Is Dissociative Identity Disorder a Form of Mass Hysteria?

A few days ago, I read a sensationalist news article that said multiple personalities are not caused by trauma. The research suggesting this was published in Current Directions in Psychological Science, a not-too-well-known psychological journal, and was written by Lynn et al. (2012).

The authors first explain two models of dissociation: the post-traumatic model, which is the most conventional, and the sociocognitive model. The former is based on the idea that dissociation is a coping strategy for dealing with severe trauma, while the latter suggests that dissociation is a cognitive style influenced by suggestion from therapists, sensationalist media portrayals, and susceptibility to fantasy or hypnosis. The authors strongly favor the sociocognitive model, and present some evidence for this, such as the fact that dissociative amnesia cannot be objectified and, in fact, people with DID have a better memory for to-be-forgotten sexual words in a directed-forgetting task.

The authors do not say that there is absolutely no role for trauma in the origins of dissociation. In fact, they claim early trauma causes persons to be more fantasy0prone, which could predispose them to cued dissociation. They also state that sleep deprivation causes dissociation, and post-traumatic symptoms often impair sleep.

In my opinion, indeed, therapists should be careful not to suggest dissociation to clients, and I do not deny that some cases of DID have been created by untethical therapists. However, the authors go so far as to say that there is often no link between trauma and psychopathology when controlling for family history of mental illness. This is a nature-based view of psychopathology which I find rather unfulfilling. Besides, as a person who knew she had alters before ever having seen a therapist, I do not feel it is appropriate to say all cases of DID have been fabricated.

Besides, even if DID is a form of mass hysteria, this doesn’t make it less real. Women – and DID occurs mostly in women – still have a hard time in today’s society. Even if DID itself does not start when a girl is two-years-old and being sexually abused, this abuse, together with other, maybe less severe, acts of oppression, may cause her to develop a psychological coping mechanism that involves fantisizing and psychological traits usually seen as unstable. Mass hysteria is still hysteria, and hysteria is a real mental illness. I am not going to buy it that people with DID are naturally attenton-seekers who want to fabricate trauma in order to have a florious story to tell.

Reference

Lynn SJ, Lilienfeld SO, Merckelbach H, Giesbrecht T, and Van der Kloet D (2012), Dissociation and Dissociative Disorders: Challenging Conventional Wisdom. Current Directions in Psychological Science, 21(1):48-53, DOI: 10.1177/0963721411429457.

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Subthreshold Hypomania: A Review and Implications for DSM-V

Should DSM-V include a diagnostic category for people with major depressive disorder with subthreshold hypomania? This isthe question that is at the center of the paper I just read. My initial answer to this question was a resounding “No”,because of some of the challenges the authors discuss. However, having read the paper, I have come to the conclusion that there may be some use for subsyndromal hypomania as a separae diagnosis.

The authors start by evaluating the prevalence and possible misdiagnosis of unipolar depression vs. bipolar disorder. Previous research found that aproximately 40-50% of people with major depressive disorder have a lifetime history ofsubsyndromal hypomania, depending on the precise criteria used. Furthermore, individuals with such a history are much more likely than individuals without subthreshold hypomania to eventually be diagnosed with bipolar disorder, usually even bipolar I.

In addition, those with major depression and a history of sunthreshold hypomania generally have a worse outcome, more mood episodes, and more work impairment than depressed individuals without a history of subsyndromal hypomania. With regards to family history, people with major depression and subthreshold hypomania are more likely to have family members with mania or other bipolar disorders than those with only depressive symptoms. An early onset (before age 21) of depression and a presentation with atypical features are also characteristic of people with subthreshold hypomania.

For the above reasons, the authors recommend that subthreshold hypomania be included in DSM-V. There is some debate as to which criteria should be used, but they advise an emphasis on overactivy rather than just mood elevation and a duration of at least two days with at least three of seven hypomania symptoms met. The authors also recommend that subthreshold hypomania should be seen as in the middle between pure depression and bipolar II. They argue against the diagnosis of individuals with major depression and subthreshold hypomania as bipolar, because of the stigma this can create.

