Understanding Dissociative Disorders E-Book

Marlene E Hunter

• Herausgeber: Crown House Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 277

Veröffentlichungsjahr: 2010

Beschreibung

Understanding Dissociative Disorders is for all physicians looking for ways to understand the idiosyncrasies of dissociative patients - their problematic ways of responding to medication, strange laboratory results and a multitude of physical and emotional symptoms. This book offers realistic, practical answers to questions you didn't even know to ask.

Leseprobe

Understanding Dissociative Disorders

A Guide for Family Physicians and Healthcare Workers

Marlene E. Hunter, MD

To Redner, with love and unending gratitude for your support.

Contents

Title Page

Dedication

Acknowledgments

Introduction: How Did I Get Into This? or, What’s a Nice Girl Like You Doing in Such a Psychotherapeutic Minefield?

Chapter One The “Thick-Chart” Patient

Chapter Two The Emergency Room and Other Critical Situations

Chapter Three Contradictory and Confusing Lab Investigation Results

Chapter Four Medication

Chapter Five Pain

Chapter Six Other Chronic Syndromes

Chapter Seven Other Organ Systems

Chapter Eight Post-traumatic Stress Disorder Symptoms

Chapter Nine Comorbid States Associated with Dissociation

Chapter Ten Body-Image Distortions

Chapter Eleven Eating Disorders

Chapter Twelve Sleep Disturbances

Chapter Thirteen Sexual Dysfunction

Chapter Fourteen Relationships

Chapter Fifteen For Children with Dissociative Parents

Chapter Sixteen Neurophysiology

Chapter Seventeen Research and References

Chapter Eighteen How and When to Refer

Chapter Nineteen Changes in the Field

Index

Copyright

Acknowledgments

My deepest appreciation to all my patients, especially in those early years of struggle, who taught me what I had to know about dissociative disorders. You are a wonderfully courageous bunch of people.

Also I want to thank Betty Jo Critchfield for her help with the references; you saved me endless hours of work and did a much better job than I would have.

Introduction

How Did I Get Into This? or, What’s a Nice Girl Like You Doing in Such a Psychotherapeutic Minefield?

I saw my first dissociative patient (at least the first one that I recognized) in 1977.

I am a family physician. I had become very interested in the medical and psychological uses of hypnosis in 1972, and within five years it had become a routine part of my everyday practice. When a colleague phoned to say that she was moving out of town and asked if I would accept one of her patients (“I know you’re not taking new patients, Marlene, but this woman really needs you”), I agreed.

Thus began a journey that never in my wildest imaginings would I have anticipated—a view into the inner world of the highly dissociative patient. Slowly, I realized that I had another such patient in my very own family practice, and yet another.

She was a pleasant and intelligent patient, and I liked her immediately. In her late twenties, she had a very responsible job in the government offices, which she did well. However, she drove me to distraction, because I never knew where I was at with her. She suffered from terrible headaches; I would prescribe the newest pharmaceutical miracle, she would phone me from work and say, “That medicine is wonderful—why didn’t you give it to me earlier?” And then, three hours later, she would be sitting in my office and when she saw me would glare at me and say, “What did you give me that crap for? It isn’t worth the paper it’s printed on!”

I will call her Jayere, because that is the name I have given her in various papers that I have presented.

Jayere had a documented history of early child abuse. My colleague had done some hypnosis with her and taken her (in hypnosis and at the patient’s request) back to a birth experience, in which Jayere reported that she had heard her mother say, “Take the little bitch away.”

Now, whether that really happened is not the issue. The issue is that this is what she believed, and if that is how one believes one has been greeted on entering this world, it doesn’t bode well for one’s future emotional harmony.

In fact, the birth mother deserted the child and the husband when Jayere was three weeks old. The husband, not well educated and in a laboring job, with absolutely no knowledge or experience of children let alone a weeks-old baby, passed her around to various friends so that he could go to work. Ultimately, at the age of thirteen months, she was found on the beach, wrapped in newspaper and left for dead, having been hit in the head with a beer bottle. Bits of beer bottle glass were embedded in her tiny scalp.

