Dissociative Spectrum Disorders in Primary Care

Dissociative Spectrum Disorders in the Primary Care Setting

James L. Elmore, M.D.

ence episodes of dissociation not secondary to abuse. 2 The

surprisingly high prevalence of dissociative disorders
Dissociative disorders have a lifetime preva-
lence of about 10%. Dissociative symptoms may prompts this review.
occur in acute stress disorder, posttraumatic stress Coastal Empire Community Mental Health Center
©

disorder, somatization disorder, substance abuse, (CECMHC), in Beaufort, S.C., serves a 50% white and
Co

trance and possession trance, Ganser’s syndrome, 50% African American population in a poor, predomi-
and dissociative identity disorder, as well as in
mood disorders, psychoses, and personality dis-
nately rural part of South Carolina. Many of our center’s
py

orders. Dissociative symptoms and disorders are clients reside on North Carolina’s Outer Banks islands and
observed frequently among patients attending our maintain voodoo-derived beliefs in spirits, sorcery, hags (a
rig

rural South Carolina community mental health threatening image that may “ride” an individual), rooting
center. Given the prevalence of mental illness in
ht

(placing a spell on an individual), and the use of amulets

primary care settings and the diagnostic difficul-
ties encountered with dissociative disorders, such
and charms to ward off evil. Voodoo possession, a cultur-
20

illness may be undiagnosed or misdiagnosed in ally sanctioned phenomenon occurring in normal indi-
primary care settings. viduals, involves trance-like behavior with an alteration of
00 ne p

We developed an intervention model that may perception, memory, and identity.3 Goodman4 holds that
O

be applicable to primary care settings or helpful glossolalia (speaking in tongues) among religious groups
Pherso

to primary care physicians. Key points of the in-

tervention are identification of dissociative symp-
in the region is an artifact of a culturally approved disso-
ys nal c

toms, patient and family education, review of the ciative trance state. Issues of “honor” and a tendency to
origin of the symptoms as a method of coping quickly resort to violence to resolve conflict result in ho-
ic op

with trauma, and supportive reinforcement of micide rates among the highest in the United States. The
ia y m

cognitive and relaxation skills during follow-up juxtaposition of strong moral-religious and violent, good-
ns ay

visits. Symptom recognition, Education of the

family, Learning new skills, and Follow-up may
versus-evil themes may foster intense conflicting emo-
be remembered by the mnemonic device SELF. tions. These issues, combined with high poverty rates and
Po be

We present several cases to illustrate dissociative associated early emotional, physical, or sexual abuse or
symptoms and our intervention. Physicians and neglect, are associated with the development of dissocia-
stgprin

other professionals using the 4 steps and behav- tive defense mechanisms that may persist throughout indi-
ioral approaches will be able to better recognize
ra ted

and triage patients with dissociative symptoms.

viduals’ lives.
The frequent occurrence of bizarre symptoms and dan-
du

Behaviors previously thought to be secondary to

psychosis or personality disorders may be seen in gerous acting-out behavior among our patients prompted
a

a new frame of reference, strengthening the thera- the development of our approach. Severe acting-out, overt
te

peutic alliance while reducing distress and acting- psychosis, or situations involving a danger to self or others
out behaviors.
may require hospitalization. However, we are often able to
Pr

(Primary Care Companion J Clin Psychiatry 2000;2:37–41)

manage patients in their natural setting using the SELF
es

(Symptom recognition, Education of the family, Learning

s,

new skills, and Follow-up) approach, initiated in the first

contact with the patient and/or family.
In

Received Nov. 18, 1999; accepted March 14, 2000. From the Coastal
Empire Community Mental Health Center, Beaufort, S.C.
c.

Reprint requests to: James L. Elmore, M.D., Coastal Empire

Community Mental Health Center, 151 Dillon Rd., P.O. Box 23079, Hilton SYMPTOM RECOGNITION
Head, SC 29901.
DSM-IV dissociative disorders are described in Table
1. The DSM-IV5 notes that dissociative disorder not other-

N orth American interest in dissociative disorders

has surged from the early 1980s to the present. Re-
cent studies in North America found that these disorders
wise specified (NOS) includes disruption of conscious-
ness, memory, identity, or perception of the environment
but does not meet the criteria for any specific dissociative
have a lifetime prevalence of about 10%; dissociative disorder. The affected individual does not have 2 or more
identity disorder (DID; formerly multiple personality dis- distinct personality states or significant amnesia. Disso-
order) constitutes only about 1% of that figure.1 It is esti- ciative amnesia is an inability to recall important personal
mated that 6% to 10% of the general population experi- information, usually of traumatic nature, that is too exten-

