clinical assessment of dissociative identity disorder among college counseling clients

ProfessionalIssuesandInnovativePractice

JournalofCollegeCounseling ■Spring2008 ■Volume11 73

©2008bytheAmericanCounselingAssociation.Allrightsreserved.

ClinicalAssessmentofDissociativeIdentityDisorderAmongCollegeCounselingClients

Benjamin Levy and Janine E. Swanson

College counseling professionals address a wide range of complex student mental health concerns. Among these, accurately identifying client presentations of dissociative identity disorder (DID) can be especially challenging because students with DID sometimes present as if they are experiencing another problem, such as a mood, anxiety, or psychotic disorder. This article reviews DID diagnostic criteria, introduces assessment strategies for use during intake and subsequent counseling sessions, and presents case illustrations.

Collegecounselingcenterdirectorsandpractitionerscontinuetoreportthat students areexperiencingmore severementalhealthconcerns(Gallagher, 2004; Gallagher & Weaver-Graham, 2005). Although

cautionshavebeenexpressedabouttheneedtoconductempiricalresearchtoconfirmthese impressionsof increasing severity (Bishop,2006;Bishop,Gallagher,&Cohen,2000; Sharkin, 1997), counselors in college settingscertainlydoconfrontstudentswithseverementaldisordersandpsychologi-cal disabilities in their day-to-day practice (Archer & Cooper, 1998), andcollegecounselors’caseloadsseemtobeincreasinglycomplex(Humphrey,Kitchens,&Patrick,2000).Furthermore,Sharf(1989)suggestedthatevenafewdifficultcasescanhaveadrainingeffectonstaff.Althoughotherclassesof severe or complex mental disorders, such as substance use and eatingdisorders,have receivedattention in the recent literature, less informationis available to inform college counselors’work with dissociative disorders.Tohelpfillthisgap,inthisarticle,wediscussproceduresfortheassessmentofdissociative identitydisorder (DID; formerlymultiplepersonalitydisor-der)asitisexperiencedbycollegestudents.First,wereviewtheDiagnosticandStatisticalManualofMentalDisorders(4thed.,textrev.;DSM-IV-TR;AmericanPsychiatricAssociation[APA],2000)diagnosticcriteriadescribingsymptomsof thedisorder.Next,wediscuss theuseof screeningmeasuresanddiagnosticstructuredinterviewsinthecollegecontext.Wethenprovidethreecaseillustrationsdrawnfromtheexperiencesofstaffatoneuniversitymentalhealthcenterandoffersomeconclusions.

WhatIsDissociation?

DissociationisdefinedintheDSM-IV-TR(APA,2000)asasignificantdis-ruptioninaperson’susuallyintegratedfunctionsofconsciousness,memory,identity,orperceptionof theenvironment.An individualmaydevelopthe

Benjamin Levy and Janine E. Swanson, Mental Health Services, University of Massachusetts. Janine E. Swanson is now at ProHealth Connecticut Center for ADHD, Middletown, Connecticut. Correspondence concerning this article should be addressed to Benjamin Levy, Mental Health Clinic, University Health Services, University of Massachusetts, 111 Infirmary Way, OFC 1, Amherst, MA 01003 (e-mail: bfl@uhs.umass.edu).

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disturbancesuddenlyorgradually,anditmaybetransientorbecomechronic.People sometimesexperience transientdissociation in thecontextofpost-traumatic stress disorder, panic disorder, borderline personality disorder,obsessive-compulsivedisorder, impulse controldisorders, eatingdisorders,andsubstanceabusedisorders(Gold,2007).Transientdissociationalsooc-cursduringDSM-IV-TR–definedpsychogenicamnesiaorpsychogenicfuguestates.Ontheotherhand,whenapersonbeginstoexperiencedissociationchronically,heorsheismorelikelytobeexperiencingadissociativedisorder(Putnam,1989).Thechronicdissociativedisordersincludedepersonalizationdisorder,DID,anddissociativedisordernototherwisespecified(DDNOS).ThisarticlefocusesonDIDandalsodiscussesthoseformsofDDNOSthatarecharacterizedasclinicalpresentationssimilartoDIDbutfailingtomeetthefullcriteria.ThereasontoconsiderbothDIDandtheseformsofDDNOStogetheristhatsimilarassessmentproceduresandcounselinginterventionshavebeenrecommendedforbothtypesofdisorders(Kluft,2006).

AnOverviewofDID

DSM-IV-TR Diagnostic Criteria

The diagnostic criteria for DID in the DSM-IV-TR (APA, 2000) are thefollowing:

A. Thepresenceoftwoormoredistinctidentitiesorpersonalitystates(eachwithitsownrelativelyenduringpatternofperceiving,relatingto,andthinkingabouttheenviron-mentandself).

