The Dissociative Subtype of Posttraumatic Stress Disorder (PTSD) Among Adolescents: Co-Occurring PTSD, Depersonalization/Derealization, and Other Dissociation Symptoms.

OBJECTIVE: The purpose of this study was to examine the co-occurrence of posttraumatic stress disorder (PTSD) and dissociation in a clinical sample of trauma-exposed adolescents by evaluating evidence for the depersonalization/derealization dissociative subtype of PTSD as defined by the DSM-5 and then examining a broader set of dissociation symptoms. METHOD: A sample of treatment-seeking, trauma-exposed adolescents 12 to 16 years old (N = 3,081) from the National Child Traumatic Stress Network Core Data Set was used to meet the study objectives. Two models of PTSD/dissociation co-occurrence were estimated using latent class analysis, one with 2 dissociation symptoms and the other with 10 dissociation symptoms. After model selection, groups within each model were compared on demographics, trauma characteristics, and psychopathology. RESULTS: Model A, the depersonalization/derealization model, had 5 classes: dissociative subtype/high PTSD; high PTSD; anxious arousal; dysphoric arousal; and a low symptom/reference class. Model B, the expanded dissociation model, identified an additional class characterized by dissociative amnesia and detached arousal. CONCLUSION: These 2 models provide new information about the specific ways PTSD and dissociation co-occur and illuminate some differences between adult and adolescent trauma symptom expression. A dissociative subtype of PTSD can be distinguished from PTSD alone in adolescents, but assessing a wider range of dissociative symptoms is needed to fully characterize adolescent traumatic stress responses.

Dissociative disorders in DSM-5.

BACKGROUND: We present recommendations for revision of the diagnostic criteria for the Dissociative Disorders (DDs) for DSM-5. The periodic revision of the DSM provides an opportunity to revisit the assumptions underlying specific diagnoses and the empirical support, or lack of it, for the defining diagnostic criteria. METHODS: This paper reviews clinical, phenomenological, epidemiological, cultural, and neurobiological data related to the DDs in order to generate an up-to-date, evidence-based set of DD diagnoses and diagnostic criteria for DSM-5. First, we review the definitions of dissociation and the differences between the definitions of dissociation and conceptualization of DDs in the DSM-IV-TR and the ICD-10, respectively. Also, we review more general conceptual issues in defining dissociation and dissociative disorders. Based on this review, we propose a revised definition of dissociation for DSM-5 and discuss the implications of this definition for understanding dissociative symptoms and disorders. RESULTS: We make the following recommendations for DSM-5: 1. Depersonalization Disorder (DPD) should derealization symptoms as well. 2. Dissociative Fugue should become a subtype of Dissociative Amnesia (DA). 3. The diagnostic criteria for DID should be changed to emphasize the disruptive nature of the dissociation and amnesia for everyday as well as traumatic events. The experience of possession should be included in the definition of identity disruption. 4. Should Dissociative Trance Disorder should be included in the Unspecified Dissociative Disorder (UDD) category. CONCLUSIONS: There is a growing body of evidence linking the dissociative disorders to a trauma history, and to specific neural mechanisms.

Síntomas de despersonalización en pacientes psiquiátricos: la nueva escala de despersonalización presente-vida (DP-PV) / Depersonalization symptoms in psychiatric patients: the new Lifetime and Present Depersonalization Scale

Introducción: Los síntomas de despersonalización están presentes no únicamente en el Trastorno por Despersonalización, sino también de forma importante en otros trastornos psiquiátricos con notable relevancia. Esta escala presenta una nueva metodología para medir los síntomas por despersonalización presentes y pasados en población psiquiátrica. Métodos: La escala fue testada en una muestra de 44 pacientes ingresados. Se realizó test-retest para evaluar la fiabilidad y se realizaron correlaciones con la escala de Experiencias Disociativas (DES) y la Escala de Ansiedad y Depresión Hospitalaria (HADS). Resultados: Se obtuvieron coeficientes alfa de Cronbach de 0.935 y 0.910 para las dos subescalas de tiempo-vida y tiempopresente. La mayoría de los ítems obtuvieron una puntuación en el coeficiente de correlación intraclase (ICC) entre bueno y excelente. Se observan correlaciones significativas con las puntuaciones de la escala DES y la HADS. Conclusiones: La nueva escala ha demostrado ser un instrumento adecuado para identificar y medir los síntomas de despersonalización en pacientes afectos de diversos trastornos psiquiátricos (AU)

