Trauma & Dissociation in the DSM5: Where Do They Fit?

Spiegel, D. (2010).  Dissociation in the DSM5.  Journal of Trauma & Dissociation, 11, 261-265.

In David Spiegel’s most recent Editorial in the Journal of Trauma & Dissociation, he discusses some of the possible changes for dissociative disorders in the upcoming DSM5.  Speigel describes the tenuous position of dissociative disorders in our current nosology and suggests that this is because

They are right at the border of could and would, losses of control over cognitive functions such as memory, identity, and consciousness, that we take pride in managing. They both result in severe mental dysfunction and yet seem transient (at least in overt presentation) and controllable. They force us to reexamine our assumptions about the solidity of identity and the consistency of our control over our minds and bodies. And, even worse, they often result from trauma, frequently severe and repeated sexual and physical abuse early in life, leading to moral judgments and concern about the accuracy of trauma reports. Thus, dissociative disorders are contentious and have been poorly integrated into our diagnostic systems. (p. 262).

The Anxiety, Obsessive–Compulsive Spectrum, Traumatic, and Dissociative Disorders Work Group is currently considering including dissociative and traumatic stress disorders along a stress and trauma spectrum.  Spiegel notes that this would represent a rather significant ideological shift away from the DSM-IV anti-theoretical stance that avoids speculation about causality.  However, trauma-related anxiety disorders have always included an implicit assumption that they are caused by the stress or trauma that incites the symptoms.

So where’s the rub?  Dissociative disorders have never required exposure to a traumatic event in order to diagnose, although most clinicians and researchers agree that dissociative disorders are most commonly a response to severe and/or chronic trauma (Putnam, 1997; Spiegel & Cardena, 1991).  Do disorders of traumatic stress (resulting directly from exposure to a traumatic event) belong on the same spectrum as dissociative disorders (often, thought not exclusively, a result of exposure to a traumatic event)?  The DSM5 taskforce is in the process of designing field trials for new diagnostic criteria, and updates can be found here.

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