Where Are We Going? An Update on Assessment, Treatment, and Neurobiological Research in Dissociative Disorders as We Move Toward the DSM-5

Abstract

This article provides an overview of the process of developing the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association with a focus on issues related to the trauma-related disorders, particularly the dissociative disorders (DD). We also discuss the highlights of research within the past 5 years in the assessment, treatment, and neurobiological basis of trauma disorders. Recent research shows that DD are associated with severe symptoms as well as a higher rate of utilization of mental health treatment compared with other psychiatric disorders. As a result, DD, like other complex posttraumatic disorders, exact a high economic as well as personal burden for patients and society. The latest research indicates that DD patients show a suboptimal response to standard exposure-based treatments for posttraumatic stress disorder as well as high levels of attrition from treatment. An emerging body of research on DD treatment, primarily of naturalistic and open trials, indicates that patients who receive specialized treatment that addresses their trauma-based, dissociative symptoms show improved functioning and reduced symptoms. Recent studies of the underlying neurobiological basis for dissociation support a model of excessive limbic inhibition in DD that is consistent with the phenomenology and clinical presentation of these patients. We are optimistic that the forthcoming DSM-5 will stimulate research on dissociation and the DD and suggest areas for future studies.

Keywords:

• dissociative
• trauma
• DSM
• diagnosis
• assessment
• treatment

Acknowledgments

The coauthors of this paper are members of (D.S.) or advisors to (B.L.B., R.L., E.V.) the Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM-5) Anxiety, Obsessive-Compulsive Spectrum, Post-Traumatic, and Dissociative Disorders Work Group. This paper represents the authors' reports of considerations reviewed by the work group. Recommendations provided in this paper should be considered preliminary at this time; they do not necessarily reflect the final recommendations or decisions that will be made for the DSM-5, as the DSM-5 development process is still ongoing. It is possible that this paper's recommendations will be revised as additional data and input from experts and the field are obtained. In addition, the categorization of disorders discussed in this review needs to be harmonized with recommendations from other DSM-5 work groups and from the DSM-5 Task Force for the overall structure of the DSM-5.

Drs. Brand and Lanius contributed equally to this article.