She was in several foster homes over the next few years and, at the age of five, was adopted into a family where (as she told me) strict discipline was the order of the day.

As our doctor—patient relationship became established and grew, I became more and more confused. She had had, from previous family doctors, twelve psychiatric referrals. These resulted in twelve diagnoses. I made the thirteenth referral, and thus she received the thirteenth diagnosis—that she had a neurological disorder, not a psychiatric problem. The neurologist, however, said in no uncertain terms that she had a psychiatric problem, not a neurological disorder, although he could not account for the fact that on two separate occasions she had had two distinctly different EEGs.

One day, some months after she had come in to my practice, I was at an American Society of Clinical Hypnosis meeting, where there was an opportunity to discuss problem cases with one of the older physicians or psychologists. Serendipity found me with a psychiatrist from California, Dr. Donald Schafer, who listened very carefully and asked some pertinent questions. Finally he leaned back in his chair and said, “Have you ever thought of multiple personality disorder?”

I’m sure I blanched. “No,” I croaked.

“Well, I think you should think about it. She has all the criteria.”

So I thought about it. And did nothing. And then, several months later, at another hypnosis meeting, I was listening to Dr. Jack Watkins talking about “MPD” (as it was called then) and I said to myself, “Marlene, why are you refusing to believe your own eyes and ears? He is talking about your own patient.”

So, with gritted teeth and feeling scared stiff, I gathered all my courage together at one of my next meetings with Jayere and asked, while she was in hypnosis (we were working on relieving the headaches), “Is there any other part of you who would like to come and speak with me?”

And this entirely different voice gruffly said, “Of course! What took you so long?”

What does “dissociative disorder” mean?

In essence, dissociative disorder means an incredible ability to compartmentalize one’s mind—but to the point where, in the adult, it often becomes dysfunctional rather than useful.

The term “multiple personality disorder” did a great injustice to the field of dissociative disorders, in my opinion. Although coined with the best of intentions, it was flamboyant and melodramatic and, as we now know, wrong. Dissociative patients do not have multiple personalities: they have a personality structure that is separated into neat little categories and therefore compartmentalized. My metaphor is of a post office, with many post office boxes. Some of the boxes are closed, some locked tight, some with doors ajar—but there is only one post office.

The new term, dissociative identity disorder, is more accurate—and less pejorative. Many patients have all, or almost all, of the post office boxes open: it is then termed DDNOS—dissociative disorder not otherwise specified. The terminology alone is enough to send you screaming in the opposite direction.

The professional jargon for my “post office boxes” is ego states. We all have ego states: I explain to my patients that I am a slightly different person sitting here in the office than I am at home, different as a wife than I am as a mother, different in the lecture hall than when I’m enjoying myself with my friends. It’s normal. I’m lucky, however—all my ego states know each other so all the post office boxes are wide open; indeed, there are only little screens between them instead of metal walls. It is when there are amnesia barriers between the ego states, so that they do not know each other, that we have a true dissociative disorder.

We used to think that all dissociative disorders were the result of severe emotional, sexual, or physical childhood trauma, especially when the child was very young and the trauma was ongoing, and it is sadly true that that is very often the background. However, there has always been the occasional patient in whom we have not been able to attribute the dissociative symptomatology to such a history. Such anomalies have ultimately led to a whole new understand and basis: the attachment theory, first described by Dr. J. Bowlby (1969).

This theory proposes that some children, as very tiny babies, do not have the warm experience of learning a sense of positive attachment—in other words, they have a less than perfect sense of security and trust—to the primary caregiver, who is usually the mother. Instead, they may grow up being somewhat ambivalent about it, or even avoid issues that would demand that the mother show her emotional reliability. This does not necessarily imply abuse, or neglect. It could be that the mother is suffering post partum depression, for example, or her husband is going off to war, or the baby itself is in the hospital, or any one of many other possibilities where there is an interference in the normal deep connection between the very small child and his or her nearest source of security and—one hopes—love.

