inevery case. Treatment should always be individualized, and clinicians mustuse their judgment concerning the appropriateness for a particular patientof a specific method of care in light of the clinical data presented by thepatient and options available at the time of , CLINICAL DIAGNOSIS, AND DIAGNOSTICPROCEDURESDID and Dissociative disorders are not rare conditions.

8 In studies of the gen-eral population, a prevalence rate of DID of 1% to 3% of the population hasbeen described (Johnson, Cohen, Kasen, & Brook, 2006; Murphy, 1994; Ross,1991; Sar, Aky z, & Do gan, 2007; Waller & Ross, 1997). Clinical studies inNorth America, Europe, and Turkey have found that generally between 1%to 5% of patients in general inpatient psychiatric units; in adolescent inpa-tient units; and in programs that treat substance abuse, eating disorders, andobsessive-compulsive Disorder may meetDiagnostic and Statistical Manualof Mental Disorders(4th ed., text rev. [DSM IV TR]; American PsychiatricAssociation, 2000a) diagnostic criteria for DID, particularly when evaluatedwith structured diagnostic instruments (Bliss & Jeppsen, 1985; Foote, Smolin,Kaplan, Legatt, & Lipschitz, 2006; Goff, Olin, Jenike, Baer, & Buttolph, 1992;Johnson et al.)

9 , 2006; Karadag et al., 2005; Latz, Kramer, & Highes, 1995;McCallum, Lock, Kulla, Rorty, & Wetzel, 1992; Modestin, Ebner, Junghan,& Erni, 1995; Ross, Anderson, Fleisher, & Norton, 1991; Ross et al., 1992; Sar, Aky z, et al., 2007; Saxe et al., 1993; Tutkun et al., 1998). Many of thepatients in these studies had not previously been clinically diagnosed witha Dissociative clinical diagnosis affords early and appropriate treatment forthe Dissociative disorders. The difficulties in diagnosing DID result primar-ily from lack of education among clinicians about dissociation, dissociativedisorders, and the effects of psychological trauma, as well as from clini-cian bias. This leads to limited clinical suspicion about Dissociative disordersand misconceptions about their clinical presentation. Most clinicians havebeen taught (or assume) that DID is a rare Disorder with a florid, dramaticDownloaded by [ ] at 09:20 21 October 2011 118 International Society for the Study of Trauma and Dissociationpresentation.

10 Although DID is a relatively common Disorder , R. P. Kluft(2009) observed that only 6% make their DID obvious on an ongoingbasis (p. 600). R. P. Kluft (1991) has referred to these moments of visibil-ity as windows of diagnosability (also discussed by Loewenstein, 1991a).Instead of showing visibly distinct alternate identities, the typical DID patientpresents a polysymptomatic mixture of Dissociative and posttraumatic stressdisorder (PTSD) symptoms that are embedded in a matrix of ostensibly non-trauma-related symptoms ( , depression, panic attacks, substance abuse,somatoform symptoms, eating-disordered symptoms). The prominence ofthese latter, highly familiar symptoms often leads clinicians to diagnoseonly these comorbid conditions. When this happens, the undiagnosed DIDpatient may undergo a long and frequently unsuccessful treatment for theseother , almost all practitioners use the standard diagnostic interviewsand mental status examinations that they were taught during professionaltraining.


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