[Know thyself; personal psychotherapy for the psychiatrist in training]. / Ken u zelf; leertherapie in de Nederlandse opleiding tot psychiater.

BACKGROUND: For the Dutch psychiatrist in training 50 sessions of personal psychotherapy are required. The Netherlands are unique in this measure. Currently there is no discussion about this requirement.
AIM: To describe different aspects and arguments of supporters and opponents of the requirement of a personal psychotherapy.
METHOD: Review of the research literature and personal observations.
RESULTS: In the past there has been discussion regarding this requirement. Arguments to support the requirement of a personal psychotherapy as a good base to learn psychotherapy are: 1. the resident experiences what it means to be dependent in a clinical relationship; 2. the resident learns the essential competencies (empathy, reflective functioning, etc.); 3. personal therapy contributes to the deepening of feeling; and 4. personal therapy is a measure against stress and burn-out. Opponents of the requirement of a personal psychotherapy point at the lack of evidence demonstrating its effectiveness on the treatment results of the resident.
CONCLUSION: Personal psychotherapy is often viewed as an 'island' within the training programme, a private spot where everything can be discussed, but which also forms a logical conclusion between supervision and mentoring.

Is it Trauma- or Fantasy-based? Comparing dissociative identity disorder, post-traumatic stress disorder, simulators, and controls.

OBJECTIVE: The Trauma Model of dissociative identity disorder (DID) posits that DID is etiologically related to chronic neglect and physical and/or sexual abuse in childhood. In contrast, the Fantasy Model posits that DID can be simulated and is mediated by high suggestibility, fantasy proneness, and sociocultural influences. To date, these two models have not been jointly tested in individuals with DID in an empirical manner. METHOD: This study included matched groups [patients (n = 33) and controls (n = 32)] that were compared on psychological Trauma and Fantasy measures: diagnosed genuine DID (DID-G, n = 17), DID-simulating healthy controls (DID-S, n = 16), individuals with post-traumatic stress disorder (PTSD, n = 16), and healthy controls (HC, n = 16). Additionally, personality-state-dependent measures were obtained for DID-G and DID-S; both neutral personality states (NPS) and trauma-related personality states (TPS) were tested. CONCLUSION: For Trauma measures, the DID-G group had the highest scores, with TPS higher than NPS, followed by the PTSD, DID-S, and HC groups. The DID-G group was not more fantasy-prone or suggestible and did not generate more false memories. Malingering measures were inconclusive. Evidence consistently supported the Trauma Model of DID and challenges the core hypothesis of the Fantasy Model.

[Complex PTSD following early-childhood trauma: emotion-regulation training as addition to the PTSD guideline]. / Complexe PTSS na vroegkinderlijk trauma: emotieregulatietraining als aanvulling op de PTSS-richtlijn.

BACKGROUND: Posttraumatic stress disorder (PTSD) symptoms in individuals who have experienced repeated trauma (sexual and/or physical) in early childhood can lead to problems associated with emotion regulation, interpersonal functioning and self-image. This so-called complex PTSD is often accompanied by a comorbid personality disorder. Although ptsd is associated with structural and functional abnormalities in emotion-regulation areas in the brain, it is not known whether complex PTSD shows similar abnormalities. Experts take the view that before individuals with complex PTSD are given appropriate therapy they should receive a course of emotion-regulation therapy such as the one tested by Zlotnick e.a. (1997) in a randomised controlled trial (RCT).   AIM: To replicate Zlotnick's RCT in the Netherlands and to find out whether complex PTSD patients show specific structural and functional brain abnormalities and whether psychological recovery is linked to the 'normalisation' of these abnormalities. METHOD: In a RCT with complex PTSD patients (n = 71) who had experienced trauma in early childhood, we compared normal individual treatment with treatment supported by 'Before and beyond', which consists of emotion-regulation therapy combined with cognitive group therapy. In a subsample (n= 33) we also performed an mri (repeated, n = 9) in which individuals were required to execute an emotional memory and attention task. RESULTS: In complex PTSD, structural abnormalities in the brain seemed to be more extensive than in PTSD and brain activity in complex PTSD seemed to be strikingly different from the brain activity seen in PTSD patients who had experienced only single trauma. The results of the RCT indicate that 'Before and beyond' is a clinically meaningful treatment (with minimal drop-out) for complex PTSD patients with a variety of personality disorders. The psychological recovery of patients who received the emotion regulation and cognitive group treatment was associated with normalisation of brain function. CONCLUSION: Treatment guidelines for ptsd patients cannot be applied directly and automatically to complex PTSD because there is no scientific evidence to justify such a step. The neurobiological profile of PTSD differs from that of complex PTSD. Patients with complex PTSD seem to react favourably to emotion regulation therapy. This treatment therefore could be a useful addition to the current PTSD guideline for this specific group. There is a need for further research that focuses on complex PTSD patients.