This stigma was one of my initial reasons to oppose the widening of the bipolar spectrum to include subsyndromalhypomania. The other reason, which the authors also address, is the potential overprescription of antipsychotics and moodstabilizers. There is no evidence that antidepressants would be bad for individuals with major depression who might havesubthreshold hypomania, and neither is there evidence that mood stabilizers or antipsychotics prevent a worsening fromsubsyndromal hypomania to full-blown (hypo)mania. Given the fact that antipsychotics and mood stabilizers have significantside effects, it is not recommended that they be used without merit.

However, the authros do argue for better psychosocial treatmetn of individuals with depression and subthresholdhypomania. They state that cognitive-behavioral therapy, psychoeducation and some other psychosocial interventions may betailored more effectively towards those with subthreshold hypomania if this is idenftified in people with major depression.This is also in light of the worse outcome usually seen in individuals wiht subtreshold hypomania. Psychotherapy,apparrently, might help people manage their hypomanic symptoms.

So, contrary to what I expected, the authors of this study are not Big Pharma puppets who advocate the widespread use ofthe newest and most expensive medications. They also, interestingly, do not seem to suggest that mood disorders as a wholeare underdiagnosed, or that in general more people should be seen as mentally ill. They rather try to pinpoint the symptomsof a subgroup of depressed individuals more precisely than could previously be done. This does not directly change myopinion on subthreshold bipolar yet, but it does give me some thought.

Reference

Nusslock R, Frank E (2011), Subthreshold Bipolarity: Diagnostic Issues and Challenges. Bipolar Disorders, 13:587-603. DOI: 10.1111/j.1399-5618.2011.00957.x.

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High-Functioning Autism vs. Asperger’s Syndrome: Neuroanatomical Differences

First, sorry for my almost three-month hiatus. I am back, anyway. A few days ago, I commented on someone in a YouTube video claiming that high-functioning autism and Asperger’s Syndrome are subtly different in other ways than language acquisition. I disagreed based on DSM-IV criteria. However, the DSM-IV can be criticized, and it remains an ongoing debate whether HFA and Asperger’s are distinct.

Yu et al. (2011) did a meta-analysis of neuroimaging studies on people with autism and Asperger’s Syndrome to determine grey matter volume differences. In each of the analyzed studies, Asperger’s or autistic individuals were compared to controls, so the two groups were not directly compared. Note that autism or Asperger’s diagnostic status was determined based on the absence or presence of language delay.

It was found that not only did autistic individuals’ brains differ more from controls’ brains than the Asperger’s brains differed from those of controls, but that different areas within the grey matter were affected. Specifically, the studies on HFA people showed lower volumes in the cerebellum, right uncus, dorsal hippocampus and middle temporal gyrus compared with controls and grey matter volumes greater than in controls in the bilateral caudate, prefrontal lobe and ventral temporal lobe. In Asperger’s Syndrome people, lower grey matter volumes were found in the bilateral amygdala/hippocampal gyrus and prefrontal lobe, left occipital gyrus, right cerebellum, putamen and precuneus. Grey matter volumes were greater in fewer areas than among HFA subjects, including in the bilateral inferior parietal lobule and the left fusiform gyrus. The areas that are dissimilarly affected in Asperger’s versus HFA are not only related to language acquisition. The authors discuss observed differences between Asperger’s and HFA in the light of neuroimaging. They go so far as to speculate that Asperger’s should be considered more similar to schizophrenia on a continuum of neuropsychopathology than should autism.

Reference

Yu KK, Cheung C, Chua SE, McAlonan GM (2011), Can Asperger Syndrome Be Distinguished from Autism?: An Anatomic Likelihood Meta-Analysis of MRI Studies. Journal of Psychiatry and Neuroscience, 36(6): 412-421. DOI: 10.1503/jpn.100138.

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Born Unwanted: Psychosocial Consequences for Children Whose Mothers Were Denied Abortion

Abortion is, of course, a vjery controversial but relatively common means of fertity planning. A lot of research has been done on various aspects of it, such as mental health and medical consequences of abortions as compared to completed pregnancies. However, little research has been done on the consequences of completing an unwanted pregnancy for the resulting child. In the American Journal of Orthopsychiatry, april 2011, there is a very interesting study on this topic.

The study compared mental health and developmental outcomes for children whose mothers were denied abortion to those born from accepted pregnancies. In Prague in the 1960s, abortion had to be approved by a local abortion commission, and, if denied, could be approved anyway by a regional commission. Unwantedness was defined for the purposes of this study as an abortion having been denied twice. This is a very strict definition of unwantedness, because, of course, not all unwantedly pregnant women go through the bureaucratic process of twice requesting abortion.