Figure (i): Attachment relationships and the formation of a cohesive identity

A cohesive relationship and the unity of consciousness are not automatically achieved. They are developmental achievements.

At 12 months, the child has developed separate emotional states.

At 18–24 months, one begins to see the blending of emotional states and the development of megacognitive capacities.

These capacities depend on development and maturation of the orbitofrontal cortex and other prefrontal areas which concern megacognition.

Development of the orbitofrontal cortex is directly related to the quality of the attachment relationship.

With such an unreliable attachment, the emerging child is extremely vulnerable to any subsequent trauma—emotional, physical, or sexual—in his or her environment. When such trauma happens early in life, in the first five to eight years, then dissociative identity disorder may ensue because the child needs to keep things so orderly in his or her young mind that different parts of the personality structure become specifically identified to deal with whatever response is required. On the other hand, such may not be the obvious result but something akin may emerge years later, such as post-traumatic stress disorder (PTSD) among soldiers, or victims of rape or hostage taking or other disasters. In such situations the child escaped the rigid compartmentalization but is still very vulnerable to overwhelming trauma.

What does the personality structure look like?

In the highly dissociative patient, there will always be several typical ego states. There is one that appears to the outside world—some people call this part the “host”. There are also, in my experience, at least two others: the Child, and the Angry One. There will also be one or more protectors.

This is not hard to understand, when the history is of abuse and it took place throughout the early childhood years. Child ego states are usually shy, loving, and frightened. They search for what they longed their lives to be—one in which they are unconditionally cared for, nurtured and protected. Because their lives were not what they longed for them to be, there may also be the Bully, the Aggressor, the Punisher. Although they may be harder to understand, these latter ego states are often the protectors of the system—because protecting the system, which seems ludicrous to an outsider, gives consistency to their inner world.

On the other hand, the abuse that they endured, be it physical, sexual, or emotional (can you imagine physical or sexual abuse wherein there is not also emotional abuse?), was a grave injustice and that is the source of the Angry One. Children are not supposed to be angry, especially at their parents or family, or friends of the family, or other caregivers. If they do exhibit anger, they are often punished. This anger then gets pushed out of sight, but not out of the subconscious mind, although it may be out of conscience awareness in those patients at the far end of the spectrum. Angry ego states are also among the protectors, because they are exquisitely aware of possible further trauma and may do whatever seems necessary, including expressing rage, to avoid it. The perception of the possible trauma may be off base—far more “possible” than probable—but the protection is there.

As the child grows, other ego states emerge to take care of difficult situations: the one who goes (or went) to school; the one who goes to work; the sexual participant; the one who abhors sex; the one who copes with pain; the wife or husband, the mother, the artist, the whore, the one who deals with going for a job interview, the one who is writing his/her PhD—the list can be very long and of course, includes ego states appropriate for male patients.

You will have recognized, perhaps, that the ego states are connected to emotional states. Often they appear to be simple raw emotion, without connecting that emotion to whatever else is going on, including pain or other physical sensation, intellectual knowledge, or behavior. This is the source of the “BASK” model of therapy proposed by Dr. Bennett Braun in the early 1980s and published in 1986. BASK refers to behavior, affect (emotion), sensation (physical feeling) and knowledge. Reuniting all aspects of the BASK for any given situation, so that the situation itself is complete in its recognition, is an important part of psychotherapy (which may not have much to do with the family doctor but may affect the patient’s mood, ability to cope, and so on).

Achieving that reunification of remembered experience is a lot harder than it sounds. It almost always requires the involvement and cooperation of several different ego states, each of which holds one aspect of the memory. However, to make you a little more comfortable, remember that it is usually the work of the psychotherapist, not the family doctor.

There are some typical phenomena that will be useful for you to recognize.

