Dissociative experiences and disorders in forensic inpatients

Exploring the connection between childhood trauma, dissociation, and borderline personality disorder in forensic psychiatry: a comprehensive case study

This case study examines the complex relationship between childhood trauma, dissociation, and Borderline Personality Disorder (BPD) within the context of forensic psychiatry. It focuses on a young murder defendant named "Paul," who has experienced various traumatic events, including childhood maltreatment and domestic violence. These experiences have led to dissociative states marked by high emotional intensity, particularly of an aggressive nature, and impaired impulse control, resulting in violent behavior during dissociative episodes. The study employs advanced assessment tools like Raven's Standard Progressive Matrices (SPM), the Millon Clinical Multiaxial Inventory-III (MCMI-III), and the Level of Service/Case Management Inventory (LS/CMI) to gain a comprehensive understanding of Paul's psychopathological condition, risk factors, and rehabilitation needs. The LS/CMI assessment highlights a high risk of recidivism, mainly influenced by family relationships, educational challenges, interpersonal connections, and aggressive tendencies. To address the multifaceted needs of individuals like Paul, the study emphasizes the importance of using transdiagnostic models for trauma and dissociation. This approach informs tailored treatment programs that include processing past traumatic experiences, improving self-identity, nurturing healthy relational patterns, and enhancing emotional regulation. Although this study is based on a single case, it serves as a model for integrating assessment tools and theoretical-clinical models in the field of forensic psychiatry. Understanding the intricate dynamics of childhood trauma, dissociation, and BPD is crucial for making informed decisions, conducting risk assessments, and developing rehabilitation programs within the justice system. Future research should expand the scope of cases and further validate assessment tools to advance our understanding of this complex relationship.

Dissociation and its biological and clinical associations in functional neurological disorder: systematic review and meta-analysis

BACKGROUND

Studies have reported elevated rates of dissociative symptoms and comorbid dissociative disorders in functional neurological disorder (FND); however, a comprehensive review is lacking.

AIMS

To systematically review the severity of dissociative symptoms and prevalence of comorbid dissociative disorders in FND and summarise their biological and clinical associations.

METHOD

We searched Embase, PsycInfo and MEDLINE up to June 2021, combining terms for FND and dissociation. Studies were eligible if reporting dissociative symptom scores or rates of comorbid dissociative disorder in FND samples. Risk of bias was appraised using modified Newcastle-Ottawa criteria. The findings were synthesised qualitatively and dissociative symptom scores were included in a meta-analysis (PROSPERO CRD42020173263).

RESULTS

Seventy-five studies were eligible (FND n = 3940; control n = 3073), most commonly prospective case-control studies (k = 54). Dissociative disorders were frequently comorbid in FND. Psychoform dissociation was elevated in FND compared with healthy (g = 0.90, 95% CI 0.66-1.14, I² = 70%) and neurological controls (g = 0.56, 95% CI 0.19-0.92, I² = 67%). Greater psychoform dissociation was observed in FND samples with seizure symptoms versus healthy controls (g = 0.94, 95% CI 0.65-1.22, I² = 42%) and FND samples with motor symptoms (g = 0.40, 95% CI -0.18 to 1.00, I² = 54%). Somatoform dissociation was elevated in FND versus healthy controls (g = 1.80, 95% CI 1.25-2.34, I² = 75%). Dissociation in FND was associated with more severe functional symptoms, worse quality of life and brain alterations.

CONCLUSIONS

Our findings highlight the potential clinical utility of assessing patients with FND for dissociative symptomatology. However, fewer studies investigated FND samples with motor symptoms and heterogeneity between studies and risk of bias were high. Rigorous investigation of the prevalence, features and mechanistic relevance of dissociation in FND is needed.

Causal connection between dissociation and ongoing interpersonal violence: A systematic review

OBJECTIVE

To identify evidence for dissociation as a cause of ongoing interpersonal violence.

METHOD

A systematic review of the literature retrieved from ten databases.

RESULTS

Fifteen studies yielded from our search strategy have been included in the review; eleven of these were longitudinal and four were experimental. The evidence indicates that pathological dissociation may contribute towards enduring interpersonal violence. Thus, dissociation may account for instances of repeated victimisation. There are similar indications concerning offenders, but study designs in this area allow one to draw fewer causal conclusions. There is some evidence that dissociation decreases information processing from the limbic system, which may be one underlying neurofunctional mechanism of persistent violence.

CONCLUSION

There is growing evidence for dissociation as a cause of interpersonal violence. However, the available evidence is still limited, and our review rather reveals an important research gap. Future longitudinal and experimental studies aimed at clarifying the role of dissociation in the context of violence should take into account the theoretical and empirical complexity around the concept of dissociation.

Psychotic-Like Symptoms and the Temporal Lobe in Trauma-Related Disorders: Diagnosis, Treatment, and Assessment of Potential Malingering

Objective

To overview the phenomenology, etiology, assessment, and treatment of psychotic-like symptoms in trauma-related disorders focusing on the proposed role of temporal lobe dysfunction.

