User talk:Vanished user 54564fd56f45f4dsa5f4sf5/Sandbox
'Note:' I am working on this here, due to complaints to the effect that there is too much discussion on the DID talk page. Anything that editors would like to discuss can be taken from here and moved to that page, so I don't clutter either the DID talk page or the peer review page.
Consensus view for treating DID in children
See here for information on the Child Guidelines for Treating DID (p. 119-150) Also consult pdf file: the link can be found here: ChildGuidelines-ISSTD-2003.pdf
This document is older and it points out that there is still so much to learn. Keep this in mind when reading it. The recent 2011 ADULT guidelines pdf file (p.115-187) fill in a lot of questions in this document that have since reached a consensus agreement.
Important points in the document:
- "These treatment principles, therefore, are intended for children and adolescents with diagnosed dissociative disorders,as well as for those with a wide variety of presentations accompanied by dissociative features." (p.120)
- "Although even very young children appearing to meet the criteria for DID have been described, the prevalence of DID in childhood is currently unknown." (p.120)
- "...there is still no real consensus about the typical case and thus no consensus about diagnostic criteria. For this reason, in these Guidelines the perspective on assessment and treatment is symptom-based." (pg.121)
- " ...the literature reviewed here, spanning over 16 years of reporting on dissociative phenomena in children, already shows shifts in emphasis and recommendations overtime. Despite the changing and provisional nature of our knowledge in this area,it is still important to have some guidelines in approaching dissociative symptomatology... (p.121)
- "Treatment strategies aimed at increasing integration and reducing dissociation can be highly effective in treating some of the most seriously impaired child victims of maltreatment who are engaged in disruptive and self-destructive behavior." (p.121)
- "Information on the treatment of dissociation was not available when most clinicians did their training, and it is important to organize clinical information to help familiarize clinicians with current treatment approaches." (p.121)
- "Without careful consideration of developmental issues, the simplistic application of treatment approaches for adult dissociation to children may be potentially dangerous to children." (p.121)
I don't think beyond this was discussed on the WP page, if so we can address it.
I have emailed Boysen for a copy of the entire article. In the meantime:
WP DID article: "To date approximately 250 cases of DID in children have been identified"
Peer Review: To what date? See WP:ASOF.
Me: Looks like Boysen looked at published studies in the 1980's and 1990's. Boysen's exact words: "Nearly all of the research that does exist on childhood DID is from the 1980s and 1990s and does not resolve the ongoing controversies surrounding the disorder."
Peer Review: I am of the opinion that, whenever possible, every section should refer to more than one source. In children, which covers a somewhat contentious topic, only references Boysen 2011.
Me: I could not agree more about having 2 references.
WP DID paragraph: In children DID is rarely diagnosed in children. Me: {why? citation?} This fact is cited as a reason to doubt the validity of DID, and proponents of both etiologies Me: (what are both?) believe that the discovery of DID in a child that had never undergone treatment would critically undermine the SCM. Conversely the development of DID only after undergoing treatment would challenge the traumagenic model.[22] Me: I only have the abstract, but what does the Boysen article [22] have to do with this? To date approximately 250 cases of DID in children have been identified, {identified? or were found in published research in the 1980's and 1990's?) though the data does not offer unequivocal support for either theory. Me: This makes it sound like only 250 cases of DID have ever been seen in children. Me: Again, the conclusion of the article [22 Boysen] does not say any of this. While children have been diagnosed with DID before therapy, several were presented to clinicians by parents with the diagnosis; others were influenced by the appearance of DID in popular culture or due to a diagnosis of psychosis due to hearing voices - a symptom also found in DID. No studies have looked for children with DID in the general population, and the single study that attempted to look for children with DID not already in therapy did so by examining siblings of those already in therapy for DID. An analysis of diagnosis of children reported in scientific publications, 44 case studies of single patients were found to be evenly distributed (i.e. each case study was reported by a different author) but in articles regarding groups of patients, four researchers were responsible for the majority of the reports.[22] Me: Again, the conclusion of the article [22 Boysen] does not say any of this.
Peer Review: When I first read this, I could not imagine how it could possibly be relevant. Then I went back and saw this sentence: "Proponents of the iatrogenic position suggest a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position", which shed a bit of light on the matter. There are two problems here: first, we need to hold the reader's hand and guide them through the issues. We cannot just throw data at them and hope that they'll make the connection to the material they've already read, especially since there's no guarantee that the reader will travel through the article from top to bottom.