Of these, picking up the minimal cues of switching (from one ego state to another) may be among the most useful. Ego states, after you get to know them, will present different manners of speaking (soft, gruff, strident, polite), a different body posture, somewhat different facial expression, which is difficult to describe, different voices (not quite the same as different manners of speaking)—the voice of a child, or a male (in a female patient) or of one who is self-assured or, on the contrary, frightened.

Switching often occurs very quickly, within seconds; on the other hand, sometimes it evolves over several minutes. There is usually a physical clue—a tic of the facial muscles, a hand briefly touching the face, a change in the eyes. After a while, one gets to notice these things automatically. You may or may not have the kind of relationship with your patient that allows you to openly acknowledge the switches. Don’t push it, but it’s a positive thing if it happens.

Cutting or any other kind of self-harm is not uncommon with dissociative patients. Indeed, such behavior may give you a clue that they are dissociative. For as yet unknown reasons, dissociative patients usually heal very quickly and without infection, even when, for example, the instrument used for self-harm could not have been sterile.

Family members, friends, or workmates may speak of erratic mood changes for no apparent reason.

From the family physician’s perspective, there are some clues that may alert you to the possibility that your confusing patient may be dissociative. Some of these are:

the “thick-chart” patientsomatizationfrequent surgeries, or requests for sameconfusing lab resultsconfusing response to medicationthat the patient “seemed different”allergies that seem to spring up from nowhere, then disappearself-harm

There may be hospitalization issues:

surgeryanesthesiapain reliefchildbirthtrauma/the emergency roompsychiatric hospitalizationthe importance of communication with consultants

There is symptomatology in virtually all of the physiological systems. Some examples are:

Eye/ear/nose/throat:

• allergies

• visual disturbances

• mouth pain, ulcers

• choking or choking sensation

• erratic deafness

Respiratory/chest wall:

• asthma

• frequent upper respiratory infections

• chest wall pain

• air hunger

Cardiovascular:

• dysrhythmias

• tachycardia

• erratic blood pressure

• severe palpitations

• cardiac anxiety

Gastrointestinal:

• eating disorders: anorexia, bulimia, obesity

• nausea

• unexplained sudden vomiting

• irritable bowel syndrome

• colitis, regional enteritis

• constipation/diarrhea

• abdominal pain not yet diagnosed (NYD)

Genitourinary:

• sexual dysfunction: decreased libido, severe sexual aversion, dyspareunia, vaginismus, erectile dysfunction

• pelvic pain NYD

• irritable bladder

• amenorrhoea

• other menstrual disturbances

Musculoskeletal:

• pain

• unexplained soft tissue swelling

• spasm

• altered gait

• dysmorphia/disturbed body image

Central nervous system:

• seizures (temporal lobe)

• pseudoseizures

• tics and twitches

• tremors (non-Parkinson)

• “coma”—unresponsive collapse “for no reason”

Endocrine:

• thyroid

• sexual hormones, male and female

In other words, practically everything!

I will address many of these issues in the following chapters. We will also look at problems such as boundaries and limits, trust and rapport, how to deal with special favors and gifts, keeping appointments (or not), and walking the tightrope between giving good care and getting overinvolved.

Although it seems incomprehensible to those of us who work in the field, there are many detractors who assert that there is no such thing as a dissociative disorder, that they are a figment of the therapists’ imaginations. This is asserted in spite of the fact that the diagnosis has been part of the official psychological/psychiatric diagnostic manuals for more than twenty years, both in North America and other countries through out the world.

In the past decade, a vigorous determination to uncover the true factors in dissociation has led to an elegant and highly sophisticated body of research, and a robust literature. Some of this research will be discussed briefly at the end of this book. It leaves no doubt as to the legitimacy of the diagnosis.

Dissociative disorders are not new. They were described in the literature two hundred years ago. We are simply able now to put them into a more understandable perspective.

Our role

How does this impact on family physicians and other healthcare workers?

