CLINICAL SIGNS OF DISSOCIATIVE DISORDERS

Gerald Puk, Ph.D.

Senior Trainer, EMDR Institute

History of years of psychotherapy with little progress

(Kluft, 1985; Putnam et al., 1986).
a. Client has varying diagnoses over the years.
b. Client may have a history of multiple psychiatric hospitalizations with different
diagnoses.

Symptoms of depersonalization and/or derealization (Putnam et al., 1986).

For example, the client:
a. Doesn’t feel like her/himself (e.g. bigger or smaller).
b. Reports that her/his surroundings do not look the same.
c. Looks in the mirror and sees something other than typical reflection.
d. Experiences “floating” alongside or above the body.
e. Reports that daily environment seems dream-like or as if (s)he is walking in a fog.

Memory lapses (Putnam et al., 1986)

For example, the client:
a. Does not recall how she/he got to the shopping mall.
b. Finds unfamiliar items at home, and does not recall buying them or how they
were acquired.
c. (S)he cannot offer a coherent narrative history. However, this also may occur
because of substance abuse, illness, depression, dementia. Note that a highly
organized DID patient may confabulate and fill in the amnestic “gaps”.

Flashbacks and intrusive thoughts

a. The client has flashbacks and intrusive thoughts for childhood events or recent
traumata.
b. DID can be conceptualized as resulting from chronic, serial PTSD (Spiegel, 1993).

Schneiderian symptoms (Kluft, 1987; Ross et al., 1990)

Of the 11 first-rank Schneiderian symptoms, the client may endorse several of them.
For example, the most frequently reported include:
a. Hearing “audible thoughts” or “voices arguing”. However DID clients usually say
that they hear voices in the head, not externally (as in schizophrenia).
b. Experiencing “made” feelings, i.e., feelings that come out of the “blue” without
having a logical way of explaining them.
c. Having “made” thoughts and behaviors or other of the first-rank symptoms may be
reported.

DID patients report more frequent first-rank symptoms than patients having
schizophrenia (Ross et al., 1990).

The DID patient will show a full range of affect whereas the schizophrenic patient
usually will demonstrate blunted affect.
Somatic symptoms (Putnam, 1989, pp. 65-67)
The client may:
a. Report chronic headaches that are intractable to over-the-counter analgesics.
b. Have physical complaints and pain that physicians cannot account for and which
may be “somatic memories”.

Sleep disturbance (Loewenstein, 1991)

The client may report frequent nightmares or night terrors. Note that sleepwalking is
usually associated with a dissociative disorder.

Depression
One of the primary complaints of the DID patient is an affective disorder. Frequently,
there is a history of suicide attempts or suicidal ideation. (Putnam et al., 1986).
All new clients should complete the Dissociative Experiences Scale (DES; Carlson &
Putnam, 1992). On the DES, a cut-off score of 20 is recommended (Ross, 1995).
For clients scoring greater than that and/or responding positively to these clinical
signs outlined above, the clinician should suspect the presence of an underlying
dissociative disorder. Administration of the Dissociative Disorders Interview
Schedule-DSM-IV Version (DDIS; Ross, 1997, pp. 383-402) or the Structure Clinical
Interview for DSM-IV- Dissociation Revised (SCID-D Revised; see Steinberg, 1995)
can provide a thorough assessment and help to confirm the actual diagnosis.

Source:
Shapiro, F. (2011) EMDR Training Manual. Watsonville, CA. EMDR Institute Inc.
 EGO STATES
Development of Ego State Concepts: (SEE: FEDERN, WATKINS & WATKINS,
BERNE, ERSKINE, KLUFT, KLUFT and FINE, FINE, SCHWARTZ)

1. Segmentation of personality into ego states at points of the dissociation

continuum due to normal differentiation, introjection or trauma.

2. Organized system of behaviors, and experiences

3. States have varying boundaries

4. May be organized to enhance adaptability in coping with specific events or

problems.

5. Some ego states delineated by time dimensions,

6. Others delineated by function, trait or role, i.e. self hater, nurturer, critic,
executive, child states, exiles, managers, firefighters, core self etc.

7. Ego states formed in childhood may function maladaptively in present

situations.

8. Ego states function to protect their roles and existence, even if counter-
productive to the adult.

9. Ego states can conflict with each other vis-a-vis their roles leading to
intrapsychic conflict.

10. Ego states have the capacity to change, combine, grow,and form adaptively in
childhood, and adulthood.

11. Ego states may have normative imaginal/creative functions; i.e. daydreaming.
Example dialogue with a critical ego state
Prior to engaging the critical ego state, the therapist has used visual imagery to take the host
(client) to a safe and secure place (e.g. a building, forest clearing, island). In this example,
the host ego state is named John and the therapist has brought him to a communal room in
a building (in John’s imagination) which has “a circle of chairs in the centre of the room and a
number of other doors leading into it.”