There were 220 unwanted pregnancy children found eligible for the study. Each was pair-matched to a child from an accepted pregnancy (mother’s name did not appear on the abortion record) similar in age, gender, birth order and school, while mothers were matched on age and socio-economic status. Children were followed up at age 9, 14-16, 21-23, 28-31 and 32-35. In addition, a substudy was done on married people at age 26-28.

Children born out of unwanted pregnancies had similar birth weights and lenghts, a similar chance of having congenital abnormalities, and a similar score on signs of minimal brain dysfunction (a condition most like current ADHD) to the accepted pregnancy children. At age 9, the two groups also scored similar on overall IQ. However, the unwanted pregnancy children, particularly boys or only children, were significantly less sociable and well-adjusted than the controls.

In adolescence and young adulthood, problems for the unwanted pregnancy group became more significant as compared to the controls. In adolescence, unwanted pregnancy children had dropped out of school more and had obtained lower scores in school (that is, much fewer scored above-average). Social problems also continued. In young adulthood, fewer unwanted pregnancy people were satisfied with their jobs, relationships and overall mental well-being than accepted pregnancy people. Mothers were also less satsified about their unwanted pregnancy children’s developmental and educational outcomes. More unwanted pregnancy children than accepted pregnancy children had been or were still in treatment for mental health conditions, and also more unwanted pregnancy children had been sent to prison.

By about age 30, there was still a difference in psychosocial adjustment between people born from unwanted pregnancies and accepted pregnancies. However, this gap had narrowed. By this follow up, women’s outcomes were less favorable as compared to controls than men’s. There was a significant difference between unwanted pregnancy women and control women in terms of unemployment, unmarried status, and parenting difficulties that requered authority attention, to the disfavor of the unwanted pregnancy women. Such a difference could not be found among men. Unwanted pregnancy women were also less socially integrated and emotionally stable than controls. These effects were due to unwantedness. This can be seen, because, by this stage in follow up, siblings were used as an additional comparison group, and they did not show these problems.

Lastly, by age 32-35, those unwanted pregnancy and accepted pregnancy people still living in Prague and their siblings were given an extensive face-to-face interview. Mental health outcomes were compared. People born from unwanted pregnancies had significantly more problems, as indicated by nine out of ten measures of mental health – ranging from inpatient treatment to sexual satisfaction – than their siblings. This difference was not found among the accepted pregnancy people. The unwanted pregnancy people were significantly more likely to have received inpatient and outpatient mental health treatment than the accepted pregnancy people. They were also significantly more likely to suffer from anxiety and depression. By this age, however, poor social adjustment was not merely attributable to unwantedness, since siblings of unwanted pregnancy people also had poorer social outcomes than the accepted pregnancy controls’ siblings.

The substudy on married unwanted and accepted pregnancy people found some interesting things. In many ways, the female partners of unwanted pregnancy men and the male partners of unwanted pregnancy women were comparable to unwanted pregnancy women and men, respectively. Female partners of unwanted pregnancy males had more abortions (both one-time and repeat) and were more dissatisfied with their jobs and mental well-being than the famele partners of male controls. Similarly, male partners of female unwanted pregnancy people encountered more relationship difficulties than the male partners of control females. Lastly, unwanted pregnancy women who had at least one child, felt less prepared for and less happy about the pregnancy and parenthood than control females.

This study, the author concludes, shows that unwanted pregnancy and denial of abortion lays the foundation for an environment in which children are poorly reared, which subsequently leads to mental health and psychosocial problems for the unwanted child. An alternative hypothesis, whereby mothers of unwanted pregnancy children are simply emotionally unavailable mothers, is rejected.

The last wave of the Prague study was conducted in 1996/1997. The results of earlier waves of this study, in part, led the Czech government to abolish abortion commissions in 1986. The author of course advocates legal abortion and other means of fertlity regulation. It is interesting that this is argued from the point of view of the unwanted child, who is at significant risk of mental health and psychosocial problems if born. Of course, it remains to be debated, from an anti-abortion standpoint, whether these problems are worse than not to be born.