Method

We describe the literature pertaining to (i) psychotic-like symptoms and temporal lobe dysfunction in trauma-related disorders and (ii) psychological testing profiles in trauma-related disorders. We define trauma-related disorders as borderline personality disorder, post-traumatic stress disorder, and the dissociative disorders. Our search terms were dissociative disorders, temporal lobe, trauma, post-traumatic stress disorder, borderline personality disorder, psychosis, and malingering.

Results

Trauma-related psychotic-like symptoms are common and can differ in phenomenology from primary psychotic symptoms. Hallucinations consist of auditory and nonauditory content that may or may not relate to traumatic content. Child voices are highly suggestive of complex dissociative disorders. Critically, not only do these symptoms resemble those seen in temporal lobe epilepsy, but the temporal lobe is implicated in trauma-related disorders, thus providing a plausible neurobiological explanation. Despite such evidence, these symptoms are frequently considered atypical and misdiagnosed. Indeed, common structured psychological assessment tools categorize these symptoms as possible indicators of invalid testing profiles.

Conclusion

Psychotic-like symptoms are common in trauma-related disorders, may be related to temporal lobe dysfunction, and are frequently misinterpreted. This may lead to ineffective treatment and inappropriate determinations of malingering in the forensic system.

Dissociative Experiences and Psychopathology Among Inmates in Italian and Portuguese Prisons

The association between dissociation and psychopathological symptoms is well established, yet studies with inmates are lacking. If higher rates of dissociation and psychiatric symptoms are reported in inmate samples, it is not clear whether they represent two separate, albeit related, characteristics. We examined the association between dissociation and psychopathological symptoms among 320 Italian subjects (122 inmates and 198 community participants) and a Portuguese inmate sample ( n = 67). Then, we tested whether dissociation and psychopathology levels were higher among inmates. Both hypotheses were supported, confirming the relevance of dissociative, paranoid, and psychotic symptoms among inmates, as well as their interrelations. Notably, the group difference in dissociation remained significant after partialing out the variance associated with other psychopathological symptoms. Conversely, only the difference in paranoid symptoms remained-marginally-significant when controlling for the influence of dissociation. This finding suggests that dissociation may have unique relevance for the psychological functioning of inmates.

Epidemiology of Dissociative Disorders: An Overview

General psychiatric assessment instruments do not cover DSM-IV dissociative disorders. Many large-scale epidemiological studies led to biased results due to this deficit in their methodology. Nevertheless, screening studies using diagnostic tools designed to assess dissociative disorders yielded lifetime prevalence rates around 10% in clinical populations and in the community. Special populations such as psychiatric emergency ward applicants, drug addicts, and women in prostitution demonstrated the highest rates. Data derived from epidemiological studies also support clinical findings about the relationship between childhood adverse experiences and dissociative disorders. Thus, dissociative disorders constitute a hidden and neglected public health problem. Better and early recognition of dissociative disorders would increase awareness about childhood traumata in the community and support prevention of them alongside their clinical consequences.

Factor structure and correlates of the dissociative experiences scale in a large offender sample

The authors examined the psychometric properties, factor structure, and construct validity of the Dissociative Experiences Scale (DES) in a large offender sample (N = 1,515). Although the DES is widely used with community and clinical samples, minimal work has examined offender samples. Participants were administered self-report and interview measures, and a subsample was followed longitudinally to determine criminal and violent recidivism. The DES exhibited good psychometric properties, but an identified three-factor structure was of questionable replicability. Moreover, the DES factors displayed no evidence of differential correlates. DES total scores were correlated with trauma-related variables even after controlling for negative affectivity. Total scores were related to measures of antisocial behavior and aggression but did not predict recidivism. These findings support the reliability and construct validity of the DES in offenders but raise questions regarding the clinical utility of the DES factor scores above and beyond that of the total score.

Tracking scientific interest in the dissociative disorders: a study of scientific publication output 1984-2003

OBJECTIVE

We attempted to track scientific interest in dissociative amnesia and dissociative identity disorder by estimating the annual output of publications regarding these entities over the last 20 years.

METHODS

Using a standard medical index, PsycINFO, we counted the number of indexed publications involving dissociative amnesia and dissociative identity disorder listed for each year. We then compared these rates with those of well-established diagnoses such as anorexia nervosa, alcohol abuse, and schizophrenia. We also systematically reviewed all publications involving dissociative amnesia that appeared in 2003.

RESULTS

Annual publications involving dissociative amnesia and dissociative identity disorder rose from low levels in the 1980's to a sharp peak in the mid 1990's, followed by an equally sharp decline to only about one quarter of their peak levels by 2002 and 2003. In contrast, all of the 25 comparison diagnoses in our survey showed constant or steadily rising publication rates; none showed the 'bubble' pattern of the dissociative disorders. Of the 34 papers involving dissociative amnesia identified by PsycINFO for 2003, 10 (32%) appeared skeptical of the validity of dissociative amnesia and/or recovered-memory therapy. Despite a detailed search using multiple medical indices and search terms, we could find only 13 explicit cases of individuals with dissociative amnesia worldwide in the 2003 literature.

CONCLUSIONS

Dissociative amnesia and dissociative identity disorder have not generated consistent scientific interest over the years, but instead apparently enjoyed a brief period of fashion that now has waned. Overall, our observations suggest that these diagnostic entities presently do not command widespread scientific acceptance.