We feature an expert in the mental health and substance use disorder field to answer questions. This issue we talk to Dr. Rochelle Gredvig of Nystrom and Associates about dissociative disorders.
What is your current role at Nystrom & Associates? What inspired you to do the work that you’re doing?
I’m a clinical diagnostician and psychotherapist, which means that I do psychological testing as well as therapy. I’ve always enjoyed helping others. I went through substance use disorder (SUD) treatment when I was 16 years old and thought that I wanted to be a SUD counselor, until I took my first psychology class during my senior year of high school. I’ve been practicing on and off (between raising children) for over 20 years and have always been passionate about helping patients heal from trauma using Eye Movement Desensitization and Reprocessing (EMDR). In recent years, I’ve developed another passion, helping patients with dissociative disorders.
Please describe the history of dissociative disorders and how they became a part of the Diagnostic and Statistical Manual.
In an article by Dell and O’Neil, they state that “the current dissociative disorders that have been described were discovered prior to 1900 but decades passed with little study or research of this spectrum of psychiatric pathology. The existence of dissociative disorders is questioned by many in the field of psychiatry, and the diagnosis is not utilized by some clinicians. Complicating factors include misdiagnosis and under-diagnosis, which may occur due to unfamiliarity with this spectrum of disorders, disbelief that they exist, or lack of knowledge and appreciation of the epidemiology.”
When I completed my doctorate in 2000, dissociative disorders were barely discussed, and we were led to believe that they were exceedingly rare. I’ve spoken to many colleagues who have graduated in recent years, and they were taught similarly. When I began hearing clinicians describe their dissociative clients in workshops several years ago, I was flabbergasted. I thought they were exaggerating when they said that they had several or more patients with florid dissociative symptoms. Once I began looking for dissociative symptoms in my own patients with trauma and/or neglect-filled childhoods, I began to discover how common dissociative disorders are among patients with Complex Post-Traumatic Stress Disorder (CPTSD). I have a few patients whom I had seen for a few years without having any idea that they had dissociative symptoms. Once I became knowledgeable and began asking the right questions, they were as surprised as I to realize they had other parts of self. More often than not, persons with dissociative disorders have no idea that they have them because parts of self are meant to be hidden.
What are some symptoms of dissociative disorders?
In an article written by Kluft in 1999, he lists the following as possible symptoms of dissociative disorders:
- Prior treatment failure
- Three or more prior diagnoses
- Concurrent psychiatric and somatic symptoms
- Fluctuating symptoms and levels of function
- Severe headaches and other pain syndromes
- Time distortion, time lapses, or frank amnesia
- Being told of disremembered behaviors
- Others noting observable changes
- The discovery of objects, productions or handwriting in one’s possession that one cannot account for or recognize
- Hearing voices (80% or more experienced as within the head) that are experienced as separate, often urging the patient toward some activity
- The patients use of “we” or third person
- History of child abuse
- An inability to recall childhood events from the years 6 to 11
It is common for dissociative patients to experience physical sensations or pain when parts of self are activated. One of my dissociative patients has struggled with frequent migraines for years, but once they started doing “parts work,” their migraines became few and far between. Another patient struggled with debilitating Meniere’s attacks to the point where they couldn’t walk without holding onto walls in their home. She only experiences slight waves of dizziness now and has discovered that those symptoms were the result of parts controlling her behavior because the parts thought she was doing too much for others and needed more self-care.
What differentiates normal dissociation from symptoms of a dissociative disorder?
Everyone has numerous ego states that are our way of being in certain situations, like modes of functioning. Ego states retain a shared sense of belonging to the person as a whole and a person is able to move from role to role while retaining a sense of “me.” Dissociative parts are similar to ego states, except they are distinct and separate from one’s sense of self. Each dissociative part has its own sense of self and is able to think, feel, and act more or less independently of the others. They are part of a whole person whose personality is fragmented and compartmentalized. Dissociative disorders fall on a spectrum with typical dissociation that affects everyone on one end and Dissociative Identity Disorder (DID), previously known as Multiple Personality Disorder, on the opposite end.
