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Katherine L Hilton, LPC
Mississippi College
Evidence Based Practice
 Evidence Based Practices (EBPs)
(Chambless, 1998; Gertlehner, Hasenc, & Nissman, 2006)
 Applying EBP Starts with Effective Assessment
(Byng, 2012; Caldwell, Bennett, & Mellis, 2012; Rice, 2013)
 Difficult with complex clinical presentations
(Ellason, Ross, & Fuchs, 1996)
 Trauma
(Lamagna & Gleiser, 2007; Sprang, Craig, & Clark, 2007)
 Something May be Missing…
(International Society for the Study of Trauma and Dissociation [ISSTD], 2011)
 a disruption in typically integrated mental
functioning of experience, especially in regards to
consciousness, memory, identity, or perception (APA,
2000, p. 519)
 50%- 65% in a lifetime – (APA, 2013; Ross, Joshi, & Currie, 1990)
 “A normal process that is… used defensively by an
individual to handle traumatic experiences”(Putnam, 1989,
p. 9)
Types of Dissociation
 Depersonalization &
 Identity Disruption
 “Unreality or
 Not delusional
 Dissociative Amnesia
 Localized
 Selective
 Generalized
(APA, 2013; Schauer & Elbert, 2010)
Maladaptive Dissociation
 Dissociative Disorder
 Characteristic of a Trauma-Related Disorder
 Co-occurring Symptom
Dissociative Disorders
 Depersonalization/
Derealization Disorder
 Dissociative Identity
 50% - One Episode
 2% - Lifetime
 1.5% - Lifetime
 Dissociative Amnesia
 1.8% in a given year
(APA, 2013)
Dissociation in Other Disorders
 Borderline Personality
 Dissociative
 Disruption of identity
 Post-Traumatic Stress
 Flashbacks
 Specifier
(APA, 2013)
Co-Occurring Disorders
 Somatization Disorder/ Somatic Symptom Disorder
(Brown, Schrag, & Trimble, 2005)
 OCD (Hollander & Benzaquen, 1997)
 Social Anxiety (Fontonelle et al., 2007)
 Panic Disorder (Pfaltz, Michael, Meyer, & Wilhelm, 2013)
 Bulimia Nervosa & Binge Eating (Hallings-Pott, Waller,
Watson, & Scragg, 2005)
 Depression (Hagenaars, van Minnen, & Hoogduin, 2010)
 Schizophrenia (Braehler et al., 2013)
Effect on Treatment
 “poses a serious obstacle to successful treatment”
(Schauer & Elbert, 2010, p. 109)
 OCD & Dissociation - Rufer et. al (2006)
 52 participants, CBT treatment
 Baseline DES scores positively correlated with…
 Earlier Termination
 Lack of Treatment Response
 OCD Symptoms Post-Treatment
Effect on Treatment
 Borderline personality disorder (Kleindienst et al., 2011)
 57 clients; 3 months of DBT
 Agoraphobia with panic (Michelson et al., 1998)
 89 clients; CBT treatment
 Inpatient treatment for non-psychotic disorders
(Spitzer et al., 2007)
 133 clients; short-term CBT psychotherapy
Statement of Problem
 The problem of this literature review is to identify
and describe the effects of dissociation on treatment
 An additional concern is to identify specific
disorders and their treatments that are the most
impacted by dissociation.
 Results could improve screening and assessment
 Recommendations for improving course of treatment
and outcome for co-occurring disorders
Research Questions
1. What effects does dissociation have on treatment
2. Does dissociation negatively influence treatments
for certain co-occurring disorders?
3. How could screening for dissociation improve
treatment of co-occurring disorders?
 Systematic Literature Review
 Preferred Reporting Items for Systematic reviews
and Meta-Analyses (PRISMA) statement
 PRISMA Checklist
 PRISMA Flowchart
 1980 – 2014
 Databases:
Sage Premier
Wiley Online Library
 Reference Lists
 Specific Journals
 e.g. Journal of Trauma
and Dissociation
Search Terms
Co-occurring Disorders
Co-occurring Disorders
Post-traumatic Stress Disorder
Borderline Personality Disorder
Course of Treatment
Obsessive-Compulsive Disorder
Identity disruption
Anxiety Disorder
Premature Termination
Panic Disorder
Treatment Response
Eating Disorder
Post-Treatment Symptoms
Bulimia Nervosa
Inclusion Criteria
 Psychometric
assessment(s) that have
proven validity and
 Subscales or items from
other assessments (e.g.,
Briere, 1995)
 Structured Clinical
Interview for DSM–IV
Dissociative Disorders–
Revised (SCID-D-R; Steinberg, 1994)
 Multidimensional
Inventory of Dissociation
(MID; Dell, 2006)
 Dissociative Experiences
Scale (DES; Bernstein & Putnam,
 Dissociative Disorders
Interview Schedule (DDIS;
Ross et al., 1989)
Exclusion Criteria
 Non-English
 Non-peer reviewed
 Focus of Treatment is a Dissociative Disorder
Definition of Terms
 Dissociation - “a
disruption of and/or
discontinuity in the
normal integration of
memory, identity,
emotion, perception,
motor control, and
behavior” (APA, 2013, p. 519)
 Dissociation - Not
inherently pathological
Definition of Terms
 Depersonalization –”the
experience of unreality
or detachment from
one’s mind, self, or
body”(APA, 2013, p. 291)
 Derealization – “the
experience of unreality
or detachment from ”
(APA, 2013, p. 291) the
 Dissociative amnesia –the
“inability to recall
information that is
inconsistent with
normal forgetting” (APA,
2013, p. 291)
Definition of Terms
 Treatment - any number
of interventions in the
counseling and
psychotherapy field
 Treatment Outcome changes made and/or
maintained throughout
treatment that can be
reasonably attributed to
the treatment
Remainder of Study
 Chapter 2
1. Theories of
2. Current views on
how dissociation
3. Common cooccurring disorders
4. Available assessment
procedures and
 Chapter 3
 Methodology
 Procedures
 Chapter 4
 Literature Review
 Chapter 5
 Implications
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