Das entfremdete Selbst, die entfremdete Umwelt

ZUSAMMENFASSUNG

Obwohl Dissoziation einer der ältesten Forschungsgegenstände der Psychiatrie darstellt, bleibt sie bis heute ein vage definiertes und mannigfaltiges Konstrukt. Ausgeprägte dissoziative Symptome sind für eine Subgruppe von Patienten mit Borderline-Persönlichkeitsstörung (BPS) und posttraumatischer Belastungsstörung (PTBS) charakteristisch und von hoher klinischer Relevanz mit Prävalenzen von 19–34 % bei BPS und bis zu 60 % bei PTBS. Insbesondere Veränderungen der psychischen Integrität mit einer Entfremdung von Selbst und Umwelt (Derealisation/Depersonalisation) gehen mit einer ausgeprägteren BPS- und PTBS-Symptomatik sowie riskanten Verhaltensweisen wie Selbstverletzung und Suizidalität einher. Dissoziative Symptome können nach dem aktuellen Kenntnisstand als eine unwillkürliche und automatische maladaptive Form der Emotionsregulation eingestuft werden, bei welcher subjektiv eine Distanz zu internalen oder externalen bedrohlichen Ereignissen hergestellt wird, die aber objektiv mit einer erhöhten Stressreaktion und autonomer Erregung aufzutreten scheint. Insbesondere bei der BPS wirken sich dissoziative Symptome negativ auf das Behandlungsergebnis aus, während die konkrete Adressierung von Dissoziationen beispielsweise durch Psychoedukation, Achtsamkeit oder Fertigkeitentraining Therapieerfolge verbessert.

ABSTRACT

Although dissociations are one of the oldest subjects of research in psychiatry, they remain a vaguely defined and multifaceted construct. Pronounced dissociative symptoms a hallmark of a subgroup of patients with borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) with rates of 19–34 % in BPD and up to 60 % in PTSD. Dissociations are of high clinical relevance as they manifest with diverse adverse health consequences. In particular, changes in the psychological integrity with alienation from self and environment (derealization/depersonalization) are associated with more pronounced BPD and PTSD symptomatology, as well as risky behaviors such as self-harm and suicidality. Derealization/depersonalization can be classified, according to current knowledge, as an involuntary and automatic maladaptive form of emotion regulation by which a distance from internal or external threatening events is established, but seems to be accompanied by an increased stress response and autonomic arousal. In patients with BPD, dissociative symptoms predict lower treatment success while addressing dissociative symptoms directly in therapy by psychoeducation, teaching mindfulness and other skills improves the results.

Schlüsselwörter

Dissoziationen - Derealisation - Depersonalisation - Borderline-Persönlichkeitsstörung - posttraumatische Belastungsstörung

Key words

Dissociation - derealisation - depersonalisation - borderline personality disorder - post-traumatic stress disorder