Peer Review: Second, it needs to be made clear, either explicitly or implicitly, that the author made this connection in his paper. If that's not true, then this material should be removed, as it would be synthesis.
Me: I cannot see where the author said any of this. His conclusion" "Despite continuing research on the related concepts of trauma and dissociation, childhood DID itself appears to be an extremely rare phenomenon that few researchers have studied in depth. Me:(To me this sounds like it's simply something few researchers have studied in depth. Parents abusive enough to cause DID are not going to just hand their children over to be studied and children with DID MUST hide it best they can to survive at home. E. Howell says something to this effect in her 2011 book, so have many others. I can dig out the references if needed.) Nearly all of the research that does exist on childhood DID is from the 1980s and 1990s and does not resolve the ongoing controversies surrounding the disorder
The paragraph mentioned by the peer reviewer from the WP article: Therapist Induced WP paragraph: The iatrogenic position is strongly linked to the False memory syndrome, coined by the False Memory Syndrome Foundation in reaction to memories recovered by a range of controversial therapies whose effectiveness is unproven. Such a memory could be used to make a false allegation of child sexual abuse. There is little consensus between the iatrogenic and traumagenic positions regarding DID.[3] Proponents of the iatrogenic position suggest a small number of clinicians diagnosing a disproportionate number of cases would provide evidence for their position[22] though it has also been claimed that higher rates of diagnosis in specific countries like the United States, may be due to greater awareness of DID. Lower rates in other countries may be due to an artificially low recognition of the diagnosis.[12]
WLU claims to have the actual Boysen study. There is only an abstract online and this is the conclusion. I have asked Boysen to send me a copy of the study.
Despite continuing research on the related concepts of trauma and dissociation, childhood DID itself appears to be an extremely rare phenomenon that few researchers have studied in depth. Nearly all of the research that does exist on childhood DID is from the 1980s and 1990s and does not resolve the ongoing controversies surrounding the disorder.
METHODS: I searched MEDLINE and PsycINFO records for studies published since 1980 on DID/multiple personality disorder in children. For each study I coded information regarding the origin of samples and diagnostic methods.
RESULTS: The review produced a total of 255 cases of childhood DID reported as individual case studies (44) or aggregated into empirical studies (211). Nearly all cases (93%) emerged from samples of children in treatment, and multiple personalities was the presenting problem in 23% of the case studies. Four US research groups accounted for 65% of all 255 cases. Diagnostic methods typically included clinical evaluation based on Diagnostic and Statistical Manual of Mental Disorder criteria, but hypnosis, structured interviews, and multiple raters were rarely used in diagnoses.
My thoughts on this study: First it is a lit review. Second, Boysen is saying 93% of the children studied in the literature reviewed were in a clinical setting. I don't see how that small number of clinical subjects can translate to anything in the general population. Third, children outside of a clinical setting are most likely trying to survive in a hostile environment. Fourth, Children are less self aware, and much less verbally expressive than adults, especially when they are being controlled by adults. If they have DID, they are almost certain victims of their parents and children usually generalize the characteristics of their parents to all adults. If parents are not to be trusted, why would adults outside the family be? From the DSM-IV (1994), p. 485 (in the DID section): "In preadolescent children, particular care is needed in making the diagnosis because the manifestations may be less distinctive than in adolescents and adults." Fifth, many of the studies reviewed were prior to a more recent understanding of what DID is, it's symptoms and how to Dx it. The DSM-III, originally published in 1980, formally specified diagnostic criteria for MPD, and every other recognized mental illness. The DSM-III-R (1987) states on p. 271: "Onset of Multiple Personality Disorder is almost invariably in childhood, but most cases do not come to clinical attention until much later." On the same page it also states: "Recent reports suggest that this disorder is not nearly so rare as it has commonly been thought to be." Not until the DSM-IV, in 1994, was there overt recognition in the DSM that DID could be diagnosed in children. Children are addressed in a single sentence (p. 484). Explicit attention is not given to DID in children until the DSM-5, and the exact form it will take is still to be determined. These are just some of the reasons why we don't have more child DID diagnoses.