We are—or should be—the sentinels. Into our offices come hundreds of patients, and we get to know them, and get to know the families. We see the discrepancies, the unexplained and unexplainable symptoms, the distress and, often, the agony. Most of us would not choose to be the primary therapist, and rightly so; but, with good therapy, most dissociative patients improve, some completely, some at least to a much higher level of function.

When we take our role as sentinels seriously, then our patients can reap the benefits with early diagnosis, appropriate referral and good, knowledgeable therapy, and thus the opportunity to have full and rewarding lives.

Chapter One

The “Thick-Chart” Patient

I was late getting to the office because of an emergency at the hospital, and the waiting room was full when I arrived. Generally my patients were pretty sanguine about waiting, because my receptionist would always explain the reason, but this day there was one glowering at me. Oh, no! I thought. Not her today! Mrs. J. was a frequent occupant of one of my waiting room chairs. She seemed to have an endless backlog of complaints, which usually started, “Oh, Doctor, last time I was here I forgot to mention …” and went on from there.

To be fair, she had legitimate complaints (as I described them to myself) because she had been in a nasty motor-vehicle accident two years before, suffering a miserable whiplash, and her husband had advanced emphysema and required a lot of her time and attention. Nevertheless, there were days when I felt my patience slipping as I listened to yet another list of complaints, most of which I could do nothing about—the pollution in the air, the full story of the accident, the fact that her children never lifted a hand to help her. All of these contributed to whatever the symptom of the day might be. Often the problem was poor sleep, or the latest medicine for pain didn’t help, or she thought she was getting another cold, which might perhaps turn into the flu. And she always took it as a personal insult if I was late.

What does “psychosomatic” really mean?

How often have you looked at your day sheet, on entering your office, and had a pang of tension or a groan of “Oh, no! Not her today!”

One of the many burdens that dissociative patients have to bear, is being labeled “psychosomatic”. Too often this results in acrimonious relations with their medical caregivers, a sense of great injustice and much anger in the patient, inappropriate referrals, polysurgery, too much and too many prescriptions (often useless or worse than useless), multiple and overlapping lab tests, and numerous other errors of commission or omission as we do our best to navigate the stormy waters.

But remember: “psychosomatic” just means mind-and-body, and everything is psychosomatic because we are not disconnected at the neck: anxiety is reflected in muscle tension; pain is reflected in emotional distress.

Our groans come from frustration—at not being able to decipher the root of the patient’s problems or his or her apparently disproportionate reaction to them.

The patient’s groans come from the other side of the same coin—“This person’s supposed to know what’s the matter with me! That’s her job! Why can’t she just get on with it and get me better? Instead of that, she sends me for all these tests and makes me spend all that money on useless medicine and then tells me that it’s all in my head!”

Teeth-clenching abounds.

As a matter of fact, the recognition of a thick chart, and one that seems to be getting thicker with every passing month, ought to alert us that something is obviously amiss here. Allow that little voice (groan) to whisper to you that here there might be an opportunity to do some serious delving and re-evaluating. Then sit down with the chart, pretend the patient belongs to someone else (“I wish!” you might hiss in response), take two and a half minutes to do some self-calming, and start going through it from the beginning.

Look for inconsistencies—in descriptions of the problem, in the consultation reports from your favorite witch doctor(s), in lab results, in other investigative procedures, in response to medication, in what seemed so terribly important (from the patient’s perspective) yesterday but seems to be forgotten or dismissed today.

Take particular note of any little messages you may have put on the chart. When I realized that I had another dissociative patient in my practice, I reread her whole chart and sat there, stunned, as I found (in my own inimitable handwriting) a note in the margin saying that “she seems like an entirely different person today”. Indeed, she did. She had done a home pregnancy test, which was positive, and a brand-new post-office box was opened—a new ego-state formed, one whose job it was to take care of that pregnancy.