B. At least twoof these identitiesorpersonality states recurrently take controlof theperson’sbehavior.

C. Inabilitytorecallimportantpersonalinformationthatistooextensivetobeexplainedbyordinaryforgetfulness.

D. Thedisturbance is not due to the direct physiological effects of a substance (e.g.,blackoutsorchaoticbehaviorduringalcoholintoxication)orageneralmedicalcondi-tion(e.g.,complexpartialseizures).(p.529)

Whenindividualsareconfrontedwithproblematicclinicalpresentationssimi-lartoDID,butexperiencesymptomsthatdonotquitemeetthefullcriteriaforadiagnosisofDID(suchasdissociationwithout twoormoredistinctpersonalitystates,orwithoutamnesiaforimportantpersonalinformation),thentheirdifficultiesmaymeetthecriteriaforadiagnosisofDDNOS(APA,2000,p.532).

Associated Features and Disorders

TheDSM-IV-TR(APA,2000)statesthat individualsexperiencingDIDfre-quentlyreportahistoryofphysicalandsexualabuse,especiallyduringchild-hood.Individualsmaymanifestposttraumaticsymptomssuchasnightmares,flashbacks,andstartleresponses.Infact,theirsymptomsmaymeettheDSM-IV-TRcriteriaforbothposttraumaticstressdisorderandDID.Theymayalsoengage inself-mutilative, suicidal,oraggressivebehavior.Theymaytendto

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repeatpatternsstemmingfrompastrelationshipsinvolvingphysicalandsexualabuse.Certainidentitiesmayexperienceconversionsymptomssuchaspseudo-seizuresorhaveunusualabilitiestocontrolpainorotherphysicalsymptoms.Someclients’symptomsmayalsomeetthecriteriaformood,substance-related,sexual,eating,orsleepdisorders.Self-mutilativebehavior,impulsivity,andsud-denandintensechangesinrelationships,whentheyarepresent,maywarrantaconcurrentdiagnosisofborderlinepersonalitydisorder.

Specific Culture, Gender, and Age Features

DIDhasbeenfoundinawiderangeofculturesintheworld.Forexample,Sar (2006) reported thatdissociativedisorders are“ubiquitous across cul-tures”(p.240).Itisdiagnosed3to9timesmorefrequentlyinadultwomenthaninadultmen.ExaminingauniversitycampuspopulationusingclinicalmeasuresofDID,Ross,Ryan,Voigt,andEide(1991)foundthatanotablenumberofstudentswereexperiencingDID.

Course and Familial Pattern

The DSM-IV-TR (APA, 2000) describes a fluctuating clinical course thattendstobechronic,witheitherepisodicorcontinuousdissociativesymptoms.However, a number of authors have described the possibility of completeresolution of dissociative symptoms after correct diagnosis and treatmenttargetingthedissociativesymptoms(Kluft,1999,2006;Loewenstein,1994).Steinberg(1995),quotingSpiegel,notedthatdissociativedisordersbelongtothecategoryof“thefewseriouspsychiatricillnessesforwhicharecordofsuccesswithappropriatepsychotherapyisdeveloping”(p.381).

Moreover, according to information provided in the DSM-IV-TR (APA,2000),DIDoccursmorecommonlyamongfirst-degreerelativesofindividu-alswiththedisorder.

Differential Diagnosis

TheDSM-IV-TR(APA,2000)identifiesseveralcompetingdifferentialdiag-nosestobeconsideredbythecounselor.Theseincludesymptomscausedbythedirectphysiologicaleffectsofageneralmedicalcondition,complexpartialseizures,directphysiologicaleffectsofasubstance,schizophreniaandotherpsychotic disorders, bipolar disorder with rapid cycling, anxiety disorders,somatization disorders, personality disorders, malingering, and factitiousdisorder.Chefetz(2006)addedaddictionsandeatingdisorderstothislist.Furthermore,Ross(1997)foundthatasmanyas15%ofclientsexperiencingsubstancedependencymayalsobedealingwithDID.Giventhesignificantsubstance abuse problems associated with college populations (Archer &Cooper,1998;Humphreyetal.,2000),Ross’s(1997)findingssupporttheneed to screen fordissociativedisorders in those studentspresentingwithsubstanceabuseproblems.Ross(1997)suggestedthatsomeofthesestudentsmaybe“self-medicatingtheirtraumahistoriesandco-morbidity,andreinforc-

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ingtheirdissociation”(p.131).Asseeninthecaseillustrationsthatfollow,studentswhoareoriginallythoughttobeexperiencingananxietydisorder,mooddisorder,psychoticdisorder,orsubstanceabusedisordermaylaterbediscoveredtobedealingwithDID.

