Approach Considerations

Patients who are survivors of extensive childhood abuse frequently present complicated clinical dilemmas. Dissociative episodes, flashbacks, and self-destructive and suicidal impulses are common difficulties encountered by such patients.

Once the diagnosis of abuse has been made, the initial task of therapy is to detoxify the patient's environment by stopping all forms of abuse. Treatment must be geared toward trust issues, toleration of affect with the patient's understanding of himself or herself, and enabling the patient to function as effectively as possible.

Encouraging healthy coping behaviors

The primary focus is to help patients learn to control and contain their symptoms. Patients must learn to deal with dissociation, flashbacks, and intense affects such as rage, terror, and despair.

Embarking on a treatment plan can be dangerous if the patient has not developed ways to tolerate the emotional turmoil that arises when uncovering traumatic memories. Until the patient can learn healthy alternatives to tolerate feelings and control behaviors, he or she cannot adequately or safely undertake the exploratory work involved in uncovering and processing memories of abuse.

Control is a major issue for survivors of abuse, and by learning new ways to control and contain their symptoms, patients no longer view themselves as victims of the past.

The emphasis is to have patients reconnect with their sense of power. Encouraging patients to design and choose which technique to use and when to use it contributes to their sense of being in charge of themselves; patients can begin to deal correctly with feelings of helplessness.

Logging and monitoring emotions

Many patients who experience loss of time through dissociation or flashbacks describe the events as being abruptly triggered. These symptoms sometimes become so severe that patients can no longer function in their usual way.

One way to help patients begin to work with their sense of unpredictability is to have them keep a log of their emotions. The patients must first identify emotions. Once they have developed the ability to identify feelings, they can monitor the intensity of each feeling.

Patients usually report a cluster of recurrent emotions such as anxiety, sadness, or rage. Quite frequently, these symptoms precede dissociation, flashbacks, self-destructive impulses, and suicidal impulses. Patients should be coached on how to intervene long before anxiety rises to a critical level. A carefully staged trauma-focused psychotherapy for dissociative identity disorder may result in improvement of symptoms.^[30]

Developing a crisis plan

Identifying the cause of the anxiety is also important. Teaching patients to develop a list that ranges from simple to complex activities is helpful. Once patients become engaged in the activities, the intensity of emotions usually decreases. In addition, patients feel more in control. This reconnects them to personal strengths and the choices that can be exercised.

Most patients require time to learn new and effective coping skills. Emphasize that patients must practice new skills and techniques until they develop a sense of mastery.

If the difficulties experienced by patients with histories of abuse are directly related to the abuse experiences, definitive treatment cannot seemingly be successful without acknowledgment of these experiences. Clinicians treating such patients may collude with them in their beliefs about themselves if unaware of the existence of the traumatic etiologies of the current disturbance.

Consultations

If the reason for the dissociative disorder is likely abuse, promptly initiate appropriate medical, surgical, and mental health consultation. The law requires that a child suspected of being abused or neglected be reported immediately to CPS.

Psychiatrist or behavioral/developmental pediatrician
Social services representative
Child abuse and sexual abuse (CASA) specialist