Publication History

Article published online:
03 March 2023

• Literatur

• 1 Online-Wörterbuch Wortbedeutung.info. Dissoziation. 2022; Im Internet https://www.wortbedeutung.info/Dissoziation/
• 2 Bailey TD, Brand BL. Traumatic dissociation: Theory, research, and treatment. Clin Psychol Sci Pract 2017; 24: 170-185 DOI: 10.1111/cpsp.12195.
• 3 Nijenhuis ER, Van der Hart O. Dissociation in trauma: A new definition and comparison with previous formulations. J Trauma Dissociation 2011; 12: 416-445
• 4 Spiegel D, Loewenstein RJ, Lewis-Fernández R. et al Dissociative disorders in DSM-5. Depress Anxiety 2011; 28: E17-E45
• 5 Waller N, Putnam FW, Carlson EB. Types of dissociation and dissociative types: A taxometric analysis of dissociative experiences. Psychol Methods 1996; 01: 300
• 6 Spitzer C, Freyberger H, Brähler E. et al Teststatistische Überprüfung der Dissociative Experiences Scale-Taxon (DES-T). PPmP 2015; 65: 134-139 DOI: 10.1055/s-0034-1395690.
• 7 Krause-Utz A. Dissociation, trauma, and borderline personality disorder. Berlin: Springer; 2022
• 8 Putnam FW. Pierre Janet and modern views of dissociation. J Trauma Stress 1989; 02: 413-429
• 9 Krause-Utz A, Frost R, Winter D. et al Dissociation and Alterations in Brain Function and Structure: Implications for Borderline Personality Disorder. Curr Psychiatry Rep 2017; 19: 6 DOI: 10.1007/s11920-017-0757-y.
• 10 Butler C, Dorahy MJ, Middleton W. The Detachment and Compartmentalization Inventory (DCI): An assessment tool for two potentially distinct forms of dissociation. J Trauma Dissociation 2019; 20: 526-547 DOI: 10.1080/15299732.2019.1597809.
• 11 Holmes E, Brown R, Mansell W. et al Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clin Psychol Rev 2005; 25: 1-23 DOI: 10.1016/j.cpr.2004.08.006.
• 12 World Health Organization International statistical classification of diseases and related health problems. 10th ed. New York: WHO; 2016
• 13 World Health Organization International statistical classification of diseases and related health problems. 11th ed. New York: WHO; 2022
• 14 Priebe K, Schmahl C, Stiglmayr C. Dissoziation. Berlin: Springer; 2013
• 15 Spitzer C, Freyberger HJ. Dissoziative Störungen (Konversionsstörungen). Psychotherapeut 2007; 52: 223-235 DOI: 10.1007/s00278-007-0544-z.
• 16 Lyssenko L, Schmahl C, Bockhacker L. et al Dissociation in Psychiatric Disorders: A Meta-Analysis of Studies Using the Dissociative Experiences Scale. Am J Psychiatry 2018; 175: 37-46 DOI: 10.1176/appi.ajp.2017.17010025.
• 17 Lanius RA, Vermetten E, Loewenstein RJ. et al Emotion Modulation in PTSD: Clinical and Neurobiological Evidence for a Dissociative Subtype. Am J Psychiatry 2010; 167: 640-647 DOI: 10.1176/appi.ajp.2009.09081168.
• 18 van Huijstee J, Vermetten E. The Dissociative Subtype of Post-traumatic Stress Disorder: Research Update on Clinical and Neurobiological Features. In: Vermetten E, Baker DG, Risbrough VB (Hrsg.) Behavioral Neurobiology of PTSD. Cham: Springer International Publishing 2017: 229-248
• 19 Krause-Utz A, Elzinga B. Current Understanding of the Neural Mechanisms of Dissociation in Borderline Personality Disorder. Curr Behav Neurosci Rep 2018; 05: 113-123 DOI: 10.1007/s40473-018-0146-9.
• 20 Schauer M, Elbert T. Dissociation Following Traumatic Stress: Etiology and Treatment. Z Für Psychol J Psychol 2010; 218: 109-127 DOI: 10.1027/0044-3409/a000018.
• 21 Krause-Utz A, Frost R, Chatzaki E. et al Dissociation in Borderline Personality Disorder: Recent Experimental, Neurobiological Studies, and Implications for Future Research and Treatment. Curr Psychiatry Rep 2021; 23: 37 DOI: 10.1007/s11920-021-01246-8.