There may be occasions when the patient forgets to come for the appointment, or turns up when no appointment has been made but she insists that it was. This is a classic behavior in highly dissociative patients and one that is particularly confusing to the uninitiated physician, especially when the patient is so demanding. How could she have forgotten an appointment? The answer, of course, is that some other ego-state made it. This may have been one of the protectors in the system who felt that something was amiss.

What to do?

If it is a case of a missed appointment, ask if it is still necessary. Remake it, if so; if the patient says “no”, make a careful note in the chart to record the event. If she still wants to come, rebook, but with the same notations in the chart. It is all right to comment that there must have been some miscommunication, when the patient is then sitting in your office. Watch for the reaction, using your best noncommittal physician’s facial expression and body language.

If it is a case of the patient’s turning up and insisting that an appointment was made, see if you can gently get the details of when that was supposed to have happened. Did the patient phone? What time of day? to whom did she speak? Explain that you are just trying to pin down how and where the miscommunication occurred. Again, make careful notes in the chart. Such notes might, in time, form a pattern.

Be aware of the reactions that are triggered in you by your patient’s behavior, demands, or unrealistic responses. Countertransference can be an invaluable guide to the root of any problem, and this is certainly true when we are working with dissociative patients. One of the clues that alerted me to the possibility of another dissociative patient in my own practice was the realization of my irritation at some of her behavior patterns: then the light went on, alerting me that perhaps she was like Jayere.

When you put these tidbits of information together, you may have a legitimate reason to consider that maybe, perhaps, possibly, that patient just might have a different diagnosis—one that answers a whole lot of confusing questions.

Do dissociative patients abuse the medical system?

Several years ago I was given an excellent paper to review on the apparent misuse of outpatient medical clinics by some families. The author hypothesized that these were dysfunctional families, with poor personal and social resources, whose various medical problems were more an expression of the psyche than the soma. In looking for connecting links, he found family disruption and often family violence, unsuccessful employment capabilities, little extended family support (although there might be a fairly large group of relatives), past and present problems with the law, and general lack of appreciation of these factors—on the parts of both the patients and the health care workers. Other similar research projects have been published with similar results. They will be discussed in Chapter Seventeen.

He decided to investigate the families for dissociative tendencies and found a remarkable correlation between the degree of unrecognized dissociative phenomena and the frequency with which such patients presented at the outpatient clinic. Indeed, it was a very predictable and reliable correlation—the more frequently the patient attended the clinic, the greater degree of family dysfunction and the greater the incidence of dissociative tendencies and behaviors in the patient. Unfortunately, to my knowledge this paper was never published, but I felt it worthy of comment.

If we extrapolate from this very nice piece of epidemiological research, we can begin to garner a little more understanding of mind–body communication: when the psyche is in a dysfunctional dissociative state, the body responds with its own separation from a sense of wellbeing and—both parts looking for answers when neither even knows the questions—the plethora of psychosomatic problems bubble up to the surface.

Presto! Our thick-chart patient.

Further research into the somatic aspect of dissociative disorders is being done in various parts of the world. Of particular note is the elegant work being done in The Netherlands by Ellert Nijenhuis and his colleagues. Two questionnaires have evolved from this research, which enjoy an exceptional correlation to a diagnosis of dissociative disorders—the Somatoform Dissociation Questionnaire-20 (SDQ-20) and the SDQ-5. They can be found at the back of his book, Somatoform Dissociation (1999).

As physicians, we look for answers to these somatic complaints because we want our patients to be, and feel, well. It is all too easy to make yet another referral, ask for one more set of lab tests, prescribe yet another miracle from the pharmaceutical corporations.

Thus we engage in a balancing act. Of course we want to make sure that we have not forgotten anything, omitted exploring some reasonable possibility, or dismissed a potentially dangerous (or even simply annoying) medical condition. So, all too often, we err on the side of overinvestigating. Beware. Too much is not necessarily better than too little.

