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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 100-104

Individuals having cerebral palsy with tertiary structural dissociation: A preliminary report


Department of Applied Social Sciences, City University of Hong Kong, Hong Kong

Date of Web Publication12-Apr-2017

Correspondence Address:
Hong Wang Fung
Department of Applied Social Sciences, City University of Hong Kong

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-4264.204406

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  Abstract 


Cerebral palsy (CP) is one of the most common childhood physical disabilities and often requires various treatments. The experience of living with CP and receiving early-life medical treatments could be psychologically traumatic and stressful. Previous studies found that psychological problems are not uncommon among individuals with cerebral palsy. However, the comorbidity of CP and tertiary structural dissociation of the personality (TSDP) is an unaddressed topic in the field and has just been brought into the literature recently. TSDP is the extreme form of posttraumatic psychopathology, and its typical clinical example is the DSM-5 dissociative identity disorder. This paper provides a preliminary report of four patients with comorbidity of cerebral palsy and TSDP. This complicated comorbidity might be a new challenge in the field and more attention to it is needed. Further investigations of this comorbidity are necessary. Some implications for research and practice are discussed.

Keywords: Cerebral palsy, dissociative identity disorder, psychological trauma, structural dissociation


How to cite this article:
Fung HW. Individuals having cerebral palsy with tertiary structural dissociation: A preliminary report. Indian J Cereb Palsy 2016;2:100-4

How to cite this URL:
Fung HW. Individuals having cerebral palsy with tertiary structural dissociation: A preliminary report. Indian J Cereb Palsy [serial online] 2016 [cited 2018 Dec 15];2:100-4. Available from: http://www.ijcpjournal.org/text.asp?2016/2/2/100/204406




  Introduction Top


Affecting about 2.11 individuals out of every 1000, cerebral palsy (CP) is one of the most common childhood physical disabilities [1] and is a neurodevelopmental disease that often requires early-life medical treatments such as orthopedic surgery and physiotherapy. The experience of living with CP and receiving the treatments might be psychologically traumatic and stressful to children. Previous studies found that psychological health problems are common among individuals with cerebral palsy.[2],[3],[4] This paper provides a report of four patients with comorbidity between cerebral palsy and tertiary structural dissociation of the personality (TSDP). TSDP is the extreme form of posttraumatic psychopathology, and the typical clinical condition of TSDP is the DSM-5 dissociative identity disorder (DID).[5] The comorbidity of CP and TSDP is an unaddressed topic in the field and has just been brought into the literature recently.[6] There are no existing data about the prevalence rate of this comorbidity nor about the complex relationship between CP and TSDP. This paper provides a brief report of four Chinese females with both cerebral palsy and DID and summarizes their clinical presentations, self-report and structured interview data, and trauma histories. Some considerations for those health-care professionals who work with individuals with cerebral palsy will be discussed. Implications for research and practice will be highlighted as well.


  Case Reports Top


Three self-report instruments and a structured interview were administered to four Hong Kong Chinese women with cerebral palsy who reported posttraumatic and dissociative symptoms. The instruments include the Dissociative Experiences Scale (DES),[7],[8],[9],[10] the Somatoform Dissociation Questionnaire (SDQ-20),[11] the Adverse Childhood Experiences (ACE) questionnaire,[12] and the Dissociative Disorders Interview Schedule (DDIS).[13] The DES and the SDQ-20 can be used to assess the level of dissociation. The DDIS is a diagnostic interview for a number of DSM-5 diagnoses including dissociative disorders, and it also inquiries about Schneiderian first-rank symptoms and secondary features of DID. Signed informed consent forms were collected.

Case report-1

An 18-year-old female who needed to walk with canes. As she reported, she first experienced psychological problems when she was 13 years old. Her previous psychiatric diagnoses as reported by her included early psychosis and depression. On the ACE questionnaire, she was positive for emotional abuse, physical abuse, emotional neglect, physical neglect, and five household dysfunction items. She scored 43.2 on the DES and 41 on the SDQ-20. On the DDIS, she met the diagnostic criteria for DID and a number of comorbid psychological conditions.

Case report-2

A 19-year-old female who needed to use a wheelchair. Initially, she developed psychological problems when she was about 8 years old. Her previous psychiatric diagnoses as reported by her included early psychosis and depression. On the ACE questionnaire, she was positive for emotional abuse, physical abuse, emotional neglect, and four household dysfunction items. She scored 54.3 on the DES and 37 on the SDQ-20. On the DDIS, she met the diagnostic criteria for DID and a number of comorbid conditions.

