Dissociative disorder

Dissociative disorders (DD) are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception. People with dissociative disorders use dissociation as a defense mechanism, pathologically and involuntarily. Some dissociative disorders are triggered by psychological trauma, but depersonalization/derealization disorder may be preceded only by stress, psychoactive substances, or no identifiable trigger at all.[1]

Dissociative disorder
SpecialtyPsychiatry, psychology 

The dissociative disorders listed in the American Psychiatric Association's DSM-5 are as follows:[2]

  • Dissociative identity disorder (formerly multiple personality disorder): the alternation of two or more distinct personality states with impaired recall among personality states. In extreme cases, the host personality is unaware of the other, alternating personalities; however, the alternate personalities can be aware of all the existing personalities.[3]
  • Dissociative amnesia (formerly psychogenic amnesia): the temporary loss of recall memory, specifically episodic memory, due to a traumatic or stressful event. It is considered the most common dissociative disorder amongst those documented. This disorder can occur abruptly or gradually and may last minutes to years depending on the severity of the trauma and the patient.[4][5]
  • Dissociative fugue (formerly psychogenic fugue) is now subsumed under the dissociative amnesia category. It is described as reversible amnesia for personal identity, usually involving unplanned travel or wandering, sometimes accompanied by the establishment of a new identity. This state is typically associated with stressful life circumstances and can be short or lengthy.[3]
  • Depersonalization disorder: periods of detachment from self or surrounding which may be experienced as "unreal" (lacking in control of or "outside" self) while retaining awareness that this is only a feeling and not a reality.
  • The old category of dissociative disorder not otherwise specified is now split into two: Other specified dissociative disorder, and unspecified dissociative disorder. These categories are used for forms of pathological dissociation that do not fully meet the criteria of the other specified dissociative disorders, or if the correct category has not been determined.

Both dissociative amnesia and dissociative fugue usually emerge in adulthood.[6] The ICD-10 classifies conversion disorder as a dissociative disorder[7] while the DSM-IV classifies it as a somatoform disorder.

Cause and treatment

Dissociative identity disorder

Cause: Dissociative identity disorder is caused by ongoing childhood trauma that occurs before the ages of six to nine.[8][9] People with dissociative identity disorder usually have close relatives who have also had similar experiences.[10]

Treatment: Long-term psychotherapy to improve the patients quality of life.

Dissociative amnesia

Cause: A way to cope with trauma.

Treatment: Psychotherapy (e.g. talk therapy) counseling or psychosocial therapy which involves talking about your disorder and related issues with a mental health provider. Psychotherapy often involves hypnosis (help you remember and work through the trauma); creative art therapy (using creative process to help a person who cannot express his or her thoughts); cognitive therapy (talk therapy to identify unhealthy and negative beliefs/behaviors); and medications (antidepressants, anti-anxiety medications or tranquilizers). These medications help control the mental health symptoms associated with the disorders, but there are no medications that specifically treat dissociative disorders.[11] However, the medication Pentothal can sometimes help to restore the memories.[10] The length of an event of dissociative amnesia may be a few minutes or several years. If an episode is associated with a traumatic event, the amnesia may clear up when the person is removed from the traumatic situation.

Dissociative fugue

Cause: A stressful event that happens in adulthood.

Treatment: Hypnosis is often used to help patient recall true identity and remember events of the past. Psychotherapy is helpful for the person who has traumatic, past events to resolve.[10] Once dissociative fugue is discovered and treated, many people recover quickly. The problem may never happen again.[10]

Depersonalization disorder

Cause: Dissociative disorders usually develop as a way to cope with trauma. The disorders most often form in children subjected to chronic physical, sexual or emotional abuse or, less frequently, a home environment that is otherwise frightening or highly unpredictable; however, this disorder can also acutely form due to severe traumas such as war or the death of a loved one.

Treatment: Same treatment as dissociative amnesia, and same drugs. An episode of depersonalization disorder can be as brief as a few seconds or continue for several years.[10]

Specific psychopharmacology

As mentioned earlier, anti-anxiety, antidepressants and tranquilizers are treatment medications that do not cure, but may help control the symptoms of dissociative disorders.

Diagnosis and prevalence

The lifetime prevalence of dissociative disorders varies from 10% in the general population to 46% in psychiatric inpatients.[12] Diagnosis can be made with the help of structured clinical interviews such as the Dissociative Disorders Interview Schedule (DDIS) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R), and behavioral observation of dissociative signs during the interview.[12][13] Additional information can be helpful in diagnosis, including the Dissociative Experiences Scale or other questionnaires, performance-based measures, records from doctors or academic records, and information from partners, parents, or friends.[14] A dissociative disorder cannot be ruled out in a single session and it is common for patients diagnosed with a dissociative disorder to not have a previous dissociative disorder diagnosis due to a lack of clinician training.[13] Some diagnostic tests have also been adapted or developed for use with children and adolescents such as the Adolescent Dissociative Experiences Scale,[15] Children's Version of the Response Evaluation Measure (REM-Y-71), Child Interview for Subjective Dissociative Experiences, Child Dissociative Checklist (CDC), Child Behavior Checklist (CBCL) Dissociation Subscale, and the Trauma Symptom Checklist for Children Dissociation Subscale.[16]