Therapist John, I would like you to choose a seat and make yourself comfortable.
Take a look around the room. Notice the décor, the lighting conditions, the
temperature, and any sounds and smells there are … that’s good.

If you could invite into the room to join you that part of you which gives you a
hard time, that part which is critical of you whenever you get something
wrong. Just notice if anything comes into the room or if you are aware of a
presence or feeling in your body… If nothing comes in that’s fine too.

John Yeah, there’s something there.

Therapist Can you describe what you are aware of?

John There’s like a woman with sharp features. She’s wearing a black dress and
a shawl around her shoulders.

Therapist That’s good. Just invite that part over to the circle of chairs and invite it to sit
down.
John She’s sitting now.

Therapist That’s good. I would like to speak to the part that has just come in and
introduce myself. My name is Michael and I’m trying to help John. He’s the
man who was already in the room when you arrived. I’m wondering what
name I could know you by; perhaps you could let me know through John in a
way he can understand?

John She says she doesn’t have a name.

Therapist I see, can I just check if the part which came into the room is the one which
is critical of John when he gets things wrong?
John It is.

Therapist Okay, thank you. Is it okay if I know that part as ‘Critical’?

John She says that’s okay.

Therapist Critical, I would like to thank you for coming. If you wish to speak to me
directly rather than tell John so he can tell me that may be something we
could do. Would that be acceptable to you?
Critical Yes.

Therapist Would that be okay with you John?

John Yes, I’m fine with that.

Therapist Critical, I understand that when John gets things wrong you say things to him
which upset him, is that correct?

Critical Yes.

Therapist What is the reason you give John a hard time when he gets it wrong?

Critical To try to stop him messing things up and making a spectacle of himself.

Therapist So you try to get him to do things right so as not to embarrass himself ?

Critical He embarrasses me too when he messes up.

Therapist Would you be more happy if John did things right.

Critical I would.

Therapist I wonder, if John was trying to walk up a mountain and you were on his back
saying, “Look at you puffing and gasping. You’re making hard work of this.
Push yourself harder, go on you lazy lump.” Would that help him get up the
mountain?

Critical Maybe not.

Therapist Instead of that, if you were walking beside John saying, “Come on John you
can do it. Just up to that next rock and have a breath. Look how far you’ve
come, well done.” Would that help John get up the mountain?
Critical It might.

Therapist So if you were to give John praise and encouragement, instead of criticism,
is it possible that would get more out of him and help him succeed?

Critical That’s possible.

Therapist How would you feel about giving John praise and encouragement instead of
criticism, even when he gets things wrong?
Critical I don’t know …. I’ve always been critical of him.

Therapist What about doing it for a trial period?

Critical I suppose I could …. For how long?

Therapist What about three weeks and then you can evaluate whether John is doing
better?
Critical Yeah, I could try that.

Therapist Can we just check with John that he would be prepared to go along with
that?
John I’d like to do it but I’m not sure if Critical will stick to the agreement.

Therapist Well Critical, would you be prepared to stick to the agreement?

Critical I’ll try.

Therapist Are there any parts outside the room that wish to comment or add anything
to what we have been speaking about?
John No, nothing.

Therapist Thank you. Critical, we are in agreement that you will give John praise and
encouragement to try to get the best from him. Could I suggest that even
when he gets things wrong, which he will, you will help him find what he can
learn from the experience so he can get it right the next time?
Critical That’s okay.

Therapist Is there anything else you would like to say Critical?

Critical No

Therapist What about you John?

John No, nothing else, except for I hoping this works with Critical.

Therapist Critical, I would like to thank you for your input and hope we can make things
work out for John and you. Could I ask you to leave the room now and stay
wherever in the building you feel safe and secure. If you could be available
for John whenever he needs you, and remember, you are giving praise and
encouragement without reverting to your old ways for the length of the three
week trial period.

John, please let me know when Critical has left the room.

John Critical’s gone now.

Therapist Okay John, whenever you are ready. I’d like you to make your way from the
communal room back down the hallway and out through the door you
entered the building by. When you’re ready come back to join me here in the
therapy room.

John (Opening eyes) That was powerful. I feel really tired after that.

Therapist Just have a deep breath. Would you like to do one of the self soothing
exercises you learned?

Note: John is debriefed to be aware of how he handles situations where previously he would
have noticed the critical voice. He is told he can use internal dialogue to remind Critical of its
agreement to give praise and encouragement. He is also reminded about his techniques for
self soothing.

When you meet resistance, roll with it and suggest alternatives. Avoid conflict with ego
states as you need to have their cooperation.