AssessmentToolsforCollegeCounselingProfessionals

Historically,counselingprofessionalshavefoundthediagnosisofmultipleper-sonalitydisorder,orwhat isnowreferredtoasDID,“difficultandcomplex”(Solomon&Solomon,1982,p.1187).Thisisimportantinday-to-daycollegecounselingpractice“sincemisdiagnosismaypromotewell-intentionedbutharmfultreatment”(Solomon&Solomon,1982,p.1194)thatfailstomeetthestudent’sneeds.Infact,“sevenstudiesof719DIDpatientshaveshownthattheyspentfive to11.9years in thementalhealth systembefore theywerediagnosedashavingDID”(InternationalSocietyfortheStudyofDissociation,2005,p.72).However,sincescreeninganddiagnostictoolsfordissociativedisordersbecameavailableinthemid-1980s,ithasbecomepossibleforacounselortomakeamoreaccuratediagnosisofDIDearlierinthecourseofaclient’streatment.

Written Screening and Diagnostic Measures

BernsteinandPutnampublishedthefirstscreeningtoolforDID,theDissocia-tiveExperiencesScale(DES),in1986.Rossetal.publishedthefirstdiagnostictool,theDissociativeDisordersInterviewSchedule(DDIS),in1989.Then,Steinberg,Rounsaville,andCicchettipublishedaseconddiagnostictool,theStructuredClinicalInterviewforDSM-III-RDissociativeDisorders(SCID-D),in1990.TheSCID-DwasdesignedtocomplementtheStructuredClinicalInterviewforDSM-IVAxisIDisorders(First,Spitzer,Gibbon,&Williams,1997)because the latter does not have a dissociative section (Ross, 1997).ThereiscurrentlyaDSM-IVversionoftheSCID-D,theStructuredClinicalInterviewforDSM-IVDissociativeDisorders–Revised(SCID-D-R;Steinberg,1994b).ThesescreeninganddiagnostictoolsaswellasotherssubsequentlydevelopedarereviewedbyCardeñaandWeiner(2004)andCourtois(2004).Evenmorerecently,Dell(2006a,2006b)haspublishedthelatestdiagnostictool,theMultidimensionalInventoryofDissociation.BecausetheDESisthemostcommonlyusedscreeningtoolandtheDDISandtheSCID-D-Rarethemostcommonlyuseddiagnostictools(Cardeña&Weiner,2004),thisarticleexplorestheuseoftheDESforscreeningandtheDDISandSCID-D-Rfordiagnosingdissociative disorders in the context of three case discussions ofstudentspresentingformentalhealthcareatacollegementalhealthservice.

Screening Measure

TheDES is a28-item self-reportmeasureof the frequencyofdissociativeexperiences.Itwasdesignedtoassessforthepresenceofhighlevelsofdis-

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sociation.Theclientisaskedtocirclethepercentageoftimeeachsymptomdescribedinaquestionisexperiencedwhilenotundertheinfluenceofalcoholordrugs.Thetotalisaddedupanddividedby28toachievetheDESscore.Themeasurerequiresabout5to10minutesfortheclienttocompleteandanother5minutestoscore.ThelatestversionoftheDESisincludedinanarticlebyCarlsonandPutnam(1993).CarlsonandPutnam’sarticlealsoin-cludesatablewiththemeanormedianDESscoresacrossdifferentdiagnosticgroups.Acutoffscoreof30identifies74%ofthosewhoexperienceDID(i.e.,sensitivity)and80%whodonothaveDID(i.e.,specificity).

Structured Diagnostic Interviews

BecausesomeclientswithahighDESscoremightbeexperiencingposttrau-maticstressdisorderoranothermentalhealthconcernthatincludessignificantdissociative symptoms but is not DID, a clinician-administered structuredinterview(suchastheDDISandtheSCID-D-R)isalsoneededtoconfidentlymakethediagnosis.TheDDISandtheSCID-D-Raretwostructuredinter-viewsthatdiscriminateDIDfromotherpsychiatricdisorders.

TheDDISrequires30to45minutestoadministerandanother10to15minutestoscore.Thereare132itemswithayes/noformatthatassessthesymptomsofthefivedissociativedisordersdefinedbytheDSM-IV-TR(APA,2000),aswellassomatizationdisorder,borderlinepersonalitydisorder,andmajordepressivedisorder.ThefiveDSM-IV-TRdissociativedisordersarepsychogenicamnesia,psychogenicfugue,depersonalizationdisorder,DID,andDDNOS(APA,2000).Theinstructionsforscoringtheinterviewresultsareincludedwiththematerials.(AcopyoftheDDIScanbefoundinRoss’s,1997,bookDissociativeIdentityDisorder,Diagnosis,ClinicalFeatures,andTreatmentofMultiplePersonality.)