Reference

David HP (2011), Born Unwanted: Mental Health Costs and Consequences. American Journal of Orthopsychiatry, 81(2): 184-192. DOI: 10.1111/j.1939-0025.2011.01087.x.

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Suicide Among LGBT People: Review and Recommendations

There is a long report in the most recent Journal of Homosexuality on suicide, suicidal behavior and suicidal ideation among lesbian, gay, bisexual and trans people. The report starts by defining the sexual orientation and gender identity minorities described in thsi paper. The authors are aware that gender identity and sexual orientation both run on a fluid continuum, and that hence LGBT is not the right term. However, they use it anyway because it is used overall in the research community. That makes me wonder whether no-one wants to change the terminology used in research papers to more accurately reflect the reality of sexual orientation and gender identity minorities.

The authors follow by examining the rate of suicide, suicide attempts and suicidal ideation among LGB people. It is thought that gay and bisexual males are more likely to commit suicide or to attempt suicide than heterosexual males, whereas lesbian and bisexual females are more likely to have suicidal ideation than straight women do. The fact that gay or bisexual men are more likely to attempt suicide, contrasts with findings in the genral population, where women are more likely to attempt suicide. As for age at suicide attempt, this varies across studies. Some studies say that adolescents are most likely to attempt suicide, while others report that suicide attempts are more evenly distributed over the lifespan. A potential explanation may be that suicide attempts are more linked to the age at which LGB people start to identify and disclose their sexual orientation than to chronological age.

Mental illness is one of the most significant risk factors for suicide attempts in the general population. Indeed, LGB people, particularly adolescents and bisexual men, are more likely to have a mental disorder than straight people. This, however, does not explain fully why LGB people are more likely to attempt suicide: when controlling for mental disorders, one study found that LGB people were still two to three times more likely to attempt suicide than straight people.

Another risk factor for suicde attempts and mental disorders is discrimination. Several studies found a relationship between parental rejection and school bullying or violence because of sexual orientation and suicide attempts among LGB adolescents. IN LGB adults, experiences with discrimination and harrassment were also correlated to suicde attempt. There was, however, an interesting racial disparity between Whites on the one hand and Latinos and Blacks on the other, where White LGB people were more likely to have mental disorders, while Black and especially Latino people were more likely to attempt suicide. The explanation for this might be that Latino/Black people are more likely to attempt suicide because of social stressors rather than mental illness.

Instituttional discrimination is also a factor in the increased rate of mental illness among LGB people. In states which do not provide protections from discrimination based on sexual orientation or that have constitutional amendments prohibiting gay marriage, there are elevated rates of mental disorders as compared to those in states with more equality. Poor health insurance, for example due to the lack of coverage for same-sex partners, may also lead to elevated rates of untreated mental illness.

Lastly, HIV/AIDS is also a possible risk factor for suicde attempts, but data on this are inconclusive. It is suggested that substance abuse and other mental disorders may be more relevant predictors of suicide attempt among HIV-positive men than is the virus itself. However, rates of suicide attempts among HIV-positive persons have decreased since there are better antiretroviral treatments available.

There are several protective factors against suicide among LGB people. Among adolescents, family connectedness, support from other adults, and school safety protect against suicide attempts. In adults, connections to an LGB community help. It is also suggested that intimate relationships protect against suicide attempts, but that has not been studied.

The authors go on to discuss suicide risk among transgendered people. One study reports an alarming 80-fold increase in suicide deaths among trans individuals as compared to the general popluation. Another study found that trans people were more likely than any comparison group – heterosexuals, gay and lesbian people, and cis people matched on age, relationship status and several other variables -, except for lesbian females, to attempt suicide. Several risk factors are being reported among trans people for suicde attempts, among them mental disorders and discrimination, particularly rejection by parents in adolescence and on-the-job discriminination and harrassment in adults.

The researchers make many recommendations to improve mental health services, suicide prevention services, and public policies relevant to LGBT individuals. With regard to mental health programs, they encourage furthering of LGBT-specific programs and interventions in mental health and substance abuse services. There areseveral guides to LGBT care, but none provide specific guidelines on suicide prvention. It is recommended, lastly, that DSM-V be revised to make it clear that sexual and gender identity minorities are not per se mentally ill.

There are very few suicide prevention programsspecifically for LGBT people. The only one mentioned in this study is the Trevor Project. It is recommended that interventions, education and awareness related to suicide among LGBT people be increased.