I fell into this trap often, in the early years, when I was still such a novice in the dissociation field. I prescribed and prescribed, referred and referred. I am trusting my readers to know that I am not advocating any kind of neglect, but rather a healthy skepticism when the usual routes have all proven to reach such disappointing nonanswers.

Worse than that, we may actually do harm to our patients, especially with the polypharmacy. Many dissociative patients have extremely idiosyncratic responses to medication: some are able to tolerate huge doses with no effect whatsoever (or so it seems); others do well with tiny doses—sometimes only a quarter or even a tenth of the “normal” dose. I am thinking, for instance, of antidepressants. These may be used for depression and/or to relieve chronic pain such as fibromyalgia. Those of us who work with chronic-pain patients know that the usual dose of analgesics is often totally useless, yet, strangely, some conditions, such as fibromyalgia, may respond well to these tiny doses of tricyclics. Based on this, I began to offer some of my dissociative patients these very small doses of antidepressants, or of anxiolytics, with occasional rewarding results.

Furthermore, many of us feel that some medications are often contraindicated in dissociative patients. Hypnotics have no place in the therapeutic protocol, nor tranquilizers. Nor, I often used to think, antipsychotics. I have changed my mind somewhat about the antipsychotics used in very small doses. I will speak more about medication issues in Chapter Four. Of course, various medications may be used quite safely by physician therapists who are knowledgeable about dissociation, but it can be a quagmire for the unaware.

As a general rule of thumb, I think of these problems as “psychosomatic and somatopsychic issues in trauma and dissociation”. For example, I would list the following under the heading “Psychogenesis”:

panic attacksflashbackssleep disturbancesderealizationdepersonalizationvertigo

In the same way, I would list the following under “Somatogenesis”:

body memorieschronic pain syndromesheadachegastrointestinal disorders genitourinary disordersair hungereating disorderspseudoseizures

These are merely partial lists, of course, but they give an impression that can be useful to put things into a slightly different perspective. Many of these, and more, will be discussed throughout this book in the context of alerting the physician to dissociative expression.

“High-risk” populations

For those healthcare workers who work in underprivileged areas or with high-risk—in the economic and/or social sense—populations, it again behooves us to keep the possibility of a degree of dissociative disorder in the differential diagnosis. At present we have spearheaded a pilot project in the city where I live (Victoria, British Columbia) to evaluate the extent of dissociativity in the “street” population. This project has interested several levels: the tourism groups, both governmental and private; the business community; the public-health offices; the “keep our city clean and safe” groups.

If, as I strongly suspected, the degree of dissociativity is high, then we will have a better grasp of what the problem really is and can get to work putting in place some simple programs, such as opportunities to learn coping skills, problem-solving and life-management strategies, and how to look for and apply for a job. There is already an excellent project for the young street people to take basic job training in janitorial work and in the fast-food industry. It enjoys a spectacular success rate with those who enter the project—about 80 percent. Because there was already a level of trust established, we linked our project with the work-skills project. These projects are funded through several levels of government—local (municipal), regional, and provincial, as well as some community business groups and volunteer agencies that work with those whose homes are on the street. This mini-study was presented at a conference at the University of Victoria (British Columbia) in May 2003. The results were precisely as we had predicted—a level of dissociativity that indicated considerable intrusion into the person’s ability to do good problem solving, coping, and decision making. And these were the young people who had enough determination to get themselves into the project.

Local health clinics are also ideal places to begin recognizing dissociative tendencies, which impact on the wellbeing of those patient populations.

I have strayed a bit from the thick-chart patient, but the past few paragraphs seem to fit well in this part of our considerations.

Dealing with crises

From time to time, patients will call or come to the office in a state of crisis. Frequently it does not seem such a crisis to us as physicians or health care professionals. We have to realize that it is an emergency to them, and respond with true attentiveness. Use the same skills with which you would respond to any panic attack: speak clearly, in simple sentences. Reassure the patient that you are indeed hearing her. Get her to sit, if possible, and breathe. Use some basic relaxation techniques if you can, although she may resist that.