Primary Care Companion J Clin Psychiatry 2:2, April 2000 37

James L. Elmore

Table 1. General Description of DSM-IV Dissociative Disordersa

Disorder Area of Disruption Description
Dissociative amnesia Memory Inability to recall important personal information, usually of a traumatic or stressful nature,
too extensive to be explained by ordinary forgetfulness
Dissociative fugue Memory, identity Sudden, unexpected travel away from home or one’s customary place of work, accompanied
by inability to recall one’s past and confusion about personal identity or the assumption
of a new identity
Dissociative Identity, memory Presence of 2 or more distinct identities or personality states that recurrently take control of
the identity disorder individual’s behavior accompanied by an inability to recall important
personal information that is too extensive to be explained by ordinary forgetfulness
Depersonalization Perception, Persistent or recurrent feeling of being detached from one’s mental processes or
disorder consciousness body that is accompanied by intact reality testing
a
Adapted from DSM-IV.5
©
Co

sive to be explained by normal forgetfulness. Amnesia ciative disorder NOS, and DID may all occur in the pres-
py

may be localized (surrounding an event), selective ence of these diagnoses. Substance abuse populations are
(partial), generalized (involving one’s entire life), con- reported to have high levels of dissociative experiences,
rig

tinuous (having a fixed beginning with continuation to the and substance abuse is reported to be high among DID
patients.10,11
ht

present), or systematized (involving only certain catego-

ries of information). The latter 3 types are less common. Ellason et al.,12 Giese et al., 13 and Ganaway14 all report
20

Dissociative symptoms occur in acute stress disorder, on the high levels of comorbidity of dissociative disorder
posttraumatic stress disorder (PTSD), and somatization NOS and DID with borderline and other personality dis-
00 ne p

disorder as well as in alcohol and substance abuse. These orders. Atlas and Wolfson15 found that borderline adoles-
O

dissociative symptoms are usually not manifest within cents evidenced significant dissociation and depression.
Pherso

distinct and developed personalities. They may take the These reports suggest that the clinician should be wary of
ys nal c

form of ego-disruptive behavioral states.6 Dissociative diagnosing discrete dissociative syndromes in the pres-
disturbances are by definition not due to a substance or a ence of other psychiatric diagnoses.
ic op

medical condition such as complex partial seizures. They Dissociative auditory hallucinations, unlike schizo-
ia y m

are said to also occur in the face of perceived danger and phrenic hallucinations, are most often described as
ns ay

may begin as early as 6 months of age.7 “voices in one’s head” (rather than outside the individual)
These dissociative disorders encompass dissociation in talking, arguing, directing, or commenting on one’s
Po be

persons subjected to intense, coercive persuasion. Trance actions and do not have the “disintegrated quality” and
(a state of detachment from one’s physical surroundings disorganization of schizophrenic hallucinations.16 In one
stgprin

as in contemplation or daydreaming) and possession study,17 about half of the patients with DID had been diag-
ra ted

trance (replacement of the customary sense of personal nosed and treated for schizophrenia. A review of our
identity by a new identity, attributed to the influence of a clinic records confirmed past diagnoses and treatment for
du

spirit, power, deity, or other person and associated with both schizoaffective and bipolar disorders among our dis-
a

stereotyped “involuntary” movements or amnesia) are sociative patients.

te

dissociative phenomena.1 Loss of consciousness not due

to a general medical condition as well as Ganser’s syn-
Pr

EDUCATION OF PATIENT AND FAMILY

drome (amnesia and hallucinations of hysterical origin
es

marked by senseless answers to questions and absurd When dissociative features are noted, the patient and
s,

acts) commonly associated with dissociative amnesia or family are educated about the symptoms. In our center,
fugue are also included in this diagnostic category. these symptoms most commonly involve a dazed or day-
In

DID is characterized by the fragmentation of an in- dreaming state (of which the client is aware or that is ob-
c.