Lastly, several public policy changes are recommended. It is recommended that LGBT groups and allies advocate for:

• Better access to health and mental health services through non-discriminiation policies;
  
• Explicit protection against school violence and bullying based on sexual orientation or gender identity;
  
• Improvements in discriminatory legislation related to factors contributing to suicde or mental health problems;
  
• Inclusion of sexual orientation and gender identity questions on surveys relevant to health and mental health.
  

The authors conclude that, although many questions related to suicide among LGBT populations are as yet unanswered, there appears to be little doubt that a broad national effort will be needed to encourage and fund the needed research, raise awareness of the problem among LGBT and suicide prevention leaders, and develop
the interventions, prevention strategies, and policy changes through which suicidal behavior and suicide risk in LGBT populations can be reduced./P>

Reference

Haas AP, Eliason M, Mays VM, Mathy RM, Cochran SD, D’Augelli AR, Silverman MM, Fisher PW, Hughes T, Rosario M, Russell ST, Malley E, Reed J, Litts DA, Haller E, Sell RL, Remafedi G, Bradford J, Beautrais AL, Brown GK, Diamond GM, Friedman MS, Garofalo R, Turner MS, Hollibaugh A, Clayton PJ (2011), Suicide and Suicide Risk in Lesbian, Gay, Bisexual, and Transgender Populations: Review and Recommendations. Journal of Homosexuality, 58(1):10-51. DOI: 10.1080/00918369.2011.534038.

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Reduced Seclusion in a High Secure Hospital

Seclusion and its reduction is still on my mind, three years after my first and only episode of selcusion. In the most recent issue of the Journal of Psychiatric Intensive Care, seclusion reudction in a high secure hospital was being discussed. It is a very interesting paper, because it is the first study evaluating the reduction of seclusion in such a highly secure setting.

The study authors evaluated the number of seclsusion episodes and adverse incidents (attempted or actual assault) over a five-year period. At the beginning of this period, in 2002, several strategies were implemented to reduce seclusion episodes. These included:

• Use of information and transparancy;
  
• Peer and audit reviews;
  
• Positive risk management and a more recovery-focused treatment;
  
• Increased patient involvement, for example, through the use and advance directives;
  
• Staff training and education;
  
• Enhanced clinical leadership.
  

Some patients also benefited from a medication called clozapine, which is an antipsychotic with independent effects on violence.

Over the five-year period, the number of seclusion episodes decreased by two-thirds. Despite what some earlier studies suggest, there was no increase in adverse incidents within this study period. This signals that maybe an effective reduction of seclusion can be done, if it is a clinical and managerial priority. However, since it was a retrospective study, it is possible that other factors than those mentioned above contributed to the lessening in seclusion episodes.

Reference

Qurashi I, Johnson D, Shaw J, Johnson B (2010), Reduction in the Use of Seclusion in a High Secure Hospital: A Retrospective Analysis. Journal of Psychiatric Intensive Care, 6(2):109-115. DOI:10.1017/S174264640999015X.

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Zolpidem Increases Risk of Falls, Cognitive Impairment

In the department of “Oh duh!” inducing news, research from the University of Colorado-Boulder found that zolpidem increases the risk of falls and grogginess-induced cognitive impairment. Zolpidem is the most commonly used sleep medication in the U.S. It is not a benzodiazepine, but a similar drug.

The study had 25 healthy adults, both older and younger, first take placebo and then take zolpidem. The adults were tested on balance using a tandem walk on a beam. They were also tested for cognitive function using a computerized test. There was also a control condition during wakefulness.

After taking zolpidem, many more subjects had balance problems and were cognitively impaired than after taking placebo. The placebo was used to control for sleep inertia (grogginess). Surprisingly, younger adults suffered more grogginess-induced cognitive impairment after taking placebo than did older adults.

The implications of this study are that non-benzo sleep meds are not as safe as previously thought. This does not surprise me, given how similar the effects of these drugs are to those of benzodiazepines. It is important to take caution when prescribing any sleep med, because falls are an important risk factor for hip fractures and other injuries, and both cognitive impairment and balance problems can contribute to falls.

