Assessing Patient with “Black Outs”

By Lynette McDonald, MSW

I am a trained but not yet certified EMDR therapist with two years experience.

Recently an intelligent,  personable, energetic woman in her early 70s was referred to me for assessment for EMDR treatment.  I diagnosed her with depression and PTSD. In recent years this otherwise articulate, functional woman has had episodes she calls  “black outs.”

Example: patient remembers going into the door of the church where her best friend’s wedding is about to be held.  She says she must have blacked out because she cannot remember a thing more until the next day when her best friend tells her she doesn’t “want to know someone like her,” refuses to say why, never speaks to her again.

Another example: She is ending a good first date with a man she likes.  The couple is leaving a restaurant to go to the parking lot.  She thinks he may kiss her, then “blacks out” and “awakens” 100 yds or so away, by her car,  “and he never wants to see me again either, won’t return my calls.”

First time this happened was when she was 11 years old and an older boy “tried to kiss” her.  She  remembers nothing but woke up on the ground.  The patient was an only child. Her mother had severe and persistent mental illness and was institutionalized when the patient was 11 yrs old.  Patient has only a handful of memories of her early years. These point to her mother  abusing her in unpredictable, bizarre ways. From 11 yrs on she lived with her father whom she idealized but he worked long hours, leaving her alone after school and evenings.  Relatives were  ashamed of her because they associated her with her mother. She was sent away to boarding school where she excelled at age 12. She says she studied meditation and achieved a profound peace. She completed DES assessment with some indications of dissociation.

Does this sound like a patient with DID? Or a person too likely to dissociate, for whom EMDR would not be appropriate?  I would appreciate feedback.

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About EMDR

The EMDR International Association (EMDRIA) is a professional association where EMDR practitioners and EMDR researchers seek the highest standards for the clinical use of EMDR. EMDR is an accepted psychotherapy by leading mental health organizations throughout the world for the treatment of a variety of symptoms and conditions. This website provides information to the greater EMDR community including clinicians, researchers, and the public that our members serve.

2 thoughts on “Assessing Patient with “Black Outs”

  1. Lynette,

    Thank for your posting to the EMDRIA blog and for your request for me to comment.

    Given that this woman reports incidents of “black outs” starting as early as age 11 and a reported history of unpredictable and bizarre frightening behaviors from her mother related to mental illness it is essential to provide further screening to clarify whether she meets criteria for a dissociative disorder.

    “In patients who meet criteria for a dissociative disorder, but whose diagnoses
    have gone unrecognized prior to EMDR treatment, the EMDR treatment has been reported to be capable of catalyzing rapid associative chaining that overcomes their amnestic barriers, and of flooding these patients with emotions, traumatic images, and body sensations that overwhelm their defenses (Paulsen, 1995). This is not only retraumatizing to these patients, but can also lead them to potentially dangerous loss of impulse control, acting out, and parasuicidal, suicidal, and aggressive behaviors. EMDR can be successfully incorporated into the treatment of patients with dissociative disorders (International Society for the Study of Dissociation, 2005); however, this should only be done by those with appropriate specialty training and supervised experience in both the use of EMDR and the treatment of dissociative disorders (Fine, et al., 1995; Lazrove & Fine, 1996; Paulsen, 1995) “(Leeds, 2009, p. 43).

    The basic elements of how to conduct a screening for a dissociative disorder is required content in all EMDRIA approved basic training in EMDR programs. While the DES is often recommended, it is insufficient to clarify the diagnosis. In addition to a mental status examination (Lowenstein, 1991), I recommend the use of the Multidimensional Inventory of Dissociation (MID) which is available from Paul F. Dell, Ph.D. The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R) is is widely accepted in forensic evaluations and is useful for treatment planning and differential diagnosis. It is commercially available. The Dissociative Disorders Interview Schedule (DDIS) is available from the Web site of the Ross Institute at: http://www.rossinst.com/dddquest.htm

    I would suggest that you clarify this patient’s diagnosis and decide whether you are ready to obtain the education, training and consultation you might need to be ready to provide her treatment.

    Further resources can be obtained at the web site for the ISSTD.

    ISST–D. Treatment Guidelines of the International Society for the Study of Trauma and Dissociation. Web site: http://www.isstd.org/education/treatmentguide
    lines-index.htm

    TheMultidimensional Inventory of Dissociation (MID), Paul F. Dell, Trauma Recovery Center, 1709 Colley Avenue, Ste. 312, Norfolk, VA 23517. Members of the International Society for the Study of Trauma and Dissociation can request it or can download it directly from the members’ area at: http://www.isst-d.org/

    The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R) is available at American Psychiatric Publishing Inc. (703) 907-7322, toll-free order telephone number (800) 368-5777, and on their Web site at: http://www.appi.org/set.cfm?id=8862

    Dell, P. F. (2006a). The multidimensional inventory of dissociation (MID): A comprehensive measure of pathological dissociation.
    Journal of Trauma and Dissociation, 7(2), 77–106.

    Leeds, A. M. (2009) A Guide to the Standard EMDR Protocols for Clinicians, Supervisors, and Consultants. New York: Springer Publishing Company.

    Loewenstein, R. J. (1991). An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder.
    Psychiatric Clinics of North America, 14(3), 567–604.

    Paulsen, S. (1995). Eye movement desensitization and reprocessing: Its cautious use in the dissociative disorders. Dissociation, 8(1), 32–44.

    Andrew M. Leeds, Ph.D.

  2. Re: Blackouts

    Have you probed this woman for possible alcohol abuse/dependence? Her story sounds very familiar to those of us who are in the recovering community or who have worked with recovering people.

    Paul Geiger

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