There are problems with classification, diagnosis and therapeutic strategies of dissociative and conversion disorders which can be understood by the historic context of hysteria. Even current systems used to diagnose DD such as the DSM-IV and ICD-10 differ in the way the classification is determined.[17] In most cases mental health professionals are still hesitant to diagnose patients with Dissociative Disorder, because before they are considered to be diagnosed with Dissociative Disorder these patients have more than likely been diagnosed with major depression, anxiety disorder, and most often post-traumatic disorder.[18]

An important concern in the diagnosis of dissociative disorders in forensic interviews is the possibility that the patient may be feigning symptoms in order to escape negative consequences. Young criminal offenders report much higher levels of dissociative disorders, such as amnesia. In one study it was found that 1% of young offenders reported complete amnesia for a violent crime, while 19% claimed partial amnesia. There have also been cases in which people with dissociative identity disorder provide conflicting testimonies in court, depending on the personality that is present.[19]

Children and adolescents

Dissociative disorders (DD) are widely believed to have roots in traumatic childhood experience (abuse or loss), but symptomology often goes unrecognized or is misdiagnosed in children and adolescents.[16][20][21] There are several reasons why recognizing symptoms of dissociation in children is challenging: it may be difficult for children to describe their internal experiences; caregivers may miss signals or attempt to conceal their own abusive or neglectful behaviors; symptoms can be subtle or fleeting;[16] disturbances of memory, mood, or concentration associated with dissociation may be misinterpreted as symptoms of other disorders.[16]

In addition to developing diagnostic tests for children and adolescents (see above), a number of approaches have been developed to improve recognition and understanding of dissociation in children. Recent research has focused on clarifying the neurological basis of symptoms associated with dissociation by studying neurochemical, functional and structural brain abnormalities that can result from childhood trauma.[20] Others in the field have argued that recognizing disorganized attachment (DA) in children can help alert clinicians to the possibility of dissociative disorders.[21]

Clinicians and researchers also stress the importance of using a developmental model to understand both symptoms and the future course of DDs.[16][20] In other words, symptoms of dissociation may manifest differently at different stages of child and adolescent development and individuals may be more or less susceptible to developing dissociative symptoms at different ages. Further research into the manifestation of dissociative symptoms and vulnerability throughout development is needed.[16][20] Related to this developmental approach, more research is required to establish whether a young patient's recovery will remain stable over time.[22]

Current debates and the DSM-5

A number of controversies surround DD in adults as well as children. First, there is ongoing debate surrounding the etiology of dissociative identity disorder (DID). The crux of this debate is if DID is the result of childhood trauma and disorganized attachment.[20][23] A second area of controversy surrounds the question of whether or not dissociation as a defense versus pathological dissociation are qualitatively or quantitatively different. Experiences and symptoms of dissociation can range from the more mundane to those associated with posttraumatic stress disorder (PTSD) or acute stress disorder (ASD) to dissociative disorders.[16] Mirroring this complexity, the DSM-5 workgroup considered grouping dissociative disorders with other trauma/stress disorders,[24] but instead decided to put them in the following chapter to emphasize the close relationship.[2] The DSM-5 also introduced a Dissociative subtype of PTSD.[2]

A 2012 review article supports the hypothesis that current or recent trauma may affect an individual's assessment of the more distant past, changing the experience of the past and resulting in dissociative states.[25] However, experimental research in cognitive science continues to challenge claims concerning the validity of the dissociation construct, which is still based on Janetian notions of structural dissociation.[4][26] Even the claimed etiological link between trauma/abuse and dissociation has been questioned. An alternative model proposes a perspective on dissociation based on a recently established link between a labile sleep–wake cycle and memory errors, cognitive failures, problems in attentional control, and difficulties in distinguishing fantasy from reality."[27]

