# Textbook of Psychiatry/Dissociative Disorders/Special Populations

Dissociative disorders can be a difficult set of disorders to diagnose due to their significant comorbidities and overlap with other psychiatric and medical diagnoses. Studies show a range of inpatient prevalences of 5% to 21% with outpatient prevalences ranging from 12% to 29%, which highlights the difficulty in accurate diagnosis (Brand et. al 2009). Dissociative disorders are shown to have significant comorbidity with multiple other psychiatric disorders that should be screened for including depression, borderline personality disorder, social anxiety, and somatization disorders (Evren et. al 2007) (Evren et. al 2009). More research needs to be done with dissociative populations to draw more firm conclusions, but many correlations have been gathered. Special populations that should be considered in relation to dissociative disorders include suicidal/self-mutilating, traumatized, eating disordered, substance abusing, and pediatric groups.

## Suicidal and Self-Mutilating Populations

Both suicide attempts and self-mutilating behavior fall into the broader category of self-harm. While the difference between a suicidal or parasuicidal (self-mutilating) action may not always be easy to distinguish clinically, by definition they are quite distinct. Self-mutilation involves self-harm with no goal of suicide, while suicidal actions are meant to bring about one’s death.
There is a fair amount of evidence supporting a relationship between dissociative disorder and suicide ideations/attempts. In one study of drug dependent patients there is a statistically significant increase in suicide attempts when comparing patients with dissociative disorder diagnoses to those without them (Tamar-Gurol et al. 2008). Another study showed that among patients with multiple suicide attempts, dissociative disorders are the strongest predictors of multiple suicide attempts when compared with borderline personality disorder, posttraumatic stress disorder, and alcohol abuse/dependence (Foote et al. 2008). With frequent comorbidity, there can be significant overlap between dissociative disorders, other psychiatric disorders, and suicidal behaviors. While there appears to be a link between dissociative disorders and suicidal ideations, a comorbid diagnosis of somatization disorder with dissociative disorder is a significant predictor of suicidal ideation (Ozturk and Sar, 2008). While suicidal behavior can be present in each specific dissociative disorder, it is particularly prevalent in Dissociative Identity Disorder possibly due to decreased affect tolerance (Kaplan and Sadock, 2007).
While self-mutilation and suicide attempts are distinct entities, nearly 55% to 85% of people with self-mutilating behavior have made a suicide attempt (Evren et al. 2008). Thus with dissociative disorders carrying such a high risk for suicidal behaviors, it comes as no surprise that they also increase the risk for self-mutilation. Among alcohol dependent patients, those placed within a dissociative group based on results of Dissociative Experiences Scales were at higher risk for self-mutilation (Evren et al. 2008).

## Traumatized Population

Traumatic events are a common factor in many psychiatric diagnoses including anxiety disorders, such as posttraumatic stress disorder, and personality traits like borderline personality disorder. A history of traumatic experience is quite common among all of the various dissociative disorders as well. Studies have shown a statistically greater incidence of emotional abuse among subsets with dissociative diagnoses than those without such diagnoses (Tamar-Gurol et al. 2008). However, the nature of the trauma can be quite diverse or specific from one dissociative diagnosis to the next. Dissociative fugue states are frequently seen around times of natural disasters, or during wartime among military personnel. Childhood trauma, usually of physical or sexual nature, is seen in 85% to 97% of patients with Dissociative Identity Disorder. Dissociative amnesia is often due to abuse; however, it can be related to wartime experiences as well. Like posttraumatic stress disorder, the severity of symptoms is highly correlated with the intensity of the combat (Kaplan and Sadock, 2007). With the correlation of traumatic experiences and dissociative disorders, presence of one should warrant screening for the other.

## Eating Disordered Population

Many impulsive behaviors have been associated with dissociative disorders, and pathologic eating behaviors are included in this set. In fact, dissociative symptoms are frequently described in individuals with bulimic disorders (Waller et al. 2001). Among the various dissociative diagnoses, it appears that eating disorders are most prevalent with dissociative identity disorder (Kaplan and Sadock, 2007). One study looked at groups of women with eating disorders ranging from anorexia, anorexia with binge-purge subtype, bulimia nervosa, and binge-eating. These women were then administered Dissociative Experiences Scales (DES) to identify those with the most significant dissociative features. Findings showed the binge-purge subtype of anorexia to have the greatest proportion of dissociative cases while binge-eating disorder patients were lower and similar to control groups (Waller et al. 2001). Other factors like abuse or trauma may confound the analysis of studies like these. However, there appears to be a correlation between dissociative disorders and impulsive behaviors, which includes eating disorders.

## Substance Abusing Population

Substance abuse is a common comorbidity with multiple psychiatric disorders including mood, anxiety, and psychotic disorders. Among those with dissociative disorders, substance abuse is frequently reported. However, studies show varied results in regards to their association. One study included inpatients with drug dependence (marijuana, cocaine, heroine, ecstacy, solvents) that often had comorbid alcohol dependence as well. The prevalence of dissociative disorders among the drug dependent inpatients was significantly higher than the general psychiatric inpatient population, showing correlation between the two (Tamar-Gurol, 2008). Another study included inpatients with alcohol dependence excluding any other comorbid drug abuse. Here the percentage of dissociative disorders among alcohol dependent patients was very similar to the general psychiatric inpatient population. This confers no increased risk of dissociative disorders among alcohol dependent inpatients (Evren et al. 2005). The reason for the difference seen between alcohol versus drug dependence is not known. However, both studies show that dissociative symptoms were present in a majority of the population before alcohol or drug use, 90% and 59.3% respectively (Evren et al. 2005)(Tamar-Gurol, 2008). This emphasizes the importance of screening for dissociative symptoms to potentially help prevent the progression to substance abuse or dependence.

## Pediatric Population

Though pediatric populations are not frequently diagnosed with dissociative disorders, this subgroup may experience the trauma later associated with dissociative diagnoses. One study of drug dependent patients evaluated several variables between groups with dissociative disorders and those without them. Aside from suicide attempts, the only variable to reach statistical significance for increased risk for dissociative diagnoses was emotional abuse taking place during childhood (Tamar-Gurol, 2008). Another study showed that even among children and adolescents treated for dissociative disorders, 82.6% met the criteria for psychiatric disorders at an average of twelve years later. Nearly half of these had diagnosed personality disorders with significantly lower psychosocial adjustment in adulthood (Jans et al. 2008). Thus, recognizing childhood trauma and dissociative symptoms may prove helpful in starting early treatment to help adult adjustment and functioning.
As often is seen in pediatric populations, there are sometimes differences in expression of symptoms between children and adults. In dissociative identity disorder children are noted to be less able to distinguish lapses in time and abnormal behaviors, and often teachers and relatives document these changes. In dissociative fugue adults are often noted to travel large distances or for prolonged periods of time. However, children and adolescents are often much more limited in this capacity and their fugues are often of shorter distances or of shorter duration (Kaplan and Sadock, 2007).