Dissociative Disorder

Dissociative Disorder Overview

• a mental process that causes a lack of connection between a person’s conscious awareness and some aspect of him/herself (e.g. memory, sense of identity, self-perception, or subjective experience of reality)​

• Altered states of consciousness that people experience with certain drugs (cannabis, hallucinogens) is a form of dissociation

Prevalence of Pathological Dissociation​

• Non-clinical populations: 0.3-4 % (general population)​

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• The Dissociative Experience Scale​

  • College students-few studies​

  • Clinical populations​

    • 12-17 %​

  • Inpatient settings​

    • 28 %-40 %​

  • High comorbidities​

    • Depression, BPD, Anxiety, PTSD​

Depersonalization

feeling detached from one's body or mental processes

Derealization

feeling of unreality or detachment with respect to one’s surrounding

Dissociative Disorders​ Depersonalization/Derealization Disorder​

• Duration: hours to → years or decades​

• Stressful events, threat, drugs or abuse​

• Depression and anxiety common comorbid disorders​

  • Persistent, recurring, interfere with normal functioning and not in the context of another DSM diagnosis.​

  • Reality testing must remain intact (rule out schizophrenia). ​

  • Not connected to trance or meditative practices ​

• Lifetime prevalence in adults 1% (M=F) ​

• Emotional neglect and abuse are significant risk factors​

• Relationship with “out of body experiences”, unexpected perceptual experiences, and multisensory input mismatch. ​

  • rTMS might provide relief o symptoms ​

Prevalence and comorbidity

• General population: 0 % - 3 %​

• Outpatients: 5 % -20 %​

• Inpatients: 17.5 %-41.9 %​

• Often occurs in the presence of other disorders ​

  • Panic disorder​

  • Co-occurs with other disorders​

  • Distinguishable from anxiety​

Dissociative Amnesia

• Extensive memory loss, not attributable to illness, disease or substance use​

  • Formerly known as psychogenic amnesia​

  • Frequently involves a traumatic experience​

  • There is some familiarity with the forgotten material​

• Differing prevalences: 0.2 %-10 %​

• Controversial​

Dissociative Fugue

• The most controversial, after DID​

  • Can accompany DA​

  • Previously known as psychogenic fugue​

  • Rule out other disorders ​

  • Controversial because no pathology is present in the new, created identity or behaviours.​

  • Culture bound syndromes ​

Dissociative Identity Disorder ​

• Marked disruption of identity characterized by ≥2 distinct personality states and recurrent gaps in recall of everyday events, personal information, and/or traumatic events that are inconsistent with ordinary forgetting​

• Most severe dissociative disorder but diagnosis is controversial​

• Dissociation is likely an offshoot of other psychological problems (e.g., C-PTSD), with dissociative symptoms serving as a coping mechanism to mitigate the impact of highly aversive events​

• Is the disorder real or fake?​

  • Massive increase in reported cases of DID following release of the film Sybil (1976) who had 16 distinct personalities​

  • Later found that Sybil fabricated multiple identities to please her therapist (who encouraged her to develop and display different personalities in therapy)​

  • Many or most DID patients show few or no signs of the condition prior to psychotherapy​

• Some suggest DID is a form of role-play in suggestible individuals that is therapist induced​

• Many DID patients meet criteria for schizoaffective disorder ​

  • Auditory and visual hallucinations​​

Posttraumatic and Sociocognitive models​

• Correlational studies point to a medium effect between trauma and dissociation​

  • However, correlation does not meal causation​

• Cultural narrative​

  • Movies​

• DID diagnoses increases alters ​

  • A few therapists account for the majority of cases​

• Can reproduce dissociation with drugs​

• Is trauma and dissociation minimized?​

• Dissociation and suggestibility not strongly linked​

• DID and dissociation present in other countries, outside of US influence​

• controversial:​

  • They’ve become a topic of media coverage, popularized (critics of the theories suggest that those that are suggestable will more likely be diagnosed with it)​

• Post traumatic model​

  • DD is created by prior history of trauma, act as buffer​

  • Positive correlation between highly aversive experiences and association​

  • Medium effective size​

  • Doubts ​

    • Cultural narrative possess big problem with this model​

      • Media is localized to north America​

    • These alters increase over time, alters tend to increase after psychotherapy (suggestibility leads to identity stated increasing)​

    • Drugs that cause dissociation (ketamine, cannabis, cocaine)-> acute dissociation (derealization and depersonalization)​

    • Can be induced in laboratory​

    • Trauma is not a necessary condition to explain the presence of dissociative symptoms

Integrating the two models​

• Consensus on: ​

• Dissociation can be evaluated​

• Has neurophysiological and genetic correlates​

• Explore patient history without suggestions​