Dissociative disorders are not as well understood as many other psychiatric conditions. They are more controversial, and some clinicians have even questioned whether they exist. Dissociative disorders are hard to detect and underdiagnosed, and as a result of these and other factors, there is no clear clinical consensus on the best treatment protocol for dissociative disorders. However, this is beginning to change. As mental health professionals develop a better understanding of the effects of trauma on the brain, they gain insight into the psychiatric conditions linked to it. This is especially important for dissociative disorders, which are now much better understood as conditions that develop in response to trauma. Clinicians are uncovering g that these once-mysterious disorders not only exist as distinct clinical phenomena but have shared features and respond well to the right treatments.
Medications for Treating Dissociative Disorders
No psychiatric medications directly treat the symptoms of dissociative disorders. However, ongoing research is revealing that specific combinations of medications can effectively treat dissociative conditions, especially when they are comorbid with other psychiatric disorders. By treating other underlying conditions that trigger dissociative symptoms, dissociative conditions are improved as well.
Most people who have a dissociative disorder also have another psychiatric condition. Anxiety and depression are the most prevalent mental health conditions and are often comorbid with dissociative disorders. Comorbid disorders can create a vicious cycle in which the symptoms of one condition make the symptoms of another condition worse. As dissociative symptoms often develop in response to overwhelming emotional stress or pain, worsening depression and anxiety can trigger deeper and longer periods of dissociation.
Antidepressants can stabilize mood and reduce intrusive symptoms that trigger dissociation. Studies show that a combination of a selective serotonin reuptake inhibitors (SSRI), a specific kind of antidepressant medication, and lamotrigine, an anticonvulsant and mood stabilizer, is an effective treatment for dissociative disorders, especially depersonalization-derealization disorder. Common SSRIs prescribed for dissociative disorders include:
Whether these are used depends on numerous clinical factors, including the severity of comorbid depression, other co-occurring conditions and potential side effects.
Anxiety and dissociation are closely related. Both develop as responses to stress, trauma and chaos, and each can trigger the other. Dissociative symptoms and conditions are specifically linked with social anxiety disorder and panic disorder. Dissociation often occurs when symptoms of either of these conditions intensify.
Treating anxiety symptoms can reduce the severity of dissociative symptoms. Some anxiolytic medications reduce hyperarousal and the intrusive symptoms of dissociative disorders. The same SSRIs listed above are also commonly used to treat anxiety and are good choices for people with dissociative disorders. Benzodiazepines are typically contraindicated because they typically exacerbate dissociation.
Dissociative disorders are not psychotic disorders, and psychotic symptoms are rare in people with these disorders. Dissociative disorders are defined precisely by the fact that they approach psychosis without reaching it. People with dissociative disorders are usually aware that their perceptions are unusual; in fact, this intact sense of reality testing is one of the clinical criteria for diagnosis. Even so, antipsychotic medications can be used to treat dissociative disorders, just as they are used to treat a wide range of non-psychotic psychiatric disorders. Atypical antipsychotic medications have been found to stabilize mood and to reduce anxiety and intrusive symptoms in people with dissociative disorders.
Atypical antipsychotic medications used for non-psychotic disorders include:
- Aripiprazole (Abilify)
- Olanzapine (Zyprexa)
- Risperidone (Risperdal)
- Quetiapine (Seroquel)
- Ziprasidone (Geodon)
In addition to dissociative disorders, other non-psychotic disorders that have been shown to respond to this type of medication include:
- Eating disorders
- Mood disorders
- Post-traumatic stress disorder (PTSD)
- Obsessive-compulsive disorder (OCD)
- Attention-deficit hyperactivity disorder (ADHD)
- Anxiety disorders
Therapy for Dissociative Disorder
While medications can be used to treat dissociative disorders, therapy is more commonly recommended as the best intervention. Different types of therapy address different aspects of dissociative disorders, and particular combinations of therapy modalities can be especially effective. Many modern therapists incorporate multiple treatment modalities in their work with clients for this reason.
