User:Amousey/sandbox/DID

Already existing refs

 * Guidelines2011
 * Rein2008
 * Rein2008
 * Rein2008
 * Rein2008
 * Rein2008
 * Rein2008
 * Rein2008
 * Rein2008
 * Rein2008
 * Rein2008

Do these refs exist on page

 * Gleaves
 * Frankel review
 * Farrell
 * Brown chapter
 * Frankel chapter
 * Steinberg review
 * - covers things like the Frye standard used in the US
 * Brand 2017
 * Bourquet 2017 not a review but useful

Different ages
Children Guidelines for the diagnosis and treatment of children and teenagers with DID differ from those for adults.

Elderly Patients who begin treatment at an advanced age may remain in the first phase of treatment for longer or possibly for the full course of treatment, although age is only one of several factors that influence this. The first phase of treatment focuses on stabilization and symptom reduction rather than processing trauma memories or integrating identities. Patients remaining in the first phase of treatment may make "considerable improvements in safety and overall functioning".

Issue: Integration as the goal
Guidelines then state that "workable harmony between identities" called resolution is a "desirable outcome" rather than only full integration of so identities into one (which is called unification or fusion). It cites only Kluft as arguing that full integration is best.
 * The treatment section reads as if the main goal is to integrate the patient into one identity - something that most movies portray especially fictional ones - but the treatment guidelines do actually not say this. This suggestion also removes patient choice over goals. And it's also not consistent with mental health to suggest that treatment is only truly successful if there is a full cure, which is what the section reads like to me. Guidelines actually talk about shared goal's, goals for each of the 3 phases, and state "Treatment should move the patient toward better integrated functioning whenever possible." which isn't the same as fully integrating info one. Integrated functioning refers to different personalities / personality states communicating with each other, co-ordinating what needs to be done, and working together for "optimal functioning".

Guidelines: "R. P, Kluft (1993a) has argued that the most stable treatment outcome is final fusion—complete integration, merger, and loss of separateness—of all identity states, However, even after undergoing considerable treatment, a considerable number of DID patients will not be able to achieve final fusion and/or will not see fusion as desirable. Many factors can contribute to patients being unable to achieve final fusion: chronic and serious situational stress; avoidance of unresolved, extremely painful life issues, including traumatic memories; lack of financial resources for treatment; comorbid medical disorders; advanced age; significant unremitting DSM Axis I and/or Axis II comorbiditíes; and/or significant narcissistíc investment in the alternate identities and/or DID itself; among others. Accordingly, a more realistic long-term outcome for some patients may be a cooperative arrangement sometimes called a "resolution"—that is, sufficiently integrated and coordinated functioning among alternate identities to promote optimal functioning.''' However, patients who achieve a cooperative arrangement rather than final fusion may be more vulnerable to later decompensation (into florid DID and/or PTSD) when sufficiently stressed." I think it's important to clarify that full integration is not "the" goal, give the reasons why it is sometimes not possible for those patients who choose it, clarify that some choose not to attempt it, describe "resolution" and state that some patients choose that.

Issue: How many achieve full integration
Text on page states "Highly experienced therapists have few patients that achieve a unified identity." The only source is a primary study which is not really enough for MEDRS. The study cited which concludes "The last stage of treatment was less clearly delineated and more individualized, although this may be an artifact of limited data about the later stages. The data suggest that unification of self states occurs in only a minority of patients with DID, at least among this sample of clinicians, although this may be related to the types of patients referred to these experts." This qualification is missing.

Treatment guidelines (secondary source) also cited state: "In The Netherlands, a chart review study of 101 dissociative disorder patients in outpatient treatment for an average of 6 years found that clinicical improvement was related to the intensity of the treatment; more comprehensive therapies had better outcomes (Groenendijk & Van der Hart, 1995). Systematically collected outcome data from case series and treatment studies indicated that 16.7% to 33% of those DID patients achieved full integration (i.e., final fusion; Coons & Bowman, 2001; Coons & Sterne, 1986; Ellason & Ross, 1997).

However, (primary) source clarifies this may be down to highly experienced clinicians taking on more difficult cases, Treatment guidelines don't say either way.

Suggested text: How many achieve full integration
Treatment aims to for patients to achieve integrated functioning; around 15-33% of patients fully integrate all identities, some patients choose a co-operative arrangement between identities instead of fully integrating, and another group of patients may not be able to due to reasons such as lack of money for the lengthy treatment, being elderly, ongoing medical problems or serious situational stress, being unable to resolve early life issues or other "significant unremitting" mental disorders or learning disabilities.