Medication

Shipman K, Taussig H. Mental health treatment of child abuse and neglect: the promise of evidence-based practice. Pediatr Clin North Am. 2009 Apr. 56(2):417-28. [QxMD MEDLINE Link].
American Psychiatric Association. Dissociative Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 292-298.
Cicchetti D, Lynch M. Toward an ecological/transactional model of community violence and child maltreatment: consequences for children's development. Psychiatry. 1993 Feb. 56(1):96-118. [QxMD MEDLINE Link].
Cicchetti D, Rogosch FA. Psychopathology as risk for adolescent substance use disorders: a developmental psychopathology perspective. J Clin Child Psychol. 1999 Sep. 28(3):355-65. [QxMD MEDLINE Link].
Kluft RP. Diagnosing multiple personality disorder. Pa Med. 1984 Sep. 87(9):44, 46. [QxMD MEDLINE Link].
Kluft RP. An update on multiple personality disorder. Hosp Community Psychiatry. 1987 Apr. 38(4):363-73. [QxMD MEDLINE Link].
Rehan MA, Kuppa A, Ahuja A, Khalid S, Patel N, Budi Cardi FS, et al. A Strange Case of Dissociative Identity Disorder: Are There Any Triggers?. Cureus. 2018 Jul 10. 10 (7):e2957. [QxMD MEDLINE Link].
Carmen EH, Rieker PP, Mills T. Victims of violence and psychiatric illness. Am J Psychiatry. 1984 Mar. 141(3):378-83. [QxMD MEDLINE Link].
Richter JA, Serena A, Charvet MA, Virto R, Errasti P. Ureteral fistula after renal transplantation: the significance of delayed images. Eur J Nucl Med. 1984. 9(9):436-7. [QxMD MEDLINE Link].
U.S. Department of Health & Human Services, Administration for Children and Families, Administration Children, Youth and Families, Children’s Bureau. on. Child Maltreatment 2014. Children's Bureau. Available at http://www.acf.hhs.gov/sites/default/files/cb/cm2014.pdf. 2016; Accessed: March 15, 2016.
Lauterbach D, Somer E, Dell P, Vondeylen H. Abuse history and pathological dissociation among Israeli and American college students: a comparative study. J Trauma Dissociation. 2008. 9(1):51-62. [QxMD MEDLINE Link].
Edwards VJ, Holden GW, Felitti VJ, Anda RF. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study. Am J Psychiatry. 2003 Aug. 160(8):1453-60. [QxMD MEDLINE Link].
Wherry JN, Neil DA, Taylor TN. Pathological dissociation as measured by the child dissociative checklist. J Child Sex Abus. 2009 Jan-Feb. 18(1):93-102. [QxMD MEDLINE Link].
Bozkurt H, Duzman Mutluer T, Kose C, Zoroglu S. High psychiatric comorbidity in adolescents with dissociative disorders. Psychiatry Clin Neurosci. 2015 Jun. 69 (6):369-74. [QxMD MEDLINE Link].
Anderson SC, Bach CM, Griffith S. Psychosocial sequelae in intrafamilial victims of sexual assault and abuse. 1981 April.
Tuft's New England Medical Center, Division of Child Psychiatry. Sexually exploited children: Service and research project. Final report for the office of Juvenile Justice and Delinquency Prevention. 1984.
Putnam FW, Guroff JJ, Silberman EK, Barban L, Post RM. The clinical phenomenology of multiple personality disorder: review of 100 recent cases. J Clin Psychiatry. 1986 Jun. 47(6):285-93. [QxMD MEDLINE Link].
Hagan MJ, Hulette AC, Lieberman AF. Symptoms of Dissociation in a High-Risk Sample of Young Children Exposed to Interpersonal Trauma: Prevalence, Correlates, and Contributors. J Trauma Stress. 2015 Jun. 28 (3):258-61. [QxMD MEDLINE Link].
Middleton W, Butler J. Dissociative identity disorder: an Australian series. Aust N Z J Psychiatry. 1998 Dec. 32(6):794-804. [QxMD MEDLINE Link].
Macfie J, Cicchetti D, Toth SL. The development of dissociation in maltreated preschool-aged children. Dev Psychopathol. 2001 Spring. 13(2):233-54. [QxMD MEDLINE Link].
Howe ML, Toth SL, Cicchetti D. Can maltreated children inhibit true and false memories for emotional information?. Child Dev. 2011 May-Jun. 82(3):967-81. [QxMD MEDLINE Link].
Toth SL, Pickreign Stronach E, Rogosch FA, Caplan R, Cicchetti D. Illogical thinking and thought disorder in maltreated children. J Am Acad Child Adolesc Psychiatry. 2011 Jul. 50(7):659-68. [QxMD MEDLINE Link].
Gast U, Rodewald F, Nickel V, Emrich HM. Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic. J Nerv Ment Dis. 2001 Apr. 189(4):249-57. [QxMD MEDLINE Link].
Sar V, Akyuz G, Kundakci T, Kiziltan E, Dogan O. Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder. Am J Psychiatry. 2004 Dec. 161(12):2271-6. [QxMD MEDLINE Link].
Hulette AC, Freyd JJ, Fisher PA. Dissociation in middle childhood among foster children with early maltreatment experiences. Child Abuse Negl. 2011 Feb. 35(2):123-6. [QxMD MEDLINE Link]. [Full Text].
Gutierrez Wang L, Cosden M, Bernal G. Dissociation as a mediator of posttraumatic symptoms in a Puerto Rican university sample. J Trauma Dissociation. 2011. 12(4):358-74. [QxMD MEDLINE Link].
Evren C, Sar V, Dalbudak E, Cetin R, Durkaya M, Evren B. Lifetime PTSD and quality of life among alcohol-dependent men: impact of childhood emotional abuse and dissociation. Psychiatry Res. 2011 Mar 30. 186(1):85-90. [QxMD MEDLINE Link].
Tezcan E, Atmaca M, Kuloglu M, Gecici O, Buyukbayram A, Tutkun H. Dissociative disorders in Turkish inpatients with conversion disorder. Compr Psychiatry. 2003 Jul-Aug. 44(4):324-30. [QxMD MEDLINE Link].