Case report-3

A 23-year-old female who needed to use a wheelchair. Initially, she developed psychological problems when she was 10 years old. Her previous psychiatric diagnoses as reported by her included early psychosis, depression, and anxiety disorder. On the ACE questionnaire, she was positive for sexual abuse and one household dysfunction item. She scored 37.9 on the DES and 37 on the SDQ-20. On the DDIS, she met the diagnostic criteria for DID and several comorbid conditions.

Case report-4

A 25-year-old female who needed to use a wheelchair. As reported by her, initially, she developed psychological problems when she was about 9 years old. She reported no previous psychiatric diagnosis. On the ACE questionnaire, she was positive for emotional abuse, physical abuse, emotional neglect, and three household dysfunction items. She scored 68.4 on the DES and 40 on the SDQ-20. On the DDIS, she met the diagnostic criteria for DID and several comorbid conditions.

All of the women had an early onset of psychological problems. They all met the diagnostic criteria for DID, dissociative amnesia, somatic symptom disorder, major depressive episode, and borderline personality disorder on the DDIS. In addition, since the cutoff score of the DES is suggested to be 30 and the cutoff score of the SDQ-20 is suggested to be 35; their DES and SDQ-20 scores were clearly above the average scores in the general population.[14],[15] They also reported a high frequency of experiencing the secondary features of DID, which were assessed by the DDIS. They clearly had many well-documented DID symptoms:[15],[16],[17] for example, on the DDIS, all of them reported voices talking inside their head, voices coming from inside, another person existing inside; 50% of them reported flashbacks as “fairly often” and 75% of them reported referring to self as “we” or “us.” They also had a number of ACEs. [Table 1] describes their pathological dissociation assessed by a subscale of the DES, the DES-Taxon.[9],[10] They obviously had many significant and frequent dissociative experiences that are regarded as pathological.
Table 1: Pathological dissociative experiences measured by the dissociative experiences scale-taxon (n=4)

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  Discussion Top


The background information, self-reported and structured interview data, and trauma histories of four Hong Kong Chinese females with both cerebral palsy and DID have been briefly reported. The psychopathological presentations of the four patients are consistent with the features of DID described in the literature.[17],[18],[19],[20] These patients demonstrate that the well-documented, classical DID of non-cerebral palsied individuals described in the literature also occurs among individuals with cerebral palsy. Instead of only one single case,[6] this report provides a report of four patients who are affected with both cerebral palsy and DID. [Table 2] shows that the clinical features (i.e., posttraumatic and dissociative symptoms) of cerebral palsied DID patients and of non-cerebral palsied DID patients could be similar.
Table 2: Features of dissociative identity disorder patients with and without cerebral palsy

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Despite the limitations of a small sample size and a lack of external information source other than from the patients themselves, this preliminary report aims to bring this complicated condition (i.e., the comorbidity) to the CP field and leads to more future investigations. In fact, many psychiatric studies also rely on self-report instruments and structured interviews, and the false-positive rate of using the DDIS to diagnose DID is only 1%.[15] In addition, individuals with DID are commonly having other psychiatric diagnoses for an average of 6.7–6.8 years before having a correct diagnosis of DID,[21],[22],[23] this explains why they may have been diagnosed with other mental disorders but not DID. Moreover, none of the patients had any obvious or severe thought disorder or expressed any delusions during the interviews, and their clinical features measured by the standardized trauma and dissociation instruments are consistent with the DID literature. Yet, due to the limitations of using self-report data in this report, future study and further investigation on the comorbidity of CP and DID are necessary.

The comorbidity of CP and DID reported here is a new observation in the literature.[6] Future studies should be undertaken to investigate the prevalence of dissociative disorders among individuals with CP, the complicated neurological relationships between brain disease and TSDP, and whether premature birth, early-life medical interventions, use of anesthesia in babyhood, hypoxia in the brain, and/or intensive medical treatments are risk factors for adult psychopathology, posttraumatic stress, and TSDP.

CP usually requires medical interventions, possibly including medications, therapy, intensive training, orthotics, and/or surgery. From a trauma psychology perspective, such early-life experiences could become medical trauma to some children. The occurrence of CP and related medical interventions may result in psychological trauma and chronic stress as well. A large literature has already highlighted the relationship between childhood trauma and adult psychopathology.[24] Forgey and Bursch [25] also found that children within the medical setting are usually exposed to traumatizing situations and about 25%–30% of medically ill children develop posttraumatic symptoms. Therefore, the author suggests that the awareness of medical trauma should be promoted in health service settings and the standard care for children with cerebral palsy should include the assessment of psychological well-being. Implications for clinical practice, derived from the literature, and the four patients reported here, are as follows:

For assessment:

