dissociative disorders

dissociation

“splitting” of consciousness or the separation of mental processes, such as perception, memory, and self-awareness, that are normally integrated

• removed from reality

• a spectrum

dissociation spectrum: green, mild

• meditation

• hypnosis

• concentration

• absorption

dissociation spectrum: red, extreme

• dissociative disorders

• disconnection between thoughts, identity, consciousness, memory

• sense of detachment from emotions

• lack of self-identity

• significant memory loss

dissociative amnesia

an inability to recall important autobiographical information that

• should be stored in memory

• ordinarily would be remembered

can be localized (childhood), selective (specific event), generalized (identity)

dissociative fugue specifier

unplanned travel or wandering (“wake up” at work)

confusion around personal identity or assumption of new identity (partial or full)

• extremely rare

depersonalization

detached from one’s own thoughts, feelings, and/or behaviors

• out-of-body experience

derealization

detached from one’s surroundings

• things are experienced as unreal, dreamlike

depersonalization/derealization disorder

persistent, recurrent episodes of either or both

• know these experiences are not real 

dissociative identity disorder

two or more distinct identities or personality states (called alters), each with its own enduring pattern of perceiving, relating to, and thinking about the environment and the self

• amnesia must occur, either in recall of ever day events, personal info, and/or traumatic event (forgetting how to drive, how to do one’s job)

• cultural considerations (possession, taken over by a spirit)

• average number of alters is 10

• common alters: child (who experienced trauma), protector, persecutor (acts out more), opposite sex role

• amnesia about some identities, one identity might not know another

etiology: attributed to interaction of several factors

• overwhelming stress

• dissociative capacity

• lack of sufficient nurturing/compassion, past traumas

etiology: biological factors

no evidence for genetic component, criteria rules out those caused by biological factors

etiology: environmental factors

• physical and sexual abuse

• inconsistent parenting: parents who are both abusive and loving

  • disorganized attachment style

etiology: post-traumatic model

role of trauma and state-dependent learning (learning in one state is best recalled in the same state)

Ex: mary cannot recall abuse at age 4, but alter sandy can

etiology: socio-cognitive model

DID is a consequence of social learning and expectancies 

• inadvertent therapist cueing

• media influence

• sociocultural expectations regarding manifestations of DID 

these influences combine to make vulnerable individuals believe their alters account for their experiences/symptoms

• fantasy proneness and suggestibility

etiology: disruption of sleep-wake cycle model

sleep, memory, and dissociation are inter-related

• sleep loss associated with dissociative-like experiences and executive functioning problems

• sleep hygiene intervention reduces dissociative symptoms

why we moved away from the Post-Traumatic Model

• measurement around cases of abuse are self-reported, no objective measures

• studies are based on cross-sectional design (not able to establish causality, perspective studies, longitudinal)

• researchers rarely control for overlapping conditions, similar disorders have similar presentation to DID (exposure leads to multiple different outcomes)

fantasy proneness

tendency to have deep, vivid involvement in fantasy

• high proneness —> more likely to have DID

suggestibility

tendency to incorporate misleading info into memory

• high suggestibility —> more likely to have DID

confirmation bias

tendency to seek info that is consistent with their view of the world

• people also discount info inconsistent with their world view  

therapist bias

repeatedly asking “were you ever abused as a child?”

leading questions

“is there someone else in there that I can talk to?”

iatrogenesis

the creation of a disorder by an attempt to treat it

• the power of suggestion and role-playing by therapists

DID epidemiology

• unrelated to schizophrenia

• 5% including subclinical, 3.3% clinically

• more commonly diagnosed in women

• only seems to develop in adults

• large increase in number of cases since the 80’s

increase of DID cases due to

• increased awareness (popular media depicting someone with DID)

• DID being under-diagnosed in the past

• the power of suggestion and role-playing by therapists (iatrogenesis)

• highly suggestible people being more prone to dissociative disorders

issues in DID prevalence

• malingering: faking symptoms for personal gain (money, court case)

  • don’t show comorbid symptoms, seem to enjoy having the symptoms

• people may fake DID to claim they aren’t responsible for a crime (rarely works)

factitious disorder

• falsify or induce physical/psychological symptoms

• present self as ill/injured 

• deceptive behavior evident in absence of obvious external rewards (financial gain, avoid legal problems)

• diagnosis needs evidence of deliberate deception

• person fabricates symptoms in themselves or imposed on another

treatment

• anti-depressants and anti-anxiety medications reduce distress, not symptoms

• main goal: integration (individuals’ identities will eventually become “fused” into one self)

• treatment done through multiple phases (stabilization, treatment of traumatic memories, personality integration)

• integration is not evidence-based treatment (bc DID is so rare)