TheSCID-D-Rrequiresfrom30minutesto2(ormore)hourstoadministerandanother30minutestoscore.Thereare158itemsthatassessfivesymptomsofdissociation:amnesia,depersonalization,derealization, identityconfusion,andidentityalteration.Therearenineoptionalfollow-upsectionsofabout10questionseachthataredesignedtoincreasetheunderstandingoftheextentof identitydisturbance.It isonlynecessarytochooseoneortwofollow-upsections,andthechoiceisbasedonsymptomareasendorsedintheearlypartoftheinterview.TheSCID-D-RassiststhecounselorinthediagnosisofthefiveDSM-IV-TR(APA,2000)dissociativedisorders.Italsoyieldsascoreforeachofthefivedissociativesymptomsandatotalscore.Thesescoresarebasedonfrequencyandintensityofsymptomsandreflecttheimpactofdissociativesymptomsontheindividual’ssocialfunctioningandwork(orschool)perfor-mance.Instructionsforadministering,scoring,andinterpretingtheSCID-D-RaredescribedintheInterviewer’sGuidetotheStructuredClinicalInterviewforDSM-IVDissociativeDisorders(SCID-D)–Revised(Steinberg,1994a).Theex-tensiveamountofinformationexchangedduringthecollaborativeSCID-D-Rdiagnosticinterviewnotonlycanassistwithmakinganaccuratediagnosisbutalsocanbeveryhelpfulinengagingaclientinthecounselingrelationshipandpsychotherapyprocess(Steinberg&Hall,1997).

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CaseIllustrations:ThreeCollegeCounselingClients

Case Illustration 1: DID Versus an Anxiety Disorder

Client1firstpresentedformentalhealthtreatmentbeforebeginningcollege,whenhewas16yearsold.However,heattendedonlyonesessionatthattime.Whenhewas18yearsold,hepresentedat theuniversity’sMentalHealthServicesandreportedhavingproblemswithanxiety“allmylife,”andstatedthathissymptomshadgottenworsesincearrivingatcollege.Hereportedsymptomsconsistentwithintermittentpanicepisodesandsaidhesubsequentlyisolatedhimselfinhisroombecauseofanticipatoryanxietyrelatedtothefearthathemighthaveanotherembarrassingpanicattackwhilehewasout inpubliconcampus.Hisoriginalpresentationwasconsistentwithananxietyspectrumdisorder,althoughitwasnotclearwhetherhemightbeexperiencingapanicdisorder,generalizedanxietydisorder,and/orsocialanxietydisorder.Intheinitialscreeninginterview,heacknowledged,whenaskedspecifically,thatattimesheexperiencedasenseofbeingdisconnected,orbeinglikeanobserver,orevenbeingoutsideofhisbody—althoughtheseeventsseemedtooccuronlyattheheightofapanicexperience.Itwaspresumedbyboththecounselorandthepsychiatristthatthisdepersonalizationwassecondarytopanicratherthantheotherwayaround.Acampuspsychiatristprescribedanantianxietymedication,Klonopin(clonazepam),anditseemed,basedonsubsequentsessions,thatClient1wasexperiencingananxietydisorderthatwassuccessfullyresponsivetomedication.However,bythefourthsession,hereportedexperiencingviolentdreamsandstatedthatanxietyalwayscov-eredupwhathedescribedashisfeelingsofmurderousrage.Atthispoint,itbecameunclearwhetherhewashavingaparadoxicalreactiontoKlonopinorwhetheranunderlyingproblemwasemergingaftertheinitiallysuccess-fultreatmentofhisanxietywiththismedication.Bythefifthsession,Client1spontaneouslyacknowledgedfeelingas ifheweretwopeopleandtalkedabouthimself inthethirdperson,stating,“[student’sname]killspeople.”By the seventh session, he described feeling chronically detached, spacingoutalot,beingforgetful,havingfeelingsofunreality(hisparentssometimesfeltlikestrangers),andexperiencingsuddenmoodchangesfornoapparentreason.Because the symptompicture includedamnesia,depersonalization,derealization,andpossiblyidentityalteration(three,ifnotfour,ofthefivecore symptomsofDID), theclientwas then referred toapsychotherapistwhospecializedintreatingdissociativedisorders.TheclientcollaboratedinaSCID-D-Rinterview,whichconfirmedthediagnosisofDID.Specifically,thestudent’spictureincludedthefivecoresymptomsofDID(Steinberg,1995):amnesia,depersonalization,andderealization(thatwereapparentbothintheearlierpsychotherapysessionandagainintheSCID-D-R)aswellasidentityconfusionandidentityalteration(thatwererecognizedintheSCID-D-R).Itbecameclearthathisanxiety,panic,andagoraphobiaweresecondaryto

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hisdissociativesymptoms.Client1thenengagedinpsychotherapytoaddresshisdissociativesymptoms.