Treatment effects on insular and anterior cingulate cortex activation during classic and emotional Stroop interference in child abuse-related complex post-traumatic stress disorder.

BACKGROUND: Functional neuroimaging studies have shown increased Stroop interference coupled with altered anterior cingulate cortex (ACC) and insula activation in post-traumatic stress disorder (PTSD). These brain areas are associated with error detection and emotional arousal. There is some evidence that treatment can normalize these activation patterns. METHOD: At baseline, we compared classic and emotional Stroop performance and blood oxygenation level-dependent responses (functional magnetic resonance imaging) of 29 child abuse-related complex PTSD patients with 22 non-trauma-exposed healthy controls. In 16 of these patients, we studied treatment effects of psycho-educational and cognitive behavioural stabilizing group treatment (experimental treatment; EXP) added to treatment as usual (TAU) versus TAU only, and correlations with clinical improvement. RESULTS: At baseline, complex PTSD patients showed a trend for increased left anterior insula and dorsal ACC activation in the classic Stroop task. Only EXP patients showed decreased dorsal ACC and left anterior insula activation after treatment. In the emotional Stroop contrasts, clinical improvement was associated with decreased dorsal ACC activation and decreased left anterior insula activation. CONCLUSIONS: We found further evidence that successful treatment in child abuse-related complex PTSD is associated with functional changes in the ACC and insula, which may be due to improved selective attention and lower emotional arousal, indicating greater cognitive control over PTSD symptoms.

Sensitivity of the Addiction Severity Index physical and sexual assault items: preliminary findings on gender differences.

OBJECTIVE: Evaluation of the Addiction Severity Index (ASI) as a screen for identifying sexual and physical assault histories. METHOD: The sensitivity and specificity of the ASI assault items were examined in 146 alcoholic patients with the assault questions of the Composite International Diagnostic Interview posttraumatic stress module as external criterion. RESULTS: The sensitivity of the ASI items was lower than their specificity for both physical (sensitivity = 0.35, specificity = 0.83) and sexual abuse (sensitivity = 0.69, specificity = 0.94). These findings indicate an underestimation of such abuse histories in male patients due to screening for a narrow range of possible perpetrators. CONCLUSION: The ASI method as a screen for sexual and physical assault histories could be improved, considering that men clearly outnumber women in persons applying for alcohol treatment.

Dissociative disorders in Dutch psychiatric inpatients.

OBJECTIVE: The goal of this study was to determine the frequency of dissociative disorders in Dutch psychiatric inpatients. METHOD: During a period of 12 months, 122 consecutively admitted adult psychiatric patients were screened with the Dissociative Experiences Scale. Patients scoring 25 and higher and a random selection of patients scoring lower than 25 were blindly interviewed with the Structured Clinical Interview for DSM-IV Dissociative Disorders, Revised. Interviews were scored independently by a blind rater. RESULTS: Ten (8%) of the 122 patients were diagnosed as having a dissociative disorder; two (2%) were diagnosed as having a dissociative identity disorder. Two patients (2%) had factitious dissociative identity disorder. CONCLUSIONS: The rate of dissociative disorders in this group of Dutch patients is comparable to the rates reported in other European studies but lower than rates reported in North American studies.

Prevalence of dissociative disorders in psychiatric in-patients: the impact of study characteristics.

OBJECTIVE: Prevalence rates for dissociative disorders among psychiatric in-patients vary widely. The aim of this meta-analysis is to offer an explanation for these differences. METHOD: Prevalence studies using a clinical diagnostic interview among psychiatric in-patients were included. Hypotheses concerning the impact of blind versus not blind designs, choice of diagnostic instrument and continental background were tested. RESULTS: Nine studies met the inclusion criteria. In blind studies the prevalence rate for dissociative disorders was significantly lower (but not for DID). Studies using the SCID-D (compared to the DDIS) and European studies had significantly lower prevalence rates for both dissociative disorders as well as for DID. CONCLUSION: The choice of diagnostic instrument and cultural differences in interpretation of symptoms are major explanations for differences in prevalence of dissociative disorders and DID. Comparative, blind research using both DDIS and SCID-D in the assessment of dissociative disorders is advised.