• 22 Shin GI, Goldstein LH, Pick S. Evidence for subjective emotional numbing following induced acute dissociation. Behav Res Ther 2019; 119: 103407 DOI: 10.1016/j.brat.2019.05.004.
• 23 Spitzer M. Dissoziation bei Mensch und Maus. Nervenheilkunde 2020; 39: 847-854
• 24 Kiefer M. Bewusstsein. In: Allgemeine Psychologie. Berlin: Springer; 2017: 153-182
• 25 Broome MR, Bottlender R, Rösler M. et al The AMDP System: Manual for Assessment and Documentation of Psychopathology in Psychiatry. Göttingen: Hogrefe; 2018
• 26 Heekerens J, Renneberg B, Schulze L. et al Arousal Temporally Precedes Dissociation in Patients with Borderline Personality Disorder: An Experience Sampling Approach. 2022
• 27 Steinberg M. Interviewer’s guide to the structured clinical interview for DSM-IV dissociative disorders (SCID-D). Washington: American Psychiatric Pub; 1994
• 28 Gast U, Zündorf F, Hofmann A. Strukturiertes klinisches interview für DSM-IV-dissoziative Störungen (SKID-D): Manual. Göttingen: Hogrefe; 2000
• 29 Bernstein EM, Putnam FW.. Development, Reliability, and Validity of a Dissociation Scale:. J Nerv Ment Dis 1986; 174: 727-735 DOI: 10.1097/00005053-198612000-00004.
• 30 Spitzer C, Göbel P, Wilfer T. et al Pathologische Dissoziation bei Patienten mit einer Borderline-Persönlichkeitsstörung: Häufigkeit, klinische Korrelate und prädiktive Bedeutung für den Therapieerfolg. Psychotherapeut 2021; 66: 299-305 DOI: 10.1007/s00278-021-00512-7.
• 31 Stiglmayr C, Schimke P, Wagner T. et al Development and psychometric characteristics of the dissociation tension scale. J Pers Assess 2010; 92: 269-277
• 32 Dell PF. The Multidimensional Inventory of Dissociation (MID): A comprehensive measure of pathological dissociation. J Trauma Dissociation 2006; 07: 77-106
• 33 Gast U, Rodewald F, Dehner-Rau C. et al Validation of the German version of the Multidimensional Inventory of Dissociation (MID-d). In: Annual meeting of the International Society for the Study of Dissociation Vol, Chicago, IL. 2003
• 34 Blake DD, Weathers FW, Nagy LM. et al The development of a clinician-administered PTSD scale. J Trauma Stress 1995; 08: 75-90
• 35 Schnyder U, Moergeli H. German version of clinician-administered PTSD scale. J Trauma Stress Off Publ Int Soc Trauma Stress Stud 2002; 15: 487-492
• 36 Spitzer C, Stieglitz R-D, Freyberger HJ. Der Fragebogen zu dissoziativen Symptomen (FDS). Bern: Huber 2015
• 37 Stiglmayr CE, Braakmann D, Haaf B. et al Entwicklung und psychometrische Charakteristika der Dissoziations-Spannungs-Skala akut (DSS-akut). PPmP-Psychother Psychosom Med Psychol 2003; 53: 287-294
• 38 Price CJ, Thompson EA. Measuring Dimensions of Body Connection: Body Awareness and Bodily Dissociation. J Altern Complement Med 2007; 13: 945-953 DOI: 10.1089/acm.2007.0537.
• 39 Yang J, Millman LSM, David AS. et al The Prevalence of Depersonalization-Derealization Disorder: A Systematic Review. J Trauma Dissociation 2022: 1-34 DOI: 10.1080/15299732.2022.2079796
• 40 Scalabrini A, Cavicchioli M, Fossati A. et al The extent of dissociation in borderline personality disorder: A meta-analytic review. J Trauma Dissociation 2017; 18: 522-543 DOI: 10.1080/15299732.2016.1240738.
• 41 Hansen M, Ross J, Armour C. Evidence of the dissociative PTSD subtype: A systematic literature review of latent class and profile analytic studies of PTSD. J Affect Disord 2017; 213: 59-69 DOI: 10.1016/j.jad.2017.02.004.