Reference

Frey DJ, Ortega JD, Wiseman C, Farley CT, Wright KP (2011), Influence of Zolpidem and Sleep Inertia on Balance and Cognition During Nighttime Awakening: A Randomized Placebo-Controlled Trial. Journal of the American Geriatrics Society, 59(1):73-81. DOI: 10.1111/j.1532-5415.2010.03229.x.

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Change in Autism Symptoms and Maladaptive Behavior after Exiting High School

I’m not quite in the mood for studying. However, I thought that, since I’ve been nominated for best autism spectrum blogger in the Mental Nurse TWIM blog awards, I’d better do an autism post for a change. This time, I’m going to review a study on a subject that is dear to my heart: the effects of exiting high school on autism symptomatology and maladaptive behaviors in adolescents and young adults with ASD.

The study authors measured autistic symptoms using mothers’ responses on the Autism Diagnostic Interview-Revised (ADI-R) and maladaptive behaviors using the behavior problems subscale of the Scales of Independent Behavior-Revised (SIB-R), a scale I’ve never heard of so can’t judge. The ADI-R has four subscales – non-verbal communication, verbal communication, repetitive and stereotyped behaviors, and reciprocal social interaction. A symptom was rated as either present or absent, which allowed for a conservative estimate of improvement. On the SIB-R, there are three subscales – internalized behavior, externalized behavior, and asocial behavior -, and in this case, the mothers filling out the scale did rate severity and frequency. Autism symptoms and maladaptive behaviors were assessed at five different times over a ten-year period. For this study, only those who would exit high school during the study period or who were still in high school at the end of the study period (N = 242) were eligible. They were a subgroup of a larger study of 406 autistic adolescents and adults.

The study authors hypothetized that there would be a continuing improvement in symptomatology, but that improvement would slow down after high school exiting. This hypothesis was indeed confirmed. On all autism symptom subscales except for verbal communication, progress slowed or was reversed into a decline after high school exiting. The same goes for the internazed behavior score, but not externalized or asocial behavior.

The authors hypothetize that the reason for the slowed improvement after high school, is the less stimulating adult services as compared to school services. However, they cannot prove this by comparing services, because they did not examine them. I think there are numerous other explanations: ones the authors already mentioned, such as hormonal changes and slowing cognitive development, but also post-high school burn-out from a too stimulating environment.

Unlike what the authors expecting, the slowing in improvement after high school was the greatest among those who did not have an intellectual disability (ID). The authors assume that this is because the services to adults without intellectual disabilities are poorer than those for autistics who do have ID. This is quite possible, since a lot less non-ID autistics have employment or day activities than do autistics with ID.

Family socio-economic status had some influence on trajectories, where autistics living in the lower classes had more change in improvement after exiting high school than did those in the higher classes. This was, however, difficult to prove, because the sample included an overrepresentation of Caucasians and those in the higher socio-economic classes.

The authors recommend that adult day activities and employment programs should be improved to adequately serve autistics, especially those without intellectual disabilities. This is rather an early conclusion, given that services were not examined. However, any improvement to autism services is always welcome, of course.

Reference

Taylor J, Seltzer M (2010), Changes in the Autism Behavioral Phenotype During the Transition to Adulthood. Journal of Autism and Developmental Disorders, 40(12):1431-1446. DOI: 10.1007/s10803-010-1005-z.

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PTSD in People with Intellectual Disabilities

When searching for studies on post-traumatic symptoms, I came across an interesting paper on PTSD among individuals with an intellectual disability (ID. This study is the first systematic review of prevalence, assessment and treatment of PTSD in people with ID.

There are several reasons why people with intellectual disabilities are more susceptible to PTSD than the general population. Firstly, they are more likely to experience traumatic events, such as sexual or physical abuse. They are also more likely to experience negative life events, such as serious illness or injury. Secondly, higher intelligence is associated with better ability to avoid traumatization and to cope with its consequences. Therefore, people with ID may have a lower threshold for PTSD. Thirdly, people with ID are more likely to experience early separations from primary caregivers, hence putting them even more at risk of traumatization. Lastly, the recognition of oneself as disabled may be traumatizing to some individuals. For these reasons, there is an elevated rate of PTSD among people with ID. The literature review found four articles discussing prevalence of PTSD among those with ID. However, all studies were conducted on people referred for treatment who had gone through at least one traumatic event. Studies based on a large, heterogenous sample were lacking. Prevalence rates of PTSD varied from 5% – the prevalence among the general population -, to 60%.