Introduction: Depersonalization symptoms are not specific to depersonalization disorder and are frequently observed in other psychiatric disorders. The Lifetime and Present Depersonalization Scale represents a new method designed to measure past and present depersonalization symptoms in psychiatric samples. Methods: The Lifetime and Present Depersonalization Scale was tested in a sample of 44 psychiatric inpatients. Test-retest measures were used to assess reliability. Correlations with Dissociative Experiences Scale (DES) and the Hospital Anxiety and Depression Scale (HADs) were used to assess validity. Results: The Cronbach alpha coefficients for both life-time and present-time subscales were 0,935 and 0,92 respectively. Most items obtained a good to excellent intraclass correlation coefficient (ICC). Significant correlations were found for the scores obtained in the DES and HADS. Conclusions: The Lifetime and Present Depersonalization Scale is presented as an appropriate instrument for identifying and measuring depersonalization symptoms in psychiatric samples (AU)

Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals.

BACKGROUND: Burnout has negative effects on work performance and patient care. The current standard for burnout assessment is the Maslach Burnout Inventory (MBI), a well-validated instrument consisting of 22 items answered on a 7-point Likert scale. However, the length of the MBI can limit its utility in physician surveys. OBJECTIVE: To evaluate the performance of two questions relative to the full MBI for measuring burnout. DESIGN AND PARTICIPANTS: Cross-sectional data from 2,248 medical students, 333 internal medicine residents, 465 internal medicine faculty, and 7,905 practicing surgeons. MEASUREMENTS AND MAIN RESULTS: The single questions with the highest factor loading on the emotional exhaustion (EE) ("I feel burned out from my work") and depersonalization (DP) ("I have become more callous toward people since I took this job") domains of burnout were evaluated in four large samples of medical students, internal medicine residents, internal medicine faculty, and practicing surgeons. Spearman correlations between the single EE question and the full EE domain score minus that question ranged from 0.76-0.83. Spearman correlations between the single DP question and the full DP domain score minus that question ranged from 0.61-0.72. Responses to the single item measures of emotional exhaustion and depersonalization stratified risk of high burnout in the relevant domain on the full MBI, with consistent patterns across the four sampled groups. CONCLUSIONS: Single item measures of emotional exhaustion and depersonalization provide meaningful information on burnout in medical professionals.

The older female patient with a complex chronic dissociative disorder.

Dissociative disorders are rarely considered in the diagnostic assessment of older women, despite the fact that the existence, appearance and characteristics of certain dissociative disorders in older populations has been known and described since the 1980s. This communication reviews the core phenomena of Dissociative Identity Disorder and related forms of Dissociative Disorder Not Otherwise Specified, the natural history of their phenomena from youth to old age, and describes common presentations of Dissociative Disorders in older women. It also reviews the treatment of complex chronic dissociative disorders and discusses alternative approaches to their psychotherapy in the older female patient. It is crucial to recognize and respect the importance of appreciating individual differences among older dissociative patients and to individualize their treatments accordingly.

[The validity of the depersonalisation-derealisation scale of the narcissism--inventory]. / Zur Validität der Skala Derealisation/Depersonalisation des Narzissmusinventars.

The German Narcissism-Inventory contains a 6-item scale for the assessment of depersonalization (DP) and derealization (DR). The validity of this scale (NI-DRP) was examined in comparison to the German version of the Dissociative Experiences Scale (FDS) and the Cambridge Depersonalization Scale (CDS). The sample consists of 144 psychotherapy patients, of whom showed on the basis of a structured clinical interview n = 51 none, n = 45 mild, n = 28 moderate and n = 20 severe DP-DR. The areas under the curve and the rate of misclassification did not differ for NI-DRP and the scales of the FDS. The CDS showed the lowest rate of misclassifications.

Dentists' self assessment of burnout: an internet feedback tool.

OBJECTIVES: The Stress Thermometer is an easily accessible Internet-based instrument for feedback on work stress and burnout. The aim of this paper is to describe the development of this instrument and to determine its applicability within the dental practice. METHODS: The Stress Thermometer was made accessible to all members of the Dutch Dental Association, of which 77% of all Dutch dentists are members. Frequency of use was determined, and descriptive data was collected. RESULTS: During an evaluation period of 5 months at least 12% of all possible respondents made use of the Stress Thermometer. Descriptive characteristics of the response group, as well as levels of burnout and work stress, corresponded with those found in the Dutch dentist population. However, some deviations were also present. CONCLUSIONS: Results indicate the applicability of the Stress Thermometer to a representative variety of dentists. Although the deviations found should not be ignored in future use, the Stress Thermometer was successful in reaching a population that is difficult to reach. It effectively calls attention to sensitive personal issues concerning work-related stress and burnout.