• 42 Stein DJ, Koenen KC, Friedman MJ. et al Dissociation in Posttraumatic Stress Disorder: Evidence from the World Mental Health Surveys. Biol Psychiatry 2013; 73: 302-312 DOI: 10.1016/j.biopsych.2012.08.022.
• 43 Swart S, Wildschut M, Draijer N. et al Dissociative subtype of posttraumatic stress disorder or PTSD with comorbid dissociative disorders: Comparative evaluation of clinical profiles. Psychol Trauma Theory Res Pract Policy 2020; 12: 38-45 DOI: 10.1037/tra0000474.
• 44 Korzekwa MI, Dell PF, Pain C. Dissociation and borderline personality disorder: an update for clinicians. Curr Psychiatry Rep 2009; 11: 82-88
• 45 Sommer JL, Blaney C, Mota N. et al Dissociation as a Transdiagnostic Indicator of Self-Injurious Behavior and Suicide Attempts: A Focus on Posttraumatic Stress Disorder and Borderline Personality Disorder. J Trauma Stress 2021; 34: 1149-1158 DOI: 10.1002/jts.22726.
• 46 Korzekwa MI, Dell PF, Links PS. et al Dissociation in Borderline Personality Disorder: A Detailed Look. J Trauma Dissociation 2009; 10: 346-367 DOI: 10.1080/15299730902956838.
• 47 Haaland V, Landrø NI.. Pathological dissociation and neuropsychological functioning in borderline personality disorder. Acta Psychiatr Scand 2009; 119: 383-392
• 48 Zanarini MC, Jager-Hyman S.. Dissociation in borderline personality disorder. In: Dell P, O’Neil J (eds.),. New York: Routledge/Taylor & Francis Group; 2009
• 49 Waelde LC, Silvern L, Fairbank JA. A taxometric investigation of dissociation in Vietnam veterans. J Trauma Stress 2005; 18: 359-369 DOI: 10.1002/jts.20034.
• 50 Wolf EJ, Miller MW, Reardon AF. et al A Latent Class Analysis of Dissociation and Posttraumatic Stress Disorder: Evidence for a Dissociative Subtype. Arch Gen Psychiatry 2012: 69 DOI: 10.1001/archgenpsychiatry.2011.1574
• 51 Deen A, Biedermann SV, Lotzin A. et al The dissociative subtype of PTSD in trauma-exposed individuals: a latent class analysis and examination of clinical covariates. Eur J Psychotraumatology 2022; 13: 2031591 DOI: 10.1080/20008198.2022.2031591.
• 52 Kim D, Kim D, Lee H. et al Prevalence and clinical correlates of dissociative subtype of posttraumatic stress disorder at an outpatient trauma clinic in South Korea. Eur J Psychotraumatology 2019; 10: 1657372 DOI: 10.1080/20008198.2019.1657372.
• 53 Dalenberg CJ, Brand BL, Gleaves DH. et al Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychol Bull 2012; 138: 550-588 DOI: 10.1037/a0027447.
• 54 Giesbrecht T, Lynn SJ, Lilienfeld SO. et al Cognitive processes in dissociation: An analysis of core theoretical assumptions. Psychol Bull 2008; 134: 617-647 DOI: 10.1037/0033-2909.134.5.617.
• 55 Aksen DE, Polizzi C, Lynn SJ. Correlates and mediators of dissociation: towards a transtheoretical perspective. Imagin Cogn Personal 2021; 40: 372-392
• 56 Lynn SJ, Maxwell R, Merckelbach H. et al Dissociation and its disorders: Competing models, future directions, and a way forward. Clin Psychol Rev 2019; 73: 101755 DOI: 10.1016/j.cpr.2019.101755.
• 57 Vonderlin R, Kleindienst N, Alpers GW. et al Dissociation in victims of childhood abuse or neglect: A meta-analytic review. Psychol Med 2018; 48: 2467-2476
• 58 Tschoeke S, Bichescu-Burian D, Steinert T. et al History of Childhood Trauma and Association With Borderline and Dissociative Features. J Nerv Ment Dis 2021; 209: 137-143 DOI: 10.1097/NMD.0000000000001270.
• 59 Lensvelt-Mulders G, van der Hart O, van Ochten JM. et al Relations among peritraumatic dissociation and posttraumatic stress: A meta-analysis. Clin Psychol Rev 2008; 28: 1138-1151 DOI: 10.1016/j.cpr.2008.03.006.