What E. Howell has to say about Childhood DID: 1. (pg. xvii)She sites the recent Brand study that reports: 86% of DID patients produces reports of claims of childhood abuse. 2. (pg. xvii) Other causes: "Overwhelming experience in the infant's interpersonal environment that are not caused by parental maltreatment. Parental illness, depression, or problematic attachment styles may be psychically overwhelming and lead to disorganized attachment." Personal comment: This to my mind still is trauma.
What Medscape has to say:
Updated: May 11, 2012 Author: M. Waseem, MD
"The deleterious effects of childhood abusive experiences on growth and development have been well documented and are associated with various later mental health problems. Diagnosis of dissociative identity disorder is not usually made until adulthood, long after the extreme maltreatment thought to engender the condition has occurred. Therefore, although the most common cause of the disorder is agreed to be early, ongoing, extreme physical and/or sexual abuse, accounts of such abuse are usually provided retrospectively by the patient and lack objective verification."
Relevant quotes from another page of same site, see the page for full text:
"Fully expressed MPD is not often diagnosed as such in the pediatric population; however, other forms of dissociative disorders are not uncommon, as described in this article."
"Children have a much poorer sense of continuity of their behavior and the flow of time than adults do. Symptoms such as the sense of loss of time are not easy for children to discern. Even well into adolescence, children may not recognize loss of time or discontinuity of experience as unusual or abnormal experiences."
"Dissociation reflects disruptions in the integration of memories, perception, and identity into a coherent sense of self. Disruptions in identity may assume the blurring of boundaries between a child's self and fantasy characters."
Dissociation in General - Clinical "A child who is experiencing dissociative symptoms may appear withdrawn, frightened, or uninvolved. Frequently, the child is identified as being "different" from other children, although referring clinicians, caseworkers, foster parents, and teachers are often at a loss to characterize the differences."
"Children with dissociative disorders exhibit a plethora of fluctuating abilities, moods, fears, and anxieties; shifting preferences; inconsistent knowledge; and other evidence of erratic access to information and skills."
"Auditory hallucinations are present in most children and adolescents with dissociative disorder; however, "phobic" hallucinations in severely stressed children and young adolescents do not necessarily indicate an enduring psychotic disorder and may be transient phenomena."
"Note: There is a separate Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents (ISSD, 2004) available through the ISSTD and published in the Journal of Trauma & Dissociation. The American Psychiatric Association (2004) has published Practice Guidelines for the Treatment of Patients with Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD), which may be relevant to the treatment of DID."
"DID develops during the course of childhood, and clinicians have rarely encountered cases of DID that derive from adult-onset trauma (unless it is superimposed on preexisting childhood trauma and preexisting latent or dormant fragmentation)." (p.122) 2011 ISSTD Guidelines.
Working on the below - ignore
Reply to All: To answer the questions that have been presented as succinctly as possible: This is the consensus statement of the international professional association for clinicians and researchers into trauma and dissociation disorders, as you well know. There is no competing or contending association. There is no competing consensus statement. If you wish to dispute importance you may do so, but your opinion (or mine) is not of value here - none of us here are experts on DID. Any sources you may cite will also just be opinions, albeit published ones; as I've said before, the proponents of the SC model have no data. There is nothing to empirically resolve, as there is no empirical support for the SC model. The "belief" of the authors to which you refer is all they, or you have. Science is not about belief, it is about data. They have none. The other models approved by the expert consensus on DID have plenty, and the opinion of the centrist consensus is that the data indicate the validity of the traumagenic model. That is the facts, and that's what we must report, unless you wish to turn this article in a polemic for a fringe POV. Is that your intent? If so state it. If not state this is not true. Since the DSM-III, (as previously pointed out) DID has been attributed to trauma, in statements which express probability, not certainty. Science is never about certainty, but rather about degrees of probability. The consistent statement of the DSM is that DID is most likely caused by childhood trauma. I will exhaustively document all this shortly. The DSM does make explicit statements. It is mainstream because it is the professional association for the topic. Again, this is obvious. There is no conflict here. The expert consensus statement clearly explains the mainstream expert consensus on DID. There are a number of criticisms of it, as there are of the DSM, the Jewish Bible, the Christian Bible, the US Constitution, UN Charter, ad infinitum. To assert that there is no consensus because there is dispute is to misunderstand the nature of the word. When I consult Webster's Third New International Dictionary (unabridged), it is clear that current usage allows "consensus" to mean a number of things, and there is conflict (lack of consensus) as to which meaning is preferred. It can mean unanimity. It can also mean majority. The central thrust of the definition given is "general agreement" or "collective opinion". You can lean on which ever flavor of the cited usages support your POV, can you not? (And you do.) So, you would have me accept that as long as there is disagreement there is no consensus? If so, state that here, in writing. If not, state that as well. Make yourself clear on this point, please.Tanya~talk page 23:09, 19 August 2012 (UTC)