dividual’s identity into 2 or more distinct personalities, served by others) or a loss of time (the patient may drive
which recurrently take control of the person’s behavior, as or go to a destination without recalling it or knowing why
well as inability to recall important personal information the trip was made) along with other criteria up to and in-
more extensive than ordinary forgetfulness.5 Differential cluding frank DID features.
diagnosis in adults includes comorbid disorders, such Ganaway observed that DID patients “are continually
as somatization disorder, PTSD, seizures, and amnesia. moving in and out of hypnotic trance states.” 14(p208) He
Pseudoseizures and conversion phenomena are both re- found in a group of 82 individuals that virtually all met
ported to share similar psychological processes with special criteria for Spiegel and colleagues’ Grade Five
dissociative disorders.8,9 Schizophrenia, schizoaffective Syndrome (highly hypnotizable).18 The high incidence of
disorder, and bipolar and unipolar mood disorders must trance states ascertained by either history or their emer-
also be ruled out. In fact, dissociative symptoms, disso- gence in treatment sessions has prompted us to educate

38 Primary Care Companion J Clin Psychiatry 2:2, April 2000

 Dissociative Spectrum Disorders in Primary Care

our patients about them in our earliest contacts. Bliss19 velop new coping skills such as assertion (countering a
and Butler et al.20 note that the ability to self-induce a learned submissive response and expressing his or her
trance state is central to development of dissociative own wishes instead), relaxation (a positive use of the auto-
symptoms and DID. This is compatible with our clinical hypnotic trance), and rationalization to deal with stressful
experience and supports our cognitive approach with situations.
these patients. Basic relaxation responses to anxiety include deep in-
Our patients also experience dissociative symptoms halation to a count of 4 for 4 breaths. Other self-relaxation
in the perceptual area. These include conversion reac- approaches include repeating an important word while
tions, flashbacks, self-mutilation, depersonalization (feel- breathing slowly in and out as well as visualizing a peace-
ing outside the self), derealization (setting or people seem ful scene while breathing deeply and quietly.
unreal), lack of behavioral control such as lashing out at Ross 22 holds that the primary task of the DID patient
©

someone without warning, the dissociation of affect (as in during childhood is survival through maintaining emotional
Co

acute stress disorder, binge eating, identity confusion or attachment to an ambivalently held parent-perpetrator by
alteration, finding unrecognized possessions, and age re- intrapsychic splitting. This is consistent with the develop-
py

gression), and other dissociative symptoms described in ment of alternate personalities. The persistence of the at-
the literature.21 tachment need in the adult is seen in the battered spouse
rig

The origin of the symptoms as a method of coping with who maintains her dependence on the perpetrator at any
ht

past trauma (sexual, physical, or neglect), overwhelming cost. In treatment, transference and acting out is understood
affect, or present boredom, loneliness, interpersonal con- in analytic terms, but cognitive approaches are primary
20

flict, or anxiety in a patient’s life is explained to the indi- tools. Ross uses the victim-perpetrator-rescuer model and
vidual and his or her family. We point out that the trance emphasizes that the children identify with the aggressor
00 ne p

state or other symptoms may be innate or learned and that and, by shifting the bad object inside themselves, feel they
O

the patient can, over time, develop more control over potentially have control of the abuse.
Pherso

these experiences. Well-defined psychodynamic, cognitive, and hypnotic

ys nal c

Dissociative symptoms may occur in normal individ- therapy models for treatment of DID have been developed
uals in stressful circumstances; these spontaneously im- and described in the literature.21,23,24 These approaches
ic op

prove, but patients may benefit from short-term treatment comprise integrative techniques, generally involving
ia y m

with an anxiolytic medication. In patients with psychiatric lengthy dynamic and insight-oriented therapies. Our
ns ay

disorders, medication approaches should address the pri- model differs in offering a structured, brief, crisis-oriented
mary disorder. Concurrent diagnoses such as anxiety management for the dissociative individual and his or her
Po be

disorder, depressive disorder, bipolar affective disorder, family.

schizophrenia, or schizoaffective disorder should be man- Clinicians will be aware that these patients often have
stgprin

aged with anxiolytics, antidepressants, mood stabilizers, basic personality issues and conflicts as well as problems
ra ted

or neuroleptics as indicated. For example, our patient in with attachment and dependency. However, acute therapy
case 1 (see below) was essentially psychotic and self- should focus on current stressors, avoiding expression of
du

destructive when interviewed, but benefited remarkably undue interest in any dramatic symptom presentation. This
a

from adequate doses of a neuroleptic medication. Brief focus diminishes transference-based elaboration of alter-
te

psychotherapies for crisis intervention in addition to sup- nate identities or other dissociative phenomena.
portive treatment and medications greatly reduce the anx-
Pr

iety that drives the dissociative symptoms.22 FOLLOW-UP CONTACT

es

Dissociative symptoms occur frequently in patients

s,

with borderline personality disorder who may be de- Our follow-up contact consists of brief sessions to de-
pressed or anxious or experience brief psychotic symp- termine that symptoms are in remission and to monitor
In

toms, which warrant appropriate medications. Education medication effects. We review assertion and relaxation ap-
c.