Examination of the pathological dissociation taxon in depersonalization disorder.

In recent years, the pathologic dissociation taxon developed by Waller, Putnam, and Carlson (Psychological Methods 1:300-321, 1996) from a Dissociative Identity Disorder (DID) sample has been increasingly used in studies of dissociation in general. However, the taxon's convergence with dissociative diagnoses other than DID, as well as the taxon's central premise that pathologic dissociation is a categorical rather than a dimensional construct, remain areas of exploration. This report examines the applicability of the pathologic dissociation taxon to Depersonalization Disorder (DPD). The Dissociative Experiences Scale was administered to 100 consecutively recruited DPD subjects diagnosed by semistructured clinical interview and by the SCID-D. Taxon membership probability was calculated using the recommended SAS scoring program. Approximately 2/3 of subjects (N = 64) had a very high probability (>.80) of belonging to the taxon, while 1/3 of subjects had a very low probability (<.10) of belonging to the taxon. A taxon cutoff score of 13 yielded an 81% sensitivity in detecting the presence of DPD. The modest convergence between taxonic membership and clinical dissociative disorder diagnosis suggests that the taxon may have important limitations in its use, at least when applied to DPD in its current form. As previously, we continue to recommend a low taxon cutoff score (13) for the sensitive detection of depersonalization disorder. The inference that pathologic dissociation is a unitary and categorical entity is also discussed.

[Two types of depersonalization--reconsideration from a descriptive-phenomenological view point].

The term depersonalization has been vaguely used in clinical contexts and there is confusion over its nosological positioning. Although the syndrome has been assigned a niche of its own in the European psychiatric taxonomy, the American's Diagnostic and Statistical Manual of Mental Disorders (DSM-III, IV) labeled it under the term Dissociative Disorder. The latter, which does not agree with the classical theory of Janet, seems to have no basis on traditional psychopathology and is not derived from any dissociative theories. In this paper the descriptive characteristics of depersonalization are discussed with regard to the features of "observing self" and the relationship between experiences and selves, according to which the authors distinguish two types of depersonalization: an "excessive-self-reflecting type" and an "absorbed-in-experience type". Whereas the former coinsides with the typical depersonalization neurosis, in which excessive self-reflection plays an important role in reducing the sense of reality, in the latter over-absorption in some situations leads the patient to construct a wall to block out reality. We suggest that in making a distinction between these two types, the psychopathology of depersonalization will be better clarified.

Development of a depersonalization severity scale.

Our aim was to develop a clinician-rated scale assessing depersonalization severity for use in clinical trials of Depersonalization Disorder and trauma-related disorders in general. The 6-item Depersonalization Severity Scale (DSS) was administered to 63 participants with DSM-IV Depersonalization Disorder as diagnosed by the SCID-D, and its psychometric properties were examined. The sensitivity of the DSS and of the Dissociative Experiences Scale (DES) to treatment change was assessed in blinded, controlled settings. Individual items were widely distributed across the severity range. Interrater reliability was excellent and internal consistency was moderate. The DSS had high convergent and discriminant validity and was sensitive to treatment change. The DES was also sensitive to treatment change. We recommend piloting the DSS in future treatment trials of trauma-spectrum disorders.

Primary and secondary depersonalisation disorder: a psychometric study.

INTRODUCTION: Depersonalisation may be part of a symptom-complex, a primary or a secondary disorder. Optimal methods of measurement and diagnosis have not been established. METHODS: We assessed 42 patients with primary or secondary depersonalisation, plus psychiatric and non-psychiatric controls using a variety of self-report questionnaire scales including the Beck depression and anxiety Inventories, and one developed by the authors (the Fewtrell Depersonalisation Scale (FDS)). The correlations between the scales and measures of anxiety and depression were calculated, as were sensitivity and specificity against an operational case definition. RESULTS: All the scales were highly correlated. All could distinguish depersonalisation cases from the rest but none could distinguish between primary and secondary depersonalisation disorder. Anxiety and especially depression were correlated with depersonalisation symptoms. The FDS had high sensitivity (85.7%) and specificity (92.3%) which compared favourably with other instruments. Patients with both derealisation and depersonalisation scored the highest on the FDS. DISCUSSION: Depersonalisation disorder comprises a measurable cluster of symptoms which may be quantified with the help of self-report scales. Primary and secondary forms overlap, with depressed mood a frequent feature.