Reply to WLU: Please stop posting replies if you do not expect me to reply in turn. Since the questions were raised, here is my reply. Meta-analyses of randomized controlled trials (RCTs) are they good? Well, obviously. So go get some. Also, just because something isn't ideal doesn't mean that it has no value. It just means that it could be better, and on this point, regarding the data associated with DID, whether it be treatment outcome, etiology, or epidemiology, there is little if any dispute in professional circles. As for your 3rd point on systematic reviews... The ISSTD guidelines do indeed encompass a literature review, but that is not its central purpose, which is to issue an updated set of official treatment guidelines, coming from the group of well known and highly respected clinicians who authored the document. The lit. review is there to provide basis for major portions of the guidelines, and occupies 16 1/4 pages - 20.5% of the document. At about 18 references per page, that a total of over 290 references. In what way do you find this deficient? How do you know there are no randomized studies in this set of 290 references? Can you provide, say, a table which lists each study in the reference list (they aren't all research studies, so you'll not have 290 rows in your table!), and the sample selection method used, when indeed it is a sample-based study? If you can't, you have no basis for that statement. But, far more important is this: Colin Ross is a psychiatrist who I'm sure I don't need to introduce to you, but for others - he has a large number of publications on dissociative disorders and has been treating DID in inpatient and outpatient settings since 1979, is a member of ISSTD, is cited 10 times in the ISSTD Treatment Guidelines document, is a co-author of that document, and has a chapter in Dell and O'Neil's ISSTD-commissioned 2009 review of the field - Dissociation and the Dissociative Disorders (864 pp.). In his 2009 book (co-authored by N. Halpern), Trauma Model Therapy (pp. 63-63), he has outlined the characteristics of an ideal outcome study (be it for psychotherapy or medication). These would surely also be applicable to studies of etiology, as well. The characteristics are these: sample selection is randomized; data are gathered prospectively - starting at one point and moving through time to an end point; double-blind - no one, including the professionals involved, knows who is getting treatment who is getting pseudo-treatment or placebo; placebo-controlled - some subjects get "fake" treatment. He then lists a number of additional features of a quality study, including such things as appropriate and adequate statistical analysis, replicability, and so on. Now comes the important part: These standards are hard to meet in psychotherapy studies, and especially so when DID is involved, he asserts. He reports that most study subjects are able to figure out when they are getting placebo treatment. Furthermore, studies on DID treatment outcome are atypical, compared to other disorders, because the course of treatment is typically years (at least 5, he reports elsewhere in this book). This is a problem in a study for several reasons: it hard to retain study subjects for that long (it is not unusual for people with DID to have years of therapy, but from multiple therapists). It is unethical to determine that a subject qualifies for treatment, and thus is in need, but then withhold it for the presumed lengthy period that would be required for a DID study. Finally, getting funding for a study of this length and difficulty is itself a major hurdle. I would add that any prospective study of etiology would require either deliberate traumatizing of subjects, followed by non-treatment for years, or identification of already-traumatized subjects, followed by non-treatment years. Care to apply for funding for a study of that sort? Conclusion: We are not at any time in the immediate future likely to have any data for DID etiology and treatment outcome which is not retrospective, non-blinded, unrandomized, and lacking a placebo treatment condition. It is just not reasonable. He concludes (p. 65): "One can read the entire psychiatric literature and find almost no treatment outcome or follow-up data on complicated, highly co-morbid psychiatric inpatients. Most people with DID have been inpatients at some time, or been suicidal at some time, and all have other Axis I disorders and addictions. The treatment outcome data for DID are as strong as any other body of data for any treatment method involving highly comorbid patients." So stop asking for the impossible Sir.