Comment on Case Illustration 1

Inthiscaseillustration,theclientinitiallypresentedattheuniversitymentalhealthclinicwithwhatseemedtobeanuncomplicatedpanicdisorder.Hesaidthatthedissociativesymptomshedescribedintheinitialsessionoccurredonlyattheheightofapanicattackandsowerebelievedbythecounselorandthepsychiatristtobepartofananxietydisorderandnotadissociativedisorder.Yet,astheclientspentmoretimewithhiscounselor(andperhapsbecause he became more comfortable in the therapeutic relationship overtime),hewasabletosharemoreinformationaboutthefullextentofhisdis-sociativeexperiences.SharingabouttheextentofdissociativesymptomsonlyaftertrusthasdevelopedinthepsychotherapyrelationshipisquitecommonamongclientsdealingwithDID(Putnam,1989).

Case Illustration 2: DID Versus a Mood Disorder With Psychotic Features

Client2wasamale,28-year-old,marriedgraduatestudentwhofirstcameintotheuniversitymentalhealthclinicdescribinghopelessfeelingsandex-tremelywide-rangingmoodswings.Hestated,“Igetprettymanic.”Hesaidthathesometimeshadlotsofenergy,neededonly4hoursofsleepbutstillfeltenergeticthenextday,andaccomplishedalotofwork.Healsoreportedthatatothertimeshewouldbecomesodepressedthathewouldnotgetoutofbedfordaysatatime.Hestatedthatthismoodvariabilityhadbeengo-ingonforaslongashecouldrememberbutthatsofarhehadnotsoughtprofessionalhelp.Becauserecentlyhehadstartedtofeelagitated(includingthrowingobjectsinthehouseoutoffrustration)andbegantohavesuicidalthoughts,heagreedwithhiswifetoseekcounselinghelp.Thecounselor’sinitialimpressionwasthathemighthavebipolardisorderthatwasevolvingintoamixedstate.Psychiatrichospitalizationandmood-stabilizingmedicationwererecommended,butthestudentdeclinedtheseoptions.Becausehewasnotan imminentrisktohimselforothers,hewasnot involuntarilyadmit-tedtothehospital.However,hedidagreetoreturnforfurtherevaluation.Duringthefirstfewvisits,heacknowledgedgapsinhismemory,hearingtwovoicesinhishead,andfeelingattimesasthoughhedidnothavecontrolofthewordsthatcameoutofhismouth.Hethereforeagreedtoanevaluationtoassesstheextentofhisdissociativesymptoms.OntheDES,hescored48.BecauseofthishighDESscore,aDDISwasadministered.Heendorsed7of11Schneiderianfirst-ranksymptoms(commoninDID;seeRoss,2004)and12of14featuresofDID.ThispicturewasconsistentwiththediagnosisofDID.Thestudent’ssubsequentpsychotherapysessionsweredevotedtohelping him better understand his dissociative symptoms. For example, itwasarelieftohimtoknowthatmisplacingobjectsinthehousewasrelated

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totheamnesiaofdissociationratherthanirresponsibility.Also,asaresultofcounseling,whenhewouldbegintofeelincreasingdespairandemptiness,ratherthantraveltoacasinotogamble(whichhadbeenhistraditionalwaytorelievestress),hecametopsychotherapytotalkabouthisfeelings.Muchof the subsequentcounselingprocesswasdirectedateducationaboutdis-sociation;correspondingly,hewasabletomakesenseofthemanyyearshehadspentdealingwith thedisruptive symptomsofDID.Still,becausehissymptomsweresopervasive,hewasnotabletomaintainacademicprogress,andsohetookamedical leavefromhisgraduatestudieswhilecontinuinghistherapeuticwork.

Comment on Case Illustration 2

Thisstudentwasfirstseenbyaninternattheclinic.Althoughapsychiatristprovidedconsultationonthe1stdaythestudentcamein,thestudentde-clinedtoconsiderpsychotropicmedicationandwouldnotreturntoseethepsychiatristbecauseoffearsthathemightrecommendpsychotropicmedica-tionorhospitalization.Asanalternative,thestudentengagedinanevalu-ationprocessandsubsequentpsychotherapywiththe intern,whoreceivedclose clinical supervision froma campuspsychiatrist.The internhadbeentrainedtorecognizedissociativecluesintheinterviewprocess,andso,whenthestudentdescribedgapsinhismemory,hearingvoices,andfeelingwordscomeoutofhismouthwithouthiscontrol,sheknewthatitwaslikelythisclientwasexperiencingdissociativesymptoms.TheinternthenadministeredandscoredtheDESandtheDDIS,whichconfirmedthediagnosisofadis-sociativedisorder.Shethenreviewedtheresultsinclinicalsupervision.Thestudentcametounderstandthathisproblemswithmood,whichwerehischiefcomplaint,hadstemmedfromhisdissociativesymptoms.Themorehisdissociativesymptomswereaddressedinhispsychotherapy,thelesshewouldexperiencedisruptivemoodsymptoms.Becausetheinternwasscheduledtograduate fromher internship3monthsaftermeeting this client, themaingoalsduringthis3-monthinterventionperiodweretodeterminewhetheradissociativedisorderdiagnosisaccuratelydescribedtheclient’ssymptoms,helptheclientunderstandhowhisvariedandconfusingemotionsandbehaviorswerepartofhisdissociativeexperience,helptheclientrecognizethevalueofpsychotherapy,andthenhelphimtoacceptareferraltoapsychotherapisttrainedtotreatDID.Ourexperienceintheuniversitymentalhealthclinicisthatmanystudentswhodealforyearswithdissociativesymptomsdonotun-derstandwhathasbeenhappeningintheirlivesandthereforefindtremendousreliefwhentheyareabletoconsidertheircombineddissociativesymptomsinawaythatisbothunderstandableandtreatable.Inotherwords,thediag-nostictoolsfordissociativedisordersprovideawaytohelpstudentsorganizeaconfusingmyriadofdisruptivesymptomsintoanunderstandablepicture.After3monthsofcomingtotheclinic,thisclienteventuallyunderstoodandacceptedthediagnosisofDIDandwasabletofollowthroughwithareferralforlong-termpsychotherapy.