• 60 Wagner-Skacel J, Riedl D, Kampling H. et al Mentalization and dissociation after adverse childhood experiences. Sci Rep 2022; 12: 6809 DOI: 10.1038/s41598-022-10787-8.
• 61 Lanius RA, Brand B, Vermetten E. et al The dissociative subtype of posttraumatic stress disorder: Rationale, clinical and neurobiological evidence, and implications. Depress Anxiety 2012; 29: 701-708
• 62 Schmitz M, Bertsch K, Löffler A. et al Body connection mediates the relationship between traumatic childhood experiences and impaired emotion regulation in borderline personality disorder. Borderline Personal Disord Emot Dysregulation 2021; 08: 17 DOI: 10.1186/s40479-021-00157-7.
• 63 Kleindienst N, Limberger MF, Ebner-Priemer UW. et al Dissociation predicts poor response to dialectial behavioral therapy in female patients with borderline personality disorder. J Personal Disord 2011; 25: 432
• 64 Kleindienst N, Priebe K, Görg N. et al State dissociation moderates response to dialectical behavior therapy for posttraumatic stress disorder in women with and without borderline personality disorder. Eur J Psychotraumatology 2016; 07: 30375 DOI: 10.3402/ejpt.v7.30375.
• 65 Shah R, Temes CM, Frankenburg FR. et al Levels of Depersonalization and Derealization Reported by Recovered and Non-recovered Borderline Patients Over 20 Years of Prospective Follow-up. J Trauma Dissociation 2020; 21: 337-348 DOI: 10.1080/15299732.2020.1719259.
• 66 Paret C, Hoesterey S, Kleindienst N. et al Associations of emotional arousal, dissociation and symptom severity with operant conditioning in borderline personality disorder. Psychiatry Res 2016; 244: 194-201
• 67 Hoeboer CM, De Kleine RA, Molendijk ML. et al Impact of dissociation on the effectiveness of psychotherapy for post-traumatic stress disorder: meta-analysis. BJPsych Open 2020; 06: e53 DOI: 10.1192/bjo.2020.30.
• 68 Wedig MM, Silverman MH, Frankenburg FR. et al Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up. Psychol Med 2012; 42: 2395-2404 DOI: 10.1017/S0033291712000517.
• 69 Zanarini MC, Laudate CS, Frankenburg FR. et al Predictors of self-mutilation in patients with borderline personality disorder: A 10-year follow-up study. J Psychiatr Res 2011; 45: 823-828
• 70 Ludäscher P, Bohus M, Lieb K. et al Elevated pain thresholds correlate with dissociation and aversive arousal in patients with borderline personality disorder. Psychiatry Res 2007; 149: 291-296 DOI: 10.1016/j.psychres.2005.04.009.
• 71 Chung BY, Hensel S, Schmidinger I. et al Dissociation proneness and pain hyposensitivity in current and remitted borderline personality disorder. Eur J Pain 2020; 24: 1257-1268 DOI: 10.1002/ejp.1567.
• 72 Stiglmayr CE, Shapiro DA, Stieglitz RD. et al Experience of aversive tension and dissociation in female patients with borderline personality disorder — a controlled study. J Psychiatr Res 2001; 35: 111-118 DOI: 10.1016/S0022-3956(01)00012-7.
• 73 Stiglmayr CE, Ebner-Priemer UW, Bretz J. et al Dissociative symptoms are positively related to stress in borderline personality disorder. Acta Psychiatr Scand 2008; 117: 139-147
• 74 Cavicchioli M, Scalabrini A, Northoff G. et al Dissociation and emotion regulation strategies: A meta-analytic review. J Psychiatr Res 2021; 143: 370-387
• 75 Vermetten E, Spiegel D. Trauma and Dissociation: Implications for Borderline Personality Disorder. Curr Psychiatry Rep 2014; 16: 434 DOI: 10.1007/s11920-013-0434-8.