Cognitive Behavioral Therapy
Research shows that cognitive behavioral therapy (CBT) is one of the most effective therapy modalities overall. It is especially effective to reduce the severity of a wide range of psychiatric symptoms. A primary focus of CBT is identifying is identifying negative or inaccurate thoughts and beliefs that drive painful emotions and maladaptive behaviors.
Specifically, in the case of dissociative disorders, CBT focuses on addressing obsessive thoughts that exacerbate derealization and on developing behaviors that counteract or distract from these thoughts. Behavioral treatment can also incorporate grounding techniques to counteract disembodiment and other dissociative symptoms.
Dialectical Behavioral Therapy
Dialectical behavioral therapy (DBT) is a therapy style that was developed to treat borderline personality disorder. It incorporates elements of CBT, like identifying emotional triggers, as well as mindfulness practices that can improve distress tolerance and emotion regulation.
Given those borderline personality traits and dissociative symptoms often co-occur, it makes sense that DBT has been found to be effective for both. The mindfulness techniques used in DBT, which include meditation, breathing exercises, and additional self-soothing techniques, can counteract dissociative symptoms like depersonalization. Validation combats derealization by acknowledging the reality of a person’s emotional responses.
Psychodynamic psychotherapy is an older and more traditional form of therapy based on the work of pioneering figures like Sigmund Freud and Carl Jung. In this type of therapy, a person explores the effect of their past on their present, focusing on formative childhood experiences and a person’s relationship with their parents.
The main concept behind this style of therapy is that many negative behaviors developed as adaptations to stressful circumstances in childhood. To change these behaviors, a person must develop insight into their origins. Otherwise, emotional reactions remain unconscious. While this style of treatment has fallen out of fashion, it can still be an effective approach, especially for people with histories of trauma.
In the case of dissociative disorder therapy, psychodynamic psychotherapy can help people address and resolve underlying conflicts that drive dissociative symptoms. By gaining insight into the origins of their aversion to certain emotional states, they learn the deeper causes behind their dissociation. They become able to experience emotions they had previously found intolerable and from which they had dissociated.
Eye Movement Desensitization and Reprocessing (EMDR)
Eye movement desensitization and reprocessing (EMDR) therapy uses a novel technique in which the person receiving the treatment practices repetitive eye movements while revisiting a difficult memory to re-program their response to that memory. The development of EMDR as a way to treat trauma and has been shown to be effective for people with trauma histories and trauma-related disorders.
In a way, EMDR acts like a synthesis of CBT and psychodynamic therapy. Patients delve into memories like they would in psychodynamic psychotherapy and learn to reframe them as they would in CBT or DBT. This helps them develop different and less charged ways of reacting to these memories, often by forming new beliefs about them.
Treatment for Dissociative Disorders and Co-Occurring Disorders
It is rare for someone with a dissociative disorder not to have comorbid conditions, especially depression or anxiety. The most successful treatments for dissociative disorders address these co-occurring symptoms and conditions as well as unresolved trauma.
Dissociative Disorders and Addiction
A special concern in dissociative disorder treatment is co-occurring substance use disorders. It is not uncommon for people with trauma-related and acute stress disorders like post-traumatic stress disorder, borderline personality disorder and dissociative disorders to use substances as a form of self-medication. They may use substances to push away traumatic memories, soothe anxiety or even induce dissociation.
The combination of dissociation and substance abuse can be dangerous. Untreated psychiatric symptoms can cause substance dependence to develop quickly and intensely. In turn, substance use can exacerbate dissociative symptoms and comorbid anxiety and depression. In substance-induced dissociative states, people can feel so disconnected from the consequences of their actions that they become extremely self-destructive.
Substance use disorders require different and additional treatments beyond those typically used for mental health conditions. While talk therapy and medication can help, the complex behavioral changes required to recover from substance abuse are more likely to be successful with additional interventions. Group treatment and peer support networks are two popular and effective methods used to facilitate these changes.
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