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== Working Prognosis == My last edit - Tuesday 2pm.
Hales-prognosis
Case studies report that most cases of DID resolve with proper therapy.[1] When untreated, the mental illness DID is chronic and recurrent. [1][2] A person with DID rarely recovers without treatment,[1][3]even though symptoms may appear to resolve for periods in ones life.[1]Changes in identity, loss of memory, and loss of time [4] often lead to chaotic personal lives, since it is common for highly dissociated parts of the personality to not know what other parts know [4] due to the amnestic barrier between those parts of the self.[4]
Failed suicide attempts and self-harm are common in those with DID. [4] The best prognosis is when trauma memories are processed - hospitalization can be required for some patients during this time. [4] Prognosis is best when dissociative boundaries are reduced, resulting in a unified self and elimination of the effects and symptoms of trauma memories. [4] Psychotherapy for adults usually takes years depending on the patients goal. Unifying or integrating the various dissociated parts of the personality is considered best for the patient [5] allowing them to finally operate as a unified self and to have freedom of the crippling effects of DID. [4] Some patients however, for personal reasons, cannot bring themselves to do this, instead they opt to obtain an acceptable level of coconscious, still retaining their dissociated parts, but with reduced amnesic barriers.[5] If one's DID is limited to primarily dissociative symptoms and features of posttraumatic stress disorder, then recovery is usually the result when proper treatment is complete. [6] This serious mental illness is usually attributed to events that continue to hamper the patients prognosis including: sexual and other abuse as a child, [6] disorganized attachment, [6] an early loss or illness [6] and they often cope by abusing alcohol or other substances - negative ways of coping with their victimization or loss that hamper their prognosis. [6] Prognosis becomes more grim in those who suffer co-morbidity. Any of, or a combination of common comorbid disorders such as substance abuse disorders, personality disorder, mood disorder, or eating disorders all result in a longer, slower, and more complicated recovery process. [7] Those who are living at home or in other ways still attached to their abusers face the poorest prognosis. [7]
Treatment
DID treatment is supported by a body of prospective data in a well-defined population using valid and reliable measures of psychopathology. [8]
treatment study summary
Summary: Ross and Halpern (2009): Ideally, treatment outcome studies are "...randomized, prospective, double-blind placebo-controlled.." designs. "Prospective" means we start with a condition, apply treatment, then see what happens. Most DID studies are retrospective - we're done with treatment, and we look back. This is important because retrospective studies do not have dropouts, a significant issue in proper studies.
Where DID is concerned, there are multiple essentially insurmountable hurdles here:
- Psychotherapy clients usually can figure out if they are receiving placebo (there goes half of the "blind");
- Whereas a typical drug treatment study lasts 6-8 weeks, DID treatment lasts years (5 or more); it is therefore far harder to retain study subjects in DID studies than in drug studies. Most psychotherapy last far less time than does DID therapy, so the problem is not just in comparison with drug studies.)
- It is not feasible, nor ethical to offer someone in need of treatment a placebo for years.
- For many reasons, obtaining funding for treatment outcome studies in DID is significantly more difficult than with other conditions.
What this means is that there likely will not be a really good treatment outcome study for DID any time soon, if indeed ever. The hurdles are really big. Therefore, in the meantime acceptance of other studies if the norm.
Next, we look at treatment outcome studies in mental health. Here, they look only at medication. There is no mention of psychotherapy models other than theirs. This is a major flaw of their analysis, for a reason that may not be obvious. Basically, psychotherapy typically gets better results than do drugs. For many technical reasons Ross and Halpern (2009) summarize psychotropic medication, in general, as not especially effective. Reported successes are almost surely inflated due to inherent research design errors.
Moving to DID, Ross and Halpern (2009) comment that these "patients" are so complicated that they would simply be excluded from normal treatment studies, because: most have been psychiatric inpatients or have been suicidal, and most have other Axis I disorders including addictions. Such subjects just are not used in treatment studies - too many factors are in play to do a good study.
They then present treatment outcome data for participants in their treatment program in Texas.
- Ross and Halpern's (2009) data is prospective, but not randomized, double-blind, or placebo controlled.
- All subjects were given formal assessments (involving objective tests) at admission, at discharge (an average of 18 days later), and at 3-month followups.
- All 46 participants had a dissociative disorder (DID or DDNOS - no one gets hospitalized for the others), and major depression, at admission; 85% had borderline personality disorder; 59% had somatization disorder; 48% had a substance abuse disorder. Remember, these are inpatients - the most serious subgroup of the DID diagnostic group. Non-inpatients will not look so complicated, and will respond to treatment better.
- As a group, objective assessments of symptoms showed significant improvement at discharge, with continuation of improvement seen at 3-month followup.
- A separate, more detailed, two-year follow-up study of 54 graduates of their treatment program revealed that 12 (22%) had achieved stable integration at that point. Why not more? Because at admission they were at all stages of recovery, with some having been diagnosed only a few months earlier, and full treatment usually requires at least 5 years, they say. They estimate that at 5 years, 50% will have achieved integration. This recovery rate is as good as that for recovery from depression using medication, and with simple subjects who don't have all sorts of complicating, interfering factors.
- None of those achieving integration in their 2-year study had any kind of substance-abuse problem.
Ross and Halpern (2009) conclude: "The treatment techniques described in this manual are supported by a body of prospective data in a well-defined population using valid and reliable measures of psychopathology."
- ^ a b c d .
Although there have been no controlled trails of psychotherapy outcome in patients with this disorder, case studies report a positive outcome in most cases.
{{cite book}}: Missing or empty|title=(help) Cite error: The named reference "Hales-prognosis" was defined multiple times with different content (see the help page). - ^ Sadock, BJ (2007). Kaplan & Sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry (10th ed. ed.). Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins. pp. 674. ISBN 9780781773270.
Little is known about the natural history of untreated dissociative identity disorder
{{cite book}}:|edition=has extra text (help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ "Dissociative Identity Disorder". Merck Manual. Merck & Co. Retrieved 2012-07-30.
but dissociative identity disorder does not resolve spontaneously
- ^ a b c d e f g .
Patients typically lose time; they experience frequent bouts of amnesia after which they may discover objects or samples of handwriting that they cannot account for or recognize.
{{cite book}}: Missing or empty|title=(help) Cite error: The named reference "merckdoc" was defined multiple times with different content (see the help page). - ^ a b .
Integration of the identity states is the most desirable outcome."
{{cite book}}: Missing or empty|title=(help) Cite error: The named reference "Merckdoc" was defined multiple times with different content (see the help page). - ^ a b c d e .
Patients can be divided into groups based on their symptoms: Symptoms are mainly dissociative and posttraumatic. These patients generally function well and recover completely with treatment.
{{cite journal}}: Cite journal requires|journal=(help); Missing or empty|title=(help) Cite error: The named reference "Merkdoc" was defined multiple times with different content (see the help page). - ^ a b .
Dissociative symptoms are combined with prominent symptoms of other disorders, such as personality disorders, mood disorders, eating disorders, and substance abuse disorders. These patients improve more slowly, and treatment may be less successful or longer and more crisis-ridden.
{{cite book}}: Missing or empty|title=(help) Cite error: The named reference "merkdoc" was defined multiple times with different content (see the help page). - ^ Ross, C. (2009). Trauma Model Therapy: A Treatment Approach for Trauma Dissociation and Complex Comorbidity. TX: Manitou Communication. ISBN 098218512X.