• 76 Dorahy MJ, Corry M, Shannon M. et al Complex trauma and intimate relationships: The impact of shame, guilt and dissociation. J Affect Disord 2013; 147: 72-79
• 77 Zerubavel N, Messman-Moore TL. Staying present: Incorporating mindfulness into therapy for dissociation. Mindfulness 2015; 06: 303-314
• 78 Storebø OJ, Stoffers-Winterling JM, Völlm BA. et al Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2020: 2020 DOI: 10.1002/14651858.CD012955.pub2
• 79 Flynn D, Kells M, Joyce M. Dialectical behaviour therapy: Implementation of an evidence-based intervention for borderline personality disorder in public health systems. Curr Opin Psychol 2021; 37: 152-157 DOI: 10.1016/j.copsyc.2021.01.002.
• 80 Bohus M, Haaf B, Simms T. et al Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behav Res Ther 2004; 42: 487-499
• 81 Granato HF, Wilks CR, Miga EM. et al The Use of Dialectical Behavior Therapy and Prolonged Exposure to Treat Comorbid Dissociation and Self-Harm: The Case of a Client With Borderline Personality Disorder and Posttraumatic Stress Disorder: Integrating DBT and PE. J Clin Psychol 2015; 71: 805-815 DOI: 10.1002/jclp.22207.
• 82 Bohus M, Kleindienst N, Hahn C. et al Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD) Compared With Cognitive Processing Therapy (CPT) in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial. JAMA Psychiatry 2020; 77: 1235 DOI: 10.1001/jamapsychiatry.2020.2148.
• 83 Harned MS, Korslund KE, Linehan MM. A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behav Res Ther 2014; 55: 7-17 DOI: 10.1016/j.brat.2014.01.008.
• 84 Resick PA, Suvak MK, Johnides BD. et al The Impact of dissiciation on ptsd treatment with cognitive processing therapy: Research Article: Impact of Dissociation on PTSD Treatment. Depress Anxiety 2012; 29: 718-730 DOI: 10.1002/da.21938.
• 85 Dutra SJ, Wolf EJ. Perspectives on the conceptualization of the dissociative subtype of PTSD and implications for treatment. Curr Opin Psychol 2017; 14: 35-39 DOI: 10.1016/j.copsyc.2016.10.003.
• 86 Bae H, Kim D, Park YC. Dissociation predicts treatment response in eye-movement desensitization and reprocessing for posttraumatic stress disorder. J Trauma Dissociation 2016; 17: 112-130
• 87 Brand BL, Schielke HJ, Putnam KT. et al An Online Educational Program for Individuals With Dissociative Disorders and Their Clinicians: 1-Year and 2-Year Follow-Up: Online Intervention for Dissociative Disorders. J Trauma Stress 2019; 32: 156-166 DOI: 10.1002/jts.22370.
• 88 Sutar R, Sahu S. Pharmacotherapy for dissociative disorders: A systematic review. Psychiatry Res 2019; 281: 112529 DOI: 10.1016/j.psychres.2019.112529.
• 89 Burton MS, Feeny NC, Connell AM. et al Exploring evidence of a dissociative subtype in PTSD: Baseline symptom structure, etiology, and treatment efficacy for those who dissociate. J Consult Clin Psychol 2018; 86: 439
• 90 Ripoll LH. Psychopharmacologic treatment of borderline personality disorder. Dialogues Clin Neurosci 2013; 15: 213-224 DOI: 10.31887/DCNS.2013.15.2/lripoll.
• 91 Lanius RA, Boyd JE, McKinnon MC. et al A Review of the Neurobiological Basis of Trauma-Related Dissociation and Its Relation to Cannabinoid- and Opioid-Mediated Stress Response: a Transdiagnostic, Translational Approach. Curr Psychiatry Rep 2018; 20: 118 DOI: 10.1007/s11920-018-0983-y.
• 92 Schmahl C, Kleindienst N, Limberger M. et al Evaluation of naltrexone for dissociative symptoms in borderline personality disorder. Int Clin Psychopharmacol 2012; 27: 61-68