of the patient and family about the nature of the symptoms proaches to deal with problems and stress. Recognition
and the role of medication will dispel the mystery and and support for progress in dealing with problems is im-
sense of helplessness they experience. portant in these sessions to build confidence. These ses-
sions may be continued at intervals for several months or
LEARNING NEW SKILLS interrupted with the assurance that the patient may return
if necessary.
We educate our patients that they are not “crazy” and The physician provides consultation to the patient’s so-
can learn to identify the precipitants of trance state or cial worker, nurse, or other medical professional working
other dissociative phenomena and develop more adaptive with the patient and family as well as ongoing medication
coping skills. This involves teaching patients to make a management as necessary. Periodic crises with symptom
conscious effort to remain in touch with reality and de- exacerbation are not uncommon; the patient is often strug-

Primary Care Companion J Clin Psychiatry 2:2, April 2000 39

James L. Elmore

gling with a maladaptive coping style developed over a 42-year-old recently separated black woman with a
lifetime. This pattern is recognized in other disorders such DSM-IV diagnosis of schizoaffective disorder, bipolar
as diabetes and congestive heart failure. Undue pessi- type (symptoms included hypomanic periods, hallucina-
mism is not warranted. tions, depression, low energy, death wishes, and recent
suicide attempt) was taking risperidone, 3 mg twice daily;
CASE REPORTS sertraline, 50 mg daily; and clonazepam, 1 mg twice daily,
and presented with a barking, guttural utterance (staccato
Three cases illustrate our results using the SELF model in nature), yelling obscenities and intimidating remarks
to engage our patients and modify their behavior over time. (“There’s a male demon inside me!”).
Between these outbursts, she spoke in a well-
Case 1 modulated voice, expressing concern about her bizarre be-
©

A 43-year-old married white woman was treated at havior. We advised that she had charge of the altered state
Co

CECMHC for DSM-IV major depression and personality in which the symptoms occurred (a possession trance), and
disorder NOS, with dependent, borderline, and dissocia- it was suggested that the symptoms would subside. Her al-
py

tive features. She had had 4 state hospital admissions in tered state was likened to those induced in television per-
the first year of her treatment in CECMHC because of de- formances, under which the hypnotized subjects may en-
rig

pressed mood, diminished interest in activities, poor en- gage in behaviors totally unlike their usual demeanors.
ht

ergy, feelings of worthlessness, suicidal ideation, and au- Although outbursts occurred initially every few sec-
ditory hallucinations. During a dissociative episode, she onds, they abated during our supportive and educational
20

slapped her alcoholic husband with no recall of the event. interview, indicating to the patient and her sister (present
He was actively drinking and had life-threatening liver in the session) how readily the symptoms were modified.
00 ne p

disease. This along with fear of losing the husband by Two days later, the patient reported by phone that the
O

death and ensuing isolation and financial problems were symptoms were much improved.
Pherso

precipitating factors in the patient’s symptomatology. She denied sexual/physical abuse and did not present
ys nal c

After 4 years of treatment in our clinic with multiple pervasive, persistent, alternate personalities or other dis-
neuroleptics, minor tranquilizers, antidepressant medica- sociative symptoms subsequent to her possession trance.
ic op

tions, and supportive management that included participa- She resisted group therapy, but continued on treatment
ia y m

tion in an incest group, the patient was noted to have with her original medication and in periodic supportive
ns ay

scratches on her extremities that she indicated occurred in treatment with her case manager with no recurrence of her
a trance state during which she wandered through the possession trance. She moved from the area 4 months
Po be

woods. She experienced trance states while bowling or later. The DSM-IV diagnosis of personality disorder NOS
during road monotony when driving. Other dissociative with dependent, avoidant, and dissociative features was
stgprin

phenomena included memory loss for childhood events in added.

ra ted

general, current time loss, derealization, depersonaliza- If her symptoms had only been secondary to her schizo-
tion, and periodic behavioral lack of control. affective disorder, the risperidone should have prevented
du

We suggested that she could assume more control of them. A major psychosis should not have remitted so strik-
a

her dissociative symptoms, which began during early ingly in one session with supportive and educational ap-
te

sexual abuse by a grandfather, and we described her proaches.