What are the etiology and risk factors for dissociative disorders?
Repeated abuse, neglect and/or lack of attachment to primary caregivers before the age of 12, while the brain is still developing, can result in a child’s brain developing new neural networks that separate into separate parts of self. For example, the child is then able to get up and go to school with no memory of the abuse from the night before, as the part that holds the trauma slips into the background of the child’s consciousness.
It’s normal for children to develop imaginary friends between the ages of 2 to 6. These fantasy friends help children cope with loneliness and painful emotions. As a child’s concept of self develops and they become better able to regulate their emotions, these inner companions dissolve and are integrated into self. However, in the presence of severe, chronic and inescapable trauma, instead of outgrowing these companions, the child may come to rely more heavily upon them. Often patients with dissociative disorders recall imaginary friends vividly and/or still actively engage with them.
When a child lives in a stressful world of abuse, trauma, neglect and/or lack of attachment, they learn that it’s necessary to keep secrets from the self and from the world to survive. As Sandra Paulsen states in her book, Looking Through the Eyes of Trauma, “[These children] create a false self that serves to present a happy face to the world. Hidden behind a veil of amnesia are the other parts of self that hold traumatic experiences. The strategy of containing unacceptable material behind an amnesia curtain creates a grand illusion that abuse is happening to someone else.”
Are dissociative disorders common in people who struggle with substance use disorders and/or mental illness?
They can be, depending on their childhoods. As addiction and mental illness run in families, children being raised by parents who are addicts and/or struggle with mental illnesses, are less likely to get their needs met. The trauma and abuse can be subtle. For example, if a child is raised solely by a severely depressed mother, who is unable to engage with, nurture or empathize with the child, the child can develop a dissociative disorder. Or if the parents occasionally binge drink and exhibit erratic, frightening behavior at such times, the child can develop a dissociative disorder.
As a psychologist, what are some formal assessments that you give to assess for a dissociative disorder?
Tests like the Minnesota Multiphasic Personality Inventory (MMPI) and Millon aren’t reliable for assessing dissociative disorders as they attribute dissociative symptoms to psychotic behavior. The most thorough and well-researched assessment instrument is the Multidimensional Inventory of Dissociation (MID). It also screens for Borderline Personality Disorder and malingering. I often read the questions from the Dissociative Experiences Scale with therapy patients as a quick screen and information-gathering tool. The scores aren’t as reliable or accurate as the MID.
If someone struggles with dissociation, what are some things that they can do to practice self-regulation?
The biggest struggle for patients with dissociative disorders is when current events, sounds or smells, trigger traumas and activate parts of self. On such occasions, it helps to orient themselves to the present: talk to their parts and let them know the year, that they are in an adult body; that no one is harming them; that they have a car and can leave a situation if they are uncomfortable, etc. It’s very important for dissociative patients to have compassion for their parts of self, focusing on gratitude that they have held the trauma for the system and the fact that most parts are young and scared.
What are some resources for people looking for help?
My favorite book for both clinicians and patients is Healing the Fragmented Selves of Trauma Survivors by Janina Fisher. I’ve had several patients realize they have a dissociative disorder just from listening to the audiobook version of the introduction. The Eye Movement Desensitization and Reprocessing International Association (EMDRIA) sponsors excellent training that incorporates using EMDR for dissociative disorders. I’ve attended some of these led by various clinicians such as Sandra Paulson, Kathy Steele, and Joanne Twombly. If someone is looking for a therapist that is skilled in this area, they can go to the MN Trauma Project’s website to view the therapist directory.
Rochelle Gredvig, PsyD, works as a therapist and clinical diagnostician at Nystrom and Associates in Maple Grove. She specializes in trauma and dissociative disorders. She is trained in Eye Movement Desensitization and Reprocessing. She also completes psychological testing on adults for ADHD and diagnostic clarification. Dr. Gredvig has been in recovery from addiction since 1984.
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Last Updated on May 13, 2023