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See also

References
  1. Simeon, D; Abugel, J (2006). Feeling Unreal: Depersonalization Disorder and the Loss of the Self. New York, NY: Oxford University Press. p. 17. ISBN 0195170229. OCLC 61123091.
  2. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®) (5th ed.). American Psychiatric Pub. pp. 528–556. ISBN 978-0-89042-557-2.
  3. Schacter, D. L., Gilbert, D. T., & Wegner, D.M. (2011). Psychology: Second Edition, pages 572-573 New York, NY: Worth.
  4. Maldonado, R.J.; Spiegel, D. (2019). "Dissociative Disorders". In Weiss Roberts, Laura; Hales, Robert E.; Yudofsky, Stuart C. (eds.). The American Psychiatric Publishing Board Review Guide for Psychiatry (7th ed.). American Psychiatric Pub. ISBN 978-1-61537-150-1.
  5. First, M. B., Kay, J., Lieberman, J. A., Riba, M. B., Tasman, A., eds. Psychiatry. 4th ed. Chichester, UK: John Wiley & Sons; 2015. p1187. ISBN 978-1-118-84547-9
  6. Sackeim, H. A., & Devanand, D. P. (1991). Dissociative disorders. In M. Hersen & S. M. Turner (Eds.), Adult psychopathology and diagnosis (2nd ed., pp. 279-322). New York, NY: Wiley.
  7. International Statistical Classification of Diseases and Related Health Problems, 10th Revision. F44.9
  8. Spigel, David; et al. "Dissociative disorders in DSM5DMS". Retrieved 3 January 2018.
  9. Salter, Micahel; Dorahy, Martin; Middleton, Warwick. "Dissociative identity disorder exists and is the result of childhood trauma". The Conversation. Retrieved 3 January 2018.
  10. Miller, John L. (February 3, 2014). "Dissociative Disorders". athealth.com. Retrieved December 14, 2016.
  11. (Mayo, 2011, p.11) (3 Mar 2011). Mayo Clinic. 1-12. Retrieved May 5, 2015, from http://www.mayoclinic.com/health/dissociative-disorders/DS00574
  12. Ross; et al. (2002). "Prevalence, Reliability and Validity of Dissociative Disorders in an Inpatient Setting". Journal of Trauma and Dissociation. 3: 7–17. doi:10.1300/J229v03n01_02.
  13. Bailey, Tyson D.; Boyer, Stacey M.; Brand, Bethany L. (2019). "Dissociative Disorders". In Segal, Daniel L. (ed.). Diagnostic Interviewing (5th ed.). Springer. ISBN 978-1-4939-9127-3.
  15. "Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents: International Society for the Study of Dissociation" (PDF). Journal of Trauma & Dissociation. 5 (3): 119–150. 2004-10-04. doi:10.1300/J229v05n03_09. ISSN 1529-9732.
  16. Steiner, H.; Carrion, V.; Plattner, B.; Koopman, C. (2002). "Dissociative symptoms in posttraumatic stress disorder: diagnosis and treatment". Child and Adolescent Psychiatric Clinics North America. 12 (2): 231–249. doi:10.1016/s1056-4993(02)00103-7. PMID 12725010.
  17. Splitzer, C; Freyberger, H.J. (2007). "Dissoziative Störungen (Konversionsstörungen)". Psychotherapeut.
  18. [Nolen-Hoeksema, S. (2014). Somatic Symptom and Dissociative Disorders. In (ab)normal Psychology (6th ed., p. 164). Penn, Plaza, New York: McGraw-Hill.]
  19. Haley, J. (2003). "Defendant's wife testifies about his multiple personas". Bellingham Herald: B4.
  20. Diseth, T. (2005). "Dissociation in children and adolescents as reaction to trauma - an overview of conceptual issues and neurobiological factors". Nordic Journal of Psychiatry. 59 (2): 79–91. doi:10.1080/08039480510022963. PMID 16195104.
  21. Waters, F. (July–August 2005). "Recognizing dissociation in preschool children". The International Society for the Study of Dissociation News. 23 (4): 1–4.
  22. Jans, Thomas; Schneck-Seif, Stefanie; Weigand, Tobias; Schneider, Wolfgang; Ellgring, Heiner; Wewetzer, Christoph; Warnke, Andreas (2008). "Long-term outcome and prognosis of dissociative disorder with onset in childhood or adolescence". Child and Adolescent Psychiatry and Mental Health. 2 (1): 19. doi:10.1186/1753-2000-2-19. PMC 2517058. PMID 18651951.
  23. Boysen, Guy A. (2011). "The Scientific Status of Childhood Dissociative Identity Disorder: A Review of Published Research". Psychotherapy and Psychosomatics. 80 (6): 329–34. doi:10.1159/000323403. PMID 21829044.
  24. Brand, Bethany L.; Lanius, Ruth; Vermetten, Eric; Loewenstein, Richard J.; Spiegel, David (2012). "Where Are We Going? An Update on Assessment, Treatment, and Neurobiological Research in Dissociative Disorders as We Move Toward the DSM-5". Journal of Trauma & Dissociation. 13 (1): 9–31. doi:10.1080/15299732.2011.620687. PMID 22211439.
  25. Stern DB (January 2012). "Witnessing across time: accessing the present from the past and the past from the present". The Psychoanalytic Quarterly. 81 (1): 53–81. doi:10.1002/j.2167-4086.2012.tb00485.x. PMID 22423434.
  26. Heim, Gerhard; Bühler, Karl-Ernst (2019-04-03). Craparo, Giuseppe; Ortu, Francesca; van der Hart, Onno (eds.). Pierre Janet’s views on the etiology, pathogenesis, and therapy of dissociative disorders 1. Rediscovering Pierre Janet (1 ed.). Routledge. pp. 178–199. doi:10.4324/9780429201875-14. ISBN 978-0-429-20187-5. Retrieved 2020-07-24.
  27. Lynn, SJ; et al. (2012). "Dissociation and dissociative disorders: challenging conventional wisdom". Current Directions in Psychological Science. 21 (1): 48–53. doi:10.1177/0963721411429457.
Classification
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