trances as self-induced hypnotic states that originally pro-
Pr

tected her from overwhelming trauma. She said our view Case 3
es

was reassuring to her, relieving anxiety about the “crazy” A 33-year-old single black woman who had depressed
s,

nature of the experience, which she recognized was the mood was referred by her probation officer after a charge
same state she entered during periods of somnambulism. of shoplifting. The patient stated, “an alternate personality
In

We explained to her that several therapies could help tells me I’m ugly and to hurt myself, drink, take drugs, and
c.

her diminish the power of the dissociative responses. She steal things.” A sutured 6-inch wound on her left shoulder
declined participation in group therapy, choosing brief was inflicted at the alternate personality’s command. She
supportive sessions incorporating assertion and relaxation made the host personality (who presents for treatment over
techniques with her case manager and medication (alpra- 50% of the time, nearly always bears the legal name, and
zolam, 0.25 mg every 8 hours) monitoring at quarterly in- has certain depressed/anxious features and suffers both
tervals. The dissociative symptoms did not resurface dur- psychophysiologic symptoms and time loss or time distor-
ing the 3 years since our original discussion. tion),25 break a glass in her hand and told her to burn her
apartment. The patient saw “a shadow, ghosts, or a man in
Case 2 a tree at night.”
Dissociative symptoms may emerge in the context of The patient denied physical or sexual abuse as a child,
active interpersonal or situational difficulties. A demure although she endorsed many dissociative symptoms, in-

40 Primary Care Companion J Clin Psychiatry 2:2, April 2000

 Dissociative Spectrum Disorders in Primary Care

cluding trance states, time loss, depersonalization, the Drug names: alprazolam (Xanax and others), clonazepam (Klonopin
and others), haloperidol (Haldol and others), mirtazapine (Remeron),
familiar seeming strange, and finding clothes she did not olanzapine (Zyprexa), risperidone (Risperdal), sertraline (Zoloft).
recall purchasing. The patient did not endorse racing
thoughts, great confidence or energy, pressure of speech, REFERENCES
decreased need for sleep, excessive spending, or irritabil-
1. Ross CA. History, phenomenology, and epidemiology of dissociation.
ity, which might suggest a cycling or mixed bipolar state. In: Michelson LK, Ray WJ, eds. Handbook of Dissociation: Theoretical,
There was a history of periodic cocaine abuse. A pattern Empirical, and Clinical Perspectives. New York, NY: Plenum Press; 1996:
of neglect and isolation in her childhood persisted to 3–24
2. Mulder RT, Beautrais AL, Joyce PR, et al. Relationship between dissocia-
the present, and she lived alone in poverty, isolated from tion, childhood sexual abuse, childhood physical abuse, and mental illness
her family, enduring her frightening symptoms and the in a general population sample. Am J Psychiatry 1998;155:806–811
acting out associated with the presence of her alternate 3. Ravenscroft K. Voodoo possession: a natural experiment in hypnosis.
©

J Clin Exp Hypn 1965;13:157–182

personalities. 4. Goodman FD. Glossolalia: speaking in tongues in four cultural settings.
Co

Because the patient initially had no therapeutic alliance Contin Psychiatr 1969;12:113–129
with her psychiatrist and case manager, and because the 5. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric
py

patient’s powerful, sadistic alternate personality could in- Association; 1994:477–491

struct the patient to mutilate herself, we did not initially 6. Armstrong JG. Reflections on multiple personality disorder as a develop-
rig

suggest that the host personality could control the alternate mentally complex adaption. In: Solnit AJ, Neubauer PB, Abrams S, et al.
The Psychoanalytic Study of the Child. New Haven, Conn: Yale University
ht

personality or resist her commands. She was advised that Press; 1994:349–364
she was not “crazy” and could feel better over time. She 7. Putnam FW. Dissociation: a response to extreme trauma. In: Kluft RP, ed.
20

declined psychoeducational group therapy, but accepted Childhood of Multiple Personality. Washington, DC: American Psychiatric
Press; 1985:66–69
haloperidol, 75 mg intramuscularly every 2 weeks, for her
00 ne p