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Case Illustration 3: DID Hidden by a Substance Abuse Disorder

Client3wasafemale,20-year-old,undergraduatewhowasreferredtotheon-campusclinic after abrief in-patienthospitalization followinga suicideattempt.Whileintoxicatedwithalcoholandinthemidstofanargumentwithherboyfriend,sheswallowedahandfulofpillsandwasrushedtothehospitalwhereherstomachwaspumped.Shewasobservedfor24hoursuntilsoberandthenreleased.Herpasthistoryincludedonepriorpsychiatrichospitalizationfollowingasuicideattemptandtwoprioremergencyroomvisitsforalcoholintoxication prior to coming to college. Earlier, she had been engaged incounselingandwastakinganantidepressantmedication,Paxil(paroxetine),totreathersymptomsofdepression.However,shehadtaperedherselfoffPaxilinthehopeoflosingweightandacknowledgeddrinkingtothepointofintoxication1nightaweekforpleasure.BecauseherdepressionhadreturneduponstoppingPaxil, shedidagree tobegin takinganotherantidepressantmedication that would not have so much impact on her weight. Duringthecourseoftheinitialinterview,whenaskedsomescreeningquestionsfordissociation, she acknowledged problems with her memory. For example,shestatedthatshewasstruckbyhowmuchofthesharedexperiencewithherhighschool friendsshecouldnotremember.Shealsoacknowledgedaheightenedsenseofbeingdisconnected,orbeinginafog,aroundthetimeshewouldexperienceaninnervoicetellingherto“party.”Competingwiththisinnervoicetopartywasareportedly“sane”voicetellinghertotakebet-tercareofherself.Althoughmanystudentsexperiencesuchaninnerstruggleregardingyoungadultlifechoices,becauseofherreportofmemorygapsanddepersonalization,sheagreedtocompleteaSCID-D-Rtoassesstheextentofherexperiencesofdissociationandtoruleoutadissociativedisorder.OntheSCID-D-R,shedidendorsesignificantsymptomsofamnesia,deperson-alization, derealization, identity confusion, and identity alteration, whichare consistent with the diagnosis of DDNOS. That is, there was enoughchronicandsevereamnesia,depersonalization,derealization,andidentityconfusiontowarrantadissociativediagnosis,buther identityalterationwasnotwellenoughformedtowarrantafulldiagnosisofDID.Duringthecourseoftheevaluation,sheacknowledgedthatasayoungchildshewassexuallyabusedbyafamilyacquaintanceand“everythingsnowballedsincethen.”Sherecalledrepeated,seeminglyinvoluntary,sexuallyseduc-tivebehavior thatsomeofher friendswouldreport toherandthatshewouldnotremember.Sherecalledalso,someofthetime,wantingtobe“respectful”ofherself andothers.She said shehad longbeenawareofthisinnerstrugglebetweenbeingsexuallyseductiveandbeingrespectfulandhadoftenusedalcoholasawaytoquietthisstruggle.Bycomplet-ingtheSCID-D-R,shefeltbetterabletounderstandwhatthisstrugglerepresentedandfeltmoremotivatedtoengageinpsychotherapytotargetherdissociativesymptoms(includingthisinnerstruggle)andtofulfillherlong-termwishtofeelmoreincontrolofherlife.