 * sum of overall effects of treatment

Treatment
Treatment aims to increase integrated functioning. The International Society for the Study of Trauma and Dissociation has published guidelines for phase-oriented treatment in adults as well as children and adolescents that are widely used in the field of DID treatment. The guidelines state that "a desirable treatment outcome is a workable form of integration or harmony among alternate identities". Some experts in treating people with DID use the techniques recommended in the 2011 treatment guidelines. The empirical research includes the longitudinal TOP DD treatment study, which found that patients showed "statistically significant reductions in dissociation, PTSD, distress, depression, hospitalisations, suicide attempts, self-harm, dangerous behaviours, drug use and physical pain" and improved overall functioning. Treatment effects have been studied for over thirty years, with some studies having a follow-up of ten years. Adult and child treatment guidelines exist that suggest three phased approach, and are based on expert consensus. Highly experienced therapists have few patients that achieve a unified identity. Common treatment methods include an eclectic mix of psychotherapy techniques, including cognitive behavioral therapy (CBT), insight-oriented therapy, dialectical behavioral therapy (DBT), hypnotherapy and eye movement desensitization and reprocessing (EMDR). Medications can be used for comorbid disorders or targeted symptom relief, for example antidepressants or treatments to improve sleep. Some behavior therapists initially use behavioral treatments such as only responding to a single identity, and then use more traditional therapy once a consistent response is established. Brief treatment due to managed care may be difficult, as individuals diagnosed with DID may have unusual difficulties in trusting a therapist and take a prolonged period to form a comfortable therapeutic alliance. Regular contact (at least weekly) is recommended, and treatment generally lasts years—not weeks or months. Sleep hygiene has been suggested as a treatment option, but has not been tested. In general there are very few clinical trials on the treatment of DID, none of which were randomized controlled trials.

Therapy for DID is generally phase oriented. Different alters may appear based on their greater ability to deal with specific situational stresses or threats. While some patients may initially present with a large number of alters, this number may reduce during treatment—though it is considered important for the therapist to become familiar with at least the more prominent personality states as the "host" personality may not be the "true" identity of the patient. Specific alters may react negatively to therapy, fearing the therapist's goal is to eliminate the alter (particularly those associated with illegal or violent activities). A more realistic and appropriate goal of treatment is to integrate adaptive responses to abuse, injury or other threats into the overall personality structure. There is debate over issues such as whether exposure therapy (reliving traumatic memories, also known as abreaction), engagement with alters and physical contact during therapy are appropriate and there are clinical opinions both for and against each option with little high-quality evidence for any position.

Brandt et al., commenting on the lack of empirical studies of treatment effectiveness, conducted a survey of 36 clinicians expert in treating dissociative disorder (DD) who recommended a three-stage treatment. They agreed that skill building in the first stage is important so the patient can learn to handle high risk, potentially dangerous behavior, as well as emotional regulation, interpersonal effectiveness and other practical behaviors. In addition, they recommended "trauma-based cognitive therapy" to reduce cognitive distortions related to trauma; they also recommended that the therapist deal with the dissociated identities early in treatment. In the middle stage, they recommended graded exposure techniques, along with appropriate interventions as needed. The treatment in the last stage was more individualized; few with DD [sic] became integrated into one identity.

The first phase of therapy focuses on symptoms and relieving the distressing aspects of the condition, ensuring the safety of the individual, improving the patient's capacity to form and maintain healthy relationships, and improving general daily life functioning. Comorbid disorders such as substance abuse and eating disorders are addressed in this phase of treatment. The second phase focuses on stepwise exposure to traumatic memories and prevention of re-dissociation. The final phase focuses on reconnecting the identities of disparate alters into a single functioning identity with all its memories and experiences intact.

A study was conducted to develop an "expertise-based prognostic model for the treatment of complex posttraumatic stress disorder (PTSD) and dissociative identity disorder (DID)". Researchers constructed a two-stage survey and factor analyses performed on the survey elements found 51 factors common to complex PTSD and DID. The authors concluded from their findings: "The model is supportive of the current phase-oriented treatment model, emphasizing the strengthening of the therapeutic relationship and the patient's resources in the initial stabilization phase. Further research is needed to test the model's statistical and clinical validity."