Childhood trauma and perceived parental dysfunction in the etiology of dissociative symptoms in psychiatric inpatients.

OBJECTIVE: Research on the etiology of dissociation in adults has focused primarily on childhood sexual abuse. The role of co-occurring childhood stressors and of more chronic adverse conditions such as neglect is less clear. This study examined the level of dissociation in relation to childhood trauma (sexual/physical abuse, witnessing interparental violence), early separation from a parent, and perceived parental dysfunction. METHOD: One hundred sixty inpatients consecutively admitted to a general psychiatric hospital were administered the Dissociative Experiences Scale and the Structured Trauma Interview. RESULTS: The mean Dissociative Experiences Scale score was 17.4; 18.0% of the patients scored beyond 30. Early separation was reported by 26.4% of the patients; 30.1% had witnessed interparental violence; 23.6% reported physical abuse; 34.6% reported sexual abuse; 11.7% reported rape before age 16; and 42.1% reported sexual and/or physical abuse. The level of dissociation was primarily related to reported overwhelming childhood experiences (sexual and physical abuse). When sexual abuse was severe (involving penetration, several perpetrators, lasting more than 1 year), dissociative symptoms were even more prominent. Highest dissociation levels were found in patients reporting cumulative sexual trauma (intrafamilial and extrafamilial) or both sexual and physical abuse. In particular, maternal dysfunction was related to the level of dissociation. With control for gender and age, stepwise multiple regression analysis indicated that the severity of dissociative symptoms was best predicted by reported sexual abuse, physical abuse, and maternal dysfunction. CONCLUSIONS: These findings indicate that dissociation, although trauma-related, is neglect-related as well. This implies the importance of object relations and attachment in the diagnosis and treatment of patients with dissociative disorders.

Multiple personality disorder in The Netherlands: a clinical investigation of 71 patients.

OBJECTIVE: The aim of this study was to describe the phenomenology of multiple personality disorder as presented in a group of Dutch patients. METHOD: Seventy-one patients with multiple personality disorder were interviewed with the Dutch version of the Structured Clinical Interview for DSM-III-R Dissociative Disorders (SCID-D); following the SCID-D, the Structured Trauma Interview was administered. Before the interview, patients completed the Dissociative Experiences Scale. RESULTS: The presenting characteristics of the patients showed a striking resemblance to those in several large North American series. Patients had spent an average of 8.2 years in the mental health system prior to correct diagnosis. Patients presented with many different symptoms and frequently received other psychiatric or neurological diagnoses. A history of childhood physical and/or sexual abuse was reported by 94.4% of the subjects, and 80.6% met criteria for posttraumatic stress disorder. CONCLUSIONS: Patients with multiple personality disorder have a stable set of core symptoms throughout North America as well as in Europe. To improve the detection of patients at high risk for multiple personality disorder, standardized instruments for inquiry about dissociative pathology should be used as part of routine diagnostic assessment.

Diagnosing dissociative disorders in The Netherlands: a pilot study with the Structured Clinical Interview for DSM-III-R Dissociative Disorders.

OBJECTIVE: To improve the ability to diagnose dissociative disorders in The Netherlands, the authors conducted a study using a Dutch version of the Structured Clinical Interview for DSM-III-R Dissociative Disorders (SCID-D) with additional questions on childhood trauma and symptoms of borderline and histrionic personality disorders. METHOD: All interviews were audiotaped or videotaped and rated by two investigators separately. Forty-four patients (42 women and two men) participated in the study. Most of the patients had been referred for evaluation of dissociative symptoms; five had participated in a nationwide survey on incest. None of the patients had ever received a diagnosis of a dissociative disorder, and none had evidence of organic brain syndrome or mental retardation. All patients were in active treatment; 23 were being treated in an outpatient psychiatric service, 13 in an inpatient psychiatric service, and eight in private practice. Thirty-two patients had been psychiatric inpatients at least once. RESULTS: Four diagnostic groups of patients were identified: two with dissociative disorders (12 patients with multiple personality disorder and 11 with dissociative disorder not otherwise specified), one with DSM-III-R personality disorders (11 patients), and one without dissociative or personality disorders (10 patients). CONCLUSIONS: Dissociative disorders are clearly not only an American phenomenon. The diagnosis can be made outside of the United States if the symptoms are sought. The SCID-D proved to be a promising instrument.