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Comment on Case Illustration 3

Asdomanycollegecounselingclients,thisstudentpresentedatthepointofanalcohol-relatedemergency.Rossetal.(1992)reportedthatoutof100adultsexperiencingchemicaldependencyproblems,39%werealsoexperiencingadiagnosabledissociativedisorder(including14%withDID).Therefore,werecommendthatcollegecounselingprofessionalsroutinelyasksomequestionspertaining to dissociative symptoms when conducting intake or screeninginterviewswithstudentswhohaveproblemsstemmingfromsubstanceabuse.Inthiscase illustration,theclientreadilysharedherdissociativesymptomswhenaskedspecificquestionsaboutdissociationintheinitialinterview.Thefollow-upSCID-D-RconfirmedthediagnosisofDID.TheinformationfromtheSCID-D-Rhelpedtoinformherpsychotherapybyillustratingspecificallyhowsheexperiencedherdissociativesymptoms.Overthecourseofcounsel-ing,shebegantounderstandthatonealter-identityurgedhertopartyandtoengageinsexualbehavior,whereastheotheralter-identityurgedhertostay home and do schoolwork. Increasing the student’s understanding ofher different identity states permitted the counselor to help enhance thecomfort,communication,cooperation,andconnectionbetweenherdiffer-ent elements of self (Steinberg & Schnall, 2001). Addressing the client’sdissociativesymptomsallowedhertofeelmoreincontrolofherlifeandtofeellessofaneedtousealcoholasacopingstrategy.Thiscaseillustrationunderscorestheneedtoassessfordissociationwheneverastudentpresentswithaproblemofsubstanceabuse.

Discussion

These three cases illustrate some of the common presentations of collegestudents who are experiencing dissociative disorders. Specifically, collegecounselingclientsdealingwithadissociativedisorderofteninitiallypresentasiftheyaremanagingananxietydisorder(Client1),amoodand/orpsy-choticdisorder(Client2),orasubstanceabusedisorder(Client3).Notably,althoughitwasultimatelydeterminedthateachofthesestudentswasexpe-riencingadiagnosabledissociativedisorder,noneoftheminitiallydiscussedtheirdisruptivedissociativesymptoms.

Ourexperienceswiththese3clientsillustratewhysymptomsofdissociationhavebeendescribedas“hiddenphenomena”(Loewenstein,1991,p.568).Itcanbeespeciallychallengingforcounselorstoidentifyconcernsrelatedtodissociationamongtheirclientsbecauseitssymptomsoftenare“clandestineandcovert”(Kluft,1991,p.605),andmostpeopleexperiencingDIDdonotpresentforintakeswithobvioussignsoftheproblem.Infact,often,itrequiresseveralmonthsormoreofcontactbeforeaclientexperiencingDIDisabletobegindiscussingtheseproblematicexperienceswithhisorhercounselor(Putnam,1989).Reasonsforsuchagradualemergenceofthetopicduringthecounselingrelationshipincludememorylossthatpreventstherecallofdissociativesymptoms;fearofbeingconsidered“crazy”andsoomittingthose

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dissociativesymptomsthatareremembered;theideathatbecausesomedis-sociativesymptomsarechronictheyarenotthoughttobeunusual;andtheattributionofdissociativesymptomstoothercauses,suchasdrugs,alcohol,ormedicalproblems (Putnam,1989).Anadditional challenge to accurateassessmentofthisdisorderisthat“differencesmaybequitesubtlebetweensymptomsproducedbyadissociativeprocessandsimilaronesgeneratedbyotherdisorders”(Loewenstein,1991,p.568).Steinberg(1995)reportedthatclientsdealingwithdissociativedisordersmay“mimic”(p.14)aspectrumofmentalhealthproblems,includinganxiety,mood,psychotic,substanceabuse,eating,andcharacterdisorders.Thesethreecaseillustrationsprovideexamplesof thismimicking in the college context.Webelieve that just as cliniciansare trained to listen for suicidal concerns and for psychosis in the clinicalinterviewandmentalstatusexamination,itisequallyimportanttolistenforindicationsofdissociation(Loewenstein,1991).ThemoreacounselorusestheDES,theDDIS,andtheSCID-D-R,themorefamiliarheorshebecomeswithrecognizingdissociativesymptomsinthecourseofaroutineinterviewandaskingquestionsconcerningdissociationinamentalstatusexamination.Then,ifDIDisindicated,administeringtheDDISandtheSCID-D-Rcanhelpconfirmadiagnosisofadissociativedisorder.