Assessment of PTSD is difficult among individuals with ID, because these people tend to display different symptoms from people with normal intelligence. The Diagnostic Manual-Intellectual Disability (DM-ID, 2007), which is an adaptation of the DSM for assessing individuals with ID, has adapted PTSD criteria for people with mild to moderate ID on the one hand and severe or profound ID on the other. There are also some good instruments for measuring anxiety among people with ID, but these are not specific for PTSD.

The assessment of the traumatic event itself poses problems, as caregivers are not generally aware of a person’s trauma history or may not recognize traumatic events. Furthermore, what may not be traumatic to the average person – for example, a move arranged by others -, may be traumatic to someone with an intellectual disability.

Several treatments are recommended for PTSD in individuals with ID, but the evidence base is small. Firstly, a thorough medical evaluation is recommended, because of the high comorbidity with medical disorders. Psychopharmacology is discussed, but specific research on medication intervention for this population, is absent.

The second treatment approach focuses on changing the environment to eliminate frightening cues. Training and support of caregivers to teach them appropriate responses to PTSD symptoms, is also mentioned. This is particularly relevant for those with lower levels of intelligence.

Lastly, psychotherapy can be useful for the treatment of PTSD. There is clinical support for the use of cognitive-behavioral therapy (CBT) in people with mild ID. The techniques reported on were exposure therapy and imaginary rehearsal therapy. Two case reports were also found on the use of EMDR for PTSD among individuals with mild ID. In all therapeutic approaches described, modifications were made for the clients’ disabilities.

Reference

Mevissen L., De Jongh A. (2010), PTSD and Its Treatment in People with Intellectual Disabilities: A Review of the Literature. Clinical Psychology Review, 30(3):308-316. DOI: 10.1016/j.cpr.2009.12.005.

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Prospective Study Finds Increased Psychopathology among Persons Sexually Abused as Children

When reading the study I’m going to review here, one would almost say “Oh, duh!”: it is logical and common sense that childhood sexual abuse (CSA) leads to psychiatric disorders. What is new about this study, however, is that it is prospective rather than retrospective. The presence of abuse was ascertained using a forensic medical registry. Unlike what the title suggests, not all subjects were followed up after 43 years: all cases of CSA between 1965 and 1995 were collected. Psychiatric pathology was also ascertained using a state registry of public mental health contacts that detailed the persons’ diagnosis. The sexual abuse victims were compared to a sample of the general population.

Sexual abuse victims were over three times more likely to have contact with public mental health than were the general population controls. This held true for both males and females. They were also more likely to suffer from all types of disorders except for eating disorders. The reason there was no significant correlation between CSA and eating disorders, may be that only those treated by the public mental health system were counted. The most significant risk correlation was found for PTSD, alcohol and drug abuse, and personality disorders. Female sexual abuse victims were significantly more likely to suffer from most disorders than controls, while non-psychiatric complaints were more likely to occur in males. Of note is that three sexually abused males had a diagnosis of pedophilia, compared to none in the control group. However, significance could not be calculated.

When comparing diagnoses in childhood versus adulthood, both remained significantly higher among the CSA group. In childhood, PTSD, conduct disorder and known drug abuse were the most significant, while in adulthood, other disorders and known substance abuse were more likely to occur.

When examining abuse characteristics, it was found paradoxically that mental health contact, diagnosis of a clinical disorder, and diagnosis of a personality disorder, were significantly associated with older age at abuse. On the other hand, most clinical disorders were significantly associated with younger age of abuse. I do not understand this paradox, although it was concluded that psychopathology is not associated with younger age at abuse.

Those who were raped rather than victimized to non-penetrative abuse were more likely to have contact with mental health services and be diagnosed with most disorders. Having multiple offenders was also a significant risk factor for mental health contact and diagnosis of psychopathology. However, whether the perpetrator was related or not, was only significantly correlated with psychosis, where people abused by a non-relative were more likely to develop a psychotic disorder.

Reference

Cutajar MC, Mullen PE, Ogloff JRP, Thomas SD, Wells DL, Spataro J (in press), Psychopathology in a Large Cohort of Sexually Abused Children Followed up to 43 Years, Child Abuse & Neglect. Published online: October 2, 2010. DOI: 10.1016/j.chiabu.2010.04.004.

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