  • Professionals in the health care and social service system (e.g., pediatrics, orthopedics, and rehabilitation service) should take trauma (including medical trauma, emotional neglect, and any kind of adverse experiences) seriously and should be familiar with posttraumatic psychopathology including dissociative symptoms
  • The standard care for children with brain diseases and/or disabilities, including cerebral palsy, should include regular psychological assessment and psychological support
  • Care should be taken to distinguish among psychotic symptoms, posttraumatic and dissociative symptoms, and symptoms due to the physical conditions. These conditions could overlap and interact with each other. The clinical presentation of such patients could be complicated and easily mistaken for other conditions
  • Care should be taken to distinguish between genuine physical impairments and somatoform dissociation.[26] Individuals with a comorbidity of CP and mental disorders could have both genuine physical impairments and psychologically induced somatic symptoms
  • Safety and care issues should be assessed carefully. Continuously abusive environments are very likely to worsen the condition. It is sometimes a challenging fact that the patient might have physical limitations to live independently or take care of herself/himself, and at the same time, the caretaker might be one of the stressors, triggers, perpetrators, and/or abusers
  • The social context and interpersonal condition of individuals having cerebral palsy should be assessed carefully. This includes the patient's past and current relationship with the abuser and/or perpetrator (if any), social support level, family background, and relationship with the caretaker, and so on.


For management:

  • Psychosocial interventions should address the problems of safety and care issues (if any). Safety is a common issue for trauma survivors
  • Just as in treating any traumatized individual, it is helpful to provide psychoeducation and trauma-informed practice
  • Careful and monitored use of intervention strategies for the physical conditions (e.g., medications, occupational therapy, physiotherapy, and surgical treatment) is specifically important. Individuals with cerebral palsy might need general medical interventions such as intensive physical exercises. However, these could be traumatic and stressful for them and might worsen their psychological symptoms. For instance, the intervention strategies for the physical impairments (e.g., intensive exercises) might increase the patient's stress levels, limit her/his social life, or even worsen the psychological symptoms. On the other hand, the side effects of psychiatric medications (e.g., increased weight) might also limit individuals' mobility
  • The interventions should be integrated, and practitioners need to assist individuals with cerebral palsy in a number of aspects of their lives (e.g., internal/intrapersonal, interpersonal, medical, financial, and educational/occupational), but specialized individual psychotherapy might also be needed for trauma survivors. For treatment of individuals with cerebral palsy with TSDP, practitioners should refer to the International Society for the Study of Trauma and Dissociation guidelines.[27]



  Conclusion Top


This paper provides a preliminary report of four patients with comorbidity of cerebral palsy and TSDP. The psychopathological features of cerebral palsied DID patients and of non-cerebral palsied DID patients seem to be similar. Since this complicated comorbidity might be a new challenge in the field as this comorbidity condition has not been recognized and reported before, further investigation of this complicated condition is necessary. In this paper, the author makes a preliminary attempt to discuss the required assessment and management when working with individuals who are affected with both cerebral palsy and TSDP. Some implications for future research are highlighted as well.

Acknowledgments

The author would like to thank Dr. Colin A. Ross, M.D., for his help and comments in this paper.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Oskoui M, Coutinho F, Dykeman J, Jetté N, Pringsheim T. An update on the prevalence of cerebral palsy: A systematic review and meta-analysis. Dev Med Child Neurol 2013;55:509-19.  Back to cited text no. 1
    
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Nijenhuis ER. The scoring and interpretation of the SDQ-20 and SDQ-5. ANS. J Neurocognitive Res 2010;52:24-8.  Back to cited text no. 14
    
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Ross CA. Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of Multiple Personality Disorder. New York: John Wiley and Sons; 1997.  Back to cited text no. 15
    
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Steinberg M, Schnall M. The Stranger in the Mirror: Dissociation. The Hidden Epidemic. New York: HarperCollins; 2000.  Back to cited text no. 17
    
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Dell PF. A new model of dissociative identity disorder. Psychiatr Clin North Am 2006;29:1-26, vii.  Back to cited text no. 18
    
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Kluft RP. A clinician's understanding of dissociation. In: Dell PF, O'Neil JA, editors. Dissociation and the dissociative disorders: DSM-V and beyond. New York: Routledge; 2009. p. 599-624.  Back to cited text no. 22
    
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Dell PF, O'Neil JA. Dissociation and the Dissociative Disorders: DSM-V and Beyond. New York: Routledge; 2009.  Back to cited text no. 24
    
25.
Forgey M, Bursch B. Assessment and management of pediatric iatrogenic medical trauma. Curr Psychiatry Rep 2013;15:340.  Back to cited text no. 25
    
26.
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    Tables

  [Table 1], [Table 2]



 

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