Kaplan & Sadock’s Pocket Handbook of Clinical Psychiatry

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Dissociative Disorders

Treatment Psychotherapy

Insight-oriented psychotherapy, often with hypnotherapy or drug-assisted inter viewing, is the most efficacious approach. Hypnotherapy is useful in obtaining additional history, identifying previously unrecognized alters, and fostering ab reaction. Psychotherapeutic treatment begins by confirming the diagnosis and by identifying and characterizing the various personalities. Goals of therapy include reconciliation of disparate, split-off affects by helping the patient understand that the original reasons for the dissociation (overwhelming rage, fear, and confusion secondary to abuse) no longer exist and that the affects can be expressed by one whole personality without the self being destroyed. However, despite these treat ment modalities, hospitalization may be necessary in some cases. Pharmacotherapy Drug-assisted interviewing is helpful in obtaining additional history and identi fying unrecognized identities. Antidepressant and antianxiety medications can be useful as adjuvants to psychotherapy. In select groups of patients, anticonvulsant medications, such as carbamazepine (Tegretol), have been helpful (see Table 16-8 ). Depersonalization/Derealization Disorder Depersonalization is defined as the persistent or recurrent feeling of detachment or estrangement from one’s self. The individual may report feeling like an au tomaton or watching themselves in a movie. Derealization is somewhat related and refers to feelings of unreality or of being detached from one’s environment. TABLE 16-8. Medications for Associated Symptoms in Dissociative Identity Disorder Medications and somatic treatments for posttraumatic stress disorder (PTSD), affective disorders, anxiety disorders, and obsessive compulsive disorder (OCD) Selective serotonin reuptake inhibitors (no preferred agent, except for OCD symptoms) Fluvoxamine (Luvox) (for OCD presentations) Clomipramine (Anafranil) (for OCD presentations) Tricyclic antidepressants Monoamine oxidase inhibitors (if patient can reliably maintain diet safely) Electroconvulsive therapy (for refractory depression with persistent melancholic features across all dissociative identity disorder alters) Mood stabilizers (more useful for PTSD and anxiety than mood swings)

Dissociative Disorders

Divalproex (Depakote) Lamotrigine (Lamictal) Oral or intramuscular benzodiazepines

Medications for sleep problems

Low-dose trazodone (Desyrel) Low-dose mirtazapine (Remeron) Low-dose tricyclic antidepressants Low-dose neuroleptics Benzodiazepines (often less helpful for sleep problems in this population) Zolpidem (Ambien) Anticholinergic agents (diphenhydramine [Benadryl], hydroxyzine [Vistaril])

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Naltrexone (ReVia)

Medications for self-injury, addictions