8. Bowman ES, Markland ON. Psychodynamics and psychiatric diagnosis of

extreme personality fragmentation and mirtazapine, 30 mg pseudo seizure subjects. Am J Psychiatry 1996;153:57–63
O

daily, for her depression along with supportive manage- 9. Spitzer C, Speisberg B, Grabe HJ, et al. Dissociative experiences and psy-
Pherso

chopathology in conversion disorders. J Psychosom Res 1999;46:291–294

ment and noted “the medicine makes me [the host person- 10. Dunn GE, Paolo AM, Ryan JJ, et al. Dissociative symptoms in a substance
ys nal c

ality] strong,” although her alternate personality was still abuse population. Am J Psychiatry 1993;159:1043–1047
present. 11. McDowell DM, Levin FP, Nunes EV. Dissociative identity disorder and
ic op

substance abuse: the forgotten relationship. J Psychoactive Drugs 1999;31:

Three years later, while she was taking olanzapine, 10 71–83
ia y m

mg daily (because of the onset of tardive dyskinesia on 12. Ellason JW, Ross CA, Fuchs DL. Lifetime axis I and II comorbidity and
ns ay

haloperidol), and mirtazapine, 30 mg daily, her dissocia- childhood trauma history in dissociative identity disorder. Psychiatry
1996;59:255–266
tive symptoms and depression were in complete remission. 13. Giese AA, Thomas MR, Dubovsky SL. Dissociative symptoms in psy-
Po be

She met DSM-IV criteria for personality disorder NOS, chotic mood disorders: an example of symptom nonspecificity. Psychiatry
with dissociative, borderline, and dependent features. 1997;60:60–66
stgprin

14. Ganaway GK. Historical versus narrative truth: clarifying the role of exog-
enous trauma in the etiology of MPD and its variants. Dissociation 1989;2:
ra ted

SUMMARY AND CONCLUSION 205–222

15. Atlas JA, Wolfson MA. Depression and dissociation as features of border-
du

line personality disorders in hospitalized adolescents. Psychol Rep 1996;

Cases similar to those described may be seen in the pri- 78:624–626
a

mary care office or the emergency room. These patients 16. Boon S, Draijer N. Multiple personality disorder in the Netherlands: a clini-
te

may elect collaborative management in primary care cal investigation of 71 patients. Am J Psychiatry 1993;150:489–494
17. Ellason J, Ross C. Positive and negative symptoms in dissociative identity
where primary care physicians have good relationships
Pr

disorder and schizophrenia: a comparative analysis. J Nerv Ment Dis 1995;

with psychiatrists. Those who have less severe symptoms 183:236–241
es

or presentations related to acute stress or loss may only 18. Spiegel D, Detrick D, Frishholz E. Hypnotizability and psychopathology.
Am J Psychiatry 1982;139:431–437
s,

need the supportive care and patient education that in- 19. Bliss EL. Spontaneous self-hypnosis in multiple personality disorder.
formed primary care clinicians could provide. Spiegel and Psychiatr Clin North Am 1984;7:135–148
In

colleagues18 note that better outcomes may be expected in 20. Butler LD, Duran REF, Jasiukaitis P, et al. Hypnotizability and traumatic
c.

experience: a diathesis-stress model of dissociative symptomatology. Am J

individuals with higher levels of ego integration, greater Psychiatry 1996;153(7, suppl):42–63
psychological mindedness, and better ability to restrain 21. Kluft RP. Multiple personality disorders. In: Tasman A, Goldfinger SM,
acting-out impulses. eds. American Psychiatric Press: Review of Psychiatry, vol 10. Washing-
ton, DC: American Psychiatric Press; 1991:161–188
The 3 patients presented above had limited ego 22. Ross CA. Dissociative Identity Disorder: Diagnosis, Clinical Features and
strength and insight and were impulsive, but all remained Treatment of Multiple Personality. 2nd ed. New York, NY: John Wiley &
in supportive and medication therapy over months to Sons; 1997:279–289
23. Herman JL. Trauma and Recovery. New York, NY: Basic Books; 1992
years, voicing benefit from their treatment. Patients with 24. VI: Therapeutic intervention. In: Michelson LK, Ray WJ, eds. Handbook of
dissociative symptoms may be seen by physicians in any Dissociation: Theoretical, Empirical, and Clinical Perspectives. New York,
specialty; addressing their symptoms using the SELF NY: Plenum Press; 1996:399–474
25. Kluft RP. Dissociative identity disorder. In: Michelson LK, Ray WJ, eds.
model reassures the patient and family, enhances trust, Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspec-
and may reduce treatment resistance and acting out. tives. New York, NY: Plenum Press; 1996:337–366

Primary Care Companion J Clin Psychiatry 2:2, April 2000 41