Regardingtreatment,oncetheclient’ssymptomsareaccuratelydiagnosedandconfirmedwiththeindividual,counselingforDIDusuallyisstageorientedbecauseitoftenemergeswithothertrauma-relatedclientconcerns(Courtois,2004).Counselorsbeginbyestablishinganenvironmentofsafetyinthecol-laborativecounselingrelationship,providingsupport,andhelpingstrengthenthestudents’readinessandinternalresourcesforconfrontingtheproblem.Subsequentstagesof interventionincludehistorygatheringandpaintingaclearpictureoftheclient’sproblematicexperiences;addressingandresolv-ingtraumaticaspectsoftheclient’spastorpresentlife;movingtowardandaccomplishingintegrationandresolution;helpingtheclientlearnnewcop-ingskills;and,finally,assistingthepersontosolidifythegainsheorshehasmadeandarrangingforappropriatefollow-up(Kluft,1999).Counselingalsoincludesrecognizinganddealingwiththestudents’differentalter-identities(Courtois,2004).TurkusandKahler(2006)summarizedeffectivetherapeuticinterventionsthatmaybepotentiallyhelpfulintreatmentofDIDasincludingpsychoeducation,pacingandcontainment,grounding skills, talking to thepersonalitysystemasawhole,facilitatinginternalmeetingsofthedifferentself-states,anticipatingandaddressingtraumaticreenactment,safetyplanning,helpingclientsfinda“healingplace,”keepingajournal,andusingartworkasameansofself-expression.TurkusandKahlerdescribedahealingplaceasawaytohelpaclienttotapintohisorherinternalstrengthsandresourcesbyusingimagerythatisconsistentwiththeclient’spositivebeliefs.

CollegeCounselingLimitationsandDID

In this article, we have emphasized the need for college counselors to becognizantof the signsofDIDandDDNOS, as they arepresented in the

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DSM-IV-TR(APA,2000),whenmeetingwithclientsforintakeinterviews,walk-ins,otherscreeningmeetings,crisisresponses,andongoingcounseling.Wesuggestedusingwrittenmeasures(suchastheDES)andclinicalinterviewprotocols(suchastheDDISandtheSCID-D-R)astools fordeterminingwhethersomestudentclientsmightbeexperiencingdissociationsymptomsandevenadissociativedisorderalongwiththeirmorecommonpresentationsofanxiety,mood,andpsychoticsymptoms,aswellassubstanceuseconcerns.Cowan and Morewitz (1995) found that when college health center staffweregivenamentalhealthchecklisttouseasatoolforidentifyingcounsel-ingissuesamongtheirclients,theyweremuchmorelikelytoidentifytheirstudents’mentalhealthandwellnessneedsandmakeappropriateinterven-tionsorreferrals.Likewise,wethinkthatifcollegecounselorsbecomemoreawareofDIDandconsiderusingscreeninganddiagnostictoolsrelatedtothedisorder,theywillbemorelikelytoidentifysituationsinwhichstudentsmightbedealingwiththiscomplexmentalhealthproblem.

Wealsorecognizethatthereareseverallimitationsregardingassessmentandtreatmentofdissociativedisordersincollegecounselingcentersanduniversitymentalhealthcenters.First,counselingcenterresourcesvarywidelyamong2-yearcolleges,smallercollegecampuses,andlargeruniversities(Thomas,2000).Whereaswehaveamultidisciplinarystaffincludingpsychiatristsandcounselingandpsychotherapyprofessionals,aswellaseasyaccesstoinpatienthospitaliza-tion,othersitessuchassmall-staffcollegecounselingcentersoftendonothaveasmanytreatmentandreferraloptions.Second,workload,caseload,andresourcedemandscandelimittheenergyandfocusneededtoaddressmorecomplexanddemandingproblemssuchasDID.Becausecounselingcentersprimarilyworkto support their institution’s academicmission (AmericanCollegePersonnelAssociation,1996),counselingcenterdirectorsandstaffmustoftenmakeharddecisions aboutwhat services tooffer, includingwhere toplace thegreateststafffocus.Inparticular,aftertheassessmentphase,treatmentforDIDcanbeamultiyearcommitment(Putnam,1989),whichisbeyondtheresourcesoftypicalcounselingcenters.Third,dependingontheirprofessionaleducation,training,andlevelofclinicalexperience,somecollegecounselingprofessionalsmaybebetterpreparedthanotherstoaddressdissociationexperiencesintheirclients.Naturally,ethicalguidelinesprohibitcliniciansfrompracticingoutsidetheircompetencies.In2005,theInternationalSocietyfortheStudyofDissociation(subsequentlynamedtheInternationalSocietyfortheStudyofTraumaandDissociation)es-tablishedguidelinesfortreatingDIDinadults.Theseguidelinesareavailableatthesociety’sWebsite(www.isst-d.org).Fourth,thereisongoingdebateinsomeprofessionalsettingsabouttheuseandpotentialmisuseoroveruseofDSM-IV-TR(APA,2000)diagnosticcriteria(Lopezetal.,2006).OurapproachexplicitlyreliesonDSM-IV-TRdiagnoses.Alloftheseissuesmaylimitapplicationofoursuggestionsbyspecificprofessionalsoronspecificcampuses.Atthesametime,webelievethatcollegecounselingprofessionalsareinagoodpositiontomakeanearlydiagnosisamongstudentsexperiencingDID,helpstabilizeanyemergencypresentations,andtheneitherengageincounselingwithappropriateconsultationorhelpstudentsfollowthroughonagoodreferral.

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