Depersonalization in panic disorder: a clinical study.

Panic disorder (PD) has been hypothesized to be a heterogeneous entity, with distinct clinical subgroups. The presence of depersonalization during panic attacks may distinguish a specific subgroup of PD. We sought to analyze the differential features of a subgroup of PD patients with depersonalization. A total of 274 patients with PD were assessed and divided into 2 groups according to the presence or absence of depersonalization. The Structured Clinical Interview for DSM-III-R (SCID-UP-R) was used to assess PD and comorbid disorders. The clinical scales administered included the Hamilton Anxiety and Depression Rating Scale (HARS and HDRS), the Marks and Mathews Fears and Phobia Scale, Panic-Associated Symptom Scale (PASS), and a panic attack symptoms inventory. A total of 66 patients (24.1%) exhibited depersonalization during the attacks. Patients with depersonalization appeared to be younger and had an earlier age at onset. PD was more severe in the depersonalization group (greater number of attacks, worse level of functioning, and higher scores on most self-rating scales). Also, depersonalization patients showed more comorbidity with specific phobia. Our results support the view that PD with depersonalization may be considered a distinct and more severe subcategory of PD.

A meta-analytic examination of the correlates of the three dimensions of job burnout.

This meta-analysis examined how demand and resource correlates and behavioral and attitudinal correlates were related to each of the 3 dimensions of job burnout. Both the demand and resource correlates were more strongly related to emotional exhaustion than to either depersonalization or personal accomplishment. Consistent with the conservation of resources theory of stress, emotional exhaustion was more strongly related to the demand correlates than to the resource correlates, suggesting that workers might have been sensitive to the possibility of resource loss. The 3 burnout dimensions were differentially related to turnover intentions, organizational commitment, and control coping. Implications for research and the amelioration of burnout are discussed.

Mental symptoms: are they similar phenomena? The problem of symptom heterogeneity.

Psychiatric symptoms are heterogeneous and differ in origin, structure and clinical expression. These differences are frequently ignored both clinically and in research. Thus, patients may be described as being anxious or as having delusions, with little realisation that different aspects of the structure of symptoms are being depicted. Neglect of differences in structure between symptoms has also naturally resulted in the neglect of differences in structure between superficially 'same' symptoms. A model is offered here which provides a means of classifying heterogeneity on the basis of five levels of clinical differentiation which, in turn, carries implications for underlying symptom structure. At the 1st level, symptoms can be differentiated in terms of the conventional category 'form' but which is in fact a composite of criteria. At the 2nd level, symptoms may be separated by differences in diagnosis which may alter structure; it is suggested that one way of capturing these is to assess the qualitative dimensions of the form. At the 3rd level, differentiation can occur on the basis of sensory modality, and, using hallucinations as an illustration, it has been shown that this is a weak and confused criterion. At the 4th level, symptoms can be differentiated on the basis of abstract criteria, often of historical origin, for which there is little empirical evidence. At the 5th level, the main criterion is difference in content. That not all symptoms will be susceptible to a fivefold analysis reinforces the argument that symptoms are structurally different and that these differences have psychometric and research implications.

[The psychophysiological aspects of depersonalization disorders in schizophrenia]. / Nekotorye aspekty psikhopatologii depersonalizatsionnykh rasstroistv pri shizofrenii.

The examination included 75 schizophrenics with clinical evidence of depersonalization. Three types of depersonalization were identified: personal, psychofunctional and sensory. The personal type is characterized by the sense of loss of the identity and individual features of the psychic "self"; the psychofunctional type--by the loss of the identity or some psychic functions, psychic performance as a whole; the latter type--by the loss of the identity or some special sensations. Basing on the above variants of depersonalization, 3 basic syndromes including it are suggested: affective-depersonalizational with depressive-depersonalizational and depersonalizational-thymopathic variants, depersonalizational-phobic, depersonalizational-hypochondriac.

Classification of amok in DSM-IV.

Culture-bound syndromes have been described worldwide in many individuals and, for certain syndromes, in epidemic proportion, yet these disorders have been classified as rare and exotic conditions warranting minimal attention. Development of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders and the tenth edition of the International Classification of Diseases offers an opportunity for providing a more sophisticated classification of these phenomena. The authors examine amok, a syndrome first described in Malaysia that consists of homicidal frenzy preceded by a state of brooding and ending with somnolence and amnesia. They discuss the concept of and criteria for a culture-specific disorder and propose that amok be classified as a culture-specific explosive behavioral disorder in DSM-IV.