Foote B, Park J. Dissociative identity disorder and schizophrenia: differential diagnosis and theoretical issues. Curr Psychiatry Rep. 2008 Jun. 10(3):217-22. [QxMD MEDLINE Link].
Brand BL, Loewenstein RJ, Spiegel D. Dispelling myths about dissociative identity disorder treatment: an empirically based approach. Psychiatry. 2014 Summer. 77 (2):169-89. [QxMD MEDLINE Link].
Allison RB. Multiple personality and criminal behavior. Am J Forensic Psychiatry. 1981. 2:32-38.
Gentile JP, Dillon KS, Gillig PM. Psychotherapy and pharmacotherapy for patients with dissociative identity disorder. Innov Clin Neurosci. 2013 Feb. 10(2):22-9. [QxMD MEDLINE Link]. [Full Text].
Mueller-Pfeiffer C, Rufibach K, Perron N, et al. Global functioning and disability in dissociative disorders. Psychiatry Res. 2012 Dec 30. 200(2-3):475-81. [QxMD MEDLINE Link].
Weber S. Treatment of trauma- and abuse-related dissociative symptom disorders in children and adolescents. J Child Adolesc Psychiatr Nurs. 2009 Feb. 22(1):2-6. [QxMD MEDLINE Link].
Bierer LM, Yehuda R, Schmeidler J, et al. Abuse and neglect in childhood: relationship to personality disorder diagnoses. CNS Spectr. 2003 Oct. 8(10):737-54. [QxMD MEDLINE Link].
Brown GR, Anderson B. Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse. Am J Psychiatry. 1991 Jan. 148(1):55-61. [QxMD MEDLINE Link].
Brown RJ. Different types of "dissociation" have different psychological mechanisms. J Trauma Dissociation. 2006. 7(4):7-28. [QxMD MEDLINE Link].
Chu JA, Frey LM, Ganzel BL, Matthews JA. Memories of childhood abuse: dissociation, amnesia, and corroboration. Am J Psychiatry. 1999 May. 156(5):749-55. [QxMD MEDLINE Link].
DeFrancis V. Protecting the Child Victim of Sex Crimes Committed by Adults. Denver, CO: Children's Division, American Humane Association; 1969.
Dorahy MJ, Lewis CA. Dissociative identity disorder in Northern Ireland: a survey of attitudes and experience among clinical psychologists and psychiatrists. J Nerv Ment Dis. 2002 Oct. 190(10):707-10. [QxMD MEDLINE Link].
Ellason JW, Ross CA. Two-year follow-up of inpatients with dissociative identity disorder. Am J Psychiatry. 1997 Jun. 154(6):832-9. [QxMD MEDLINE Link].
Foote B, Smolin Y, Kaplan M, Legatt ME, Lipschitz D. Prevalence of dissociative disorders in psychiatric outpatients. Am J Psychiatry. 2006 Apr. 163(4):623-9. [QxMD MEDLINE Link].
Lewis DO, Yeager CA, Swica Y, Pincus JH, Lewis M. Objective documentation of child abuse and dissociation in 12 murderers with dissociative identity disorder. Am J Psychiatry. 1997 Dec. 154(12):1703-10. [QxMD MEDLINE Link].
Putnam FW. Diagnosis and Treatment of Multiple Personality Disorder. New York, NY: Guilford Press; 1989.
Putnam FW. Ten-year research update review: child sexual abuse. J Am Acad Child Adolesc Psychiatry. 2003 Mar. 42(3):269-78. [QxMD MEDLINE Link].
Sar V, Koyuncu A, Ozturk E, et al. Dissociative disorders in the psychiatric emergency ward. Gen Hosp Psychiatry. 2007 Jan-Feb. 29(1):45-50. [QxMD MEDLINE Link].
Simeon D, Guralnik O, Schmeidler J, Sirof B, Knutelska M. The role of childhood interpersonal trauma in depersonalization disorder. Am J Psychiatry. 2001 Jul. 158(7):1027-33. [QxMD MEDLINE Link].
Vogel M, Spitzer C, Kuwert P, Moller B, Freyberger HJ, Grabe HJ. Association of childhood neglect with adult dissociation in schizophrenic inpatients. Psychopathology. 2009. 42(2):124-30. [QxMD MEDLINE Link].
Wilbur CB. Multiple personality and child abuse. An overview. Psychiatr Clin North Am. 1984 Mar. 7(1):3-7. [QxMD MEDLINE Link].
Xiao Z, Yan H, Wang Z, et al. Trauma and dissociation in China. Am J Psychiatry. 2006 Aug. 163(8):1388-91. [QxMD MEDLINE Link].

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Author

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA Professor of Emergency Medicine and Clinical Pediatrics, Weill Cornell Medical College; Attending Physician, Departments of Emergency Medicine and Pediatrics, Lincoln Medical and Mental Health Center; Adjunct Professor of Emergency Medicine, Adjunct Professor of Pediatrics, St George's University School of Medicine, Grenada

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Academy of Urgent Care Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, Association of Clinical Research Professionals, Public Responsibility in Medicine and Research, Society for Academic Emergency Medicine, Society for Simulation in Healthcare

Disclosure: Nothing to disclose.

Coauthor(s)

Muhammad Aslam, MD Professor of Pediatrics, University of California, Irvine, School of Medicine; Neonatologist, Division of Newborn Medicine, Department of Pediatrics, UC Irvine Medical Center

Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Chief Editor

Acknowledgements

Orlando Perales, MD Associate Director of Pediatric Emergency Services, Department of Emergency Medicine, Lincoln Medical and Mental Health Center

Orlando Perales, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Richard M Switzer, Jr, MD Consulting Staff, Department of Pediatrics, Brooklyn Hospital Center

Richard M Switzer, Jr, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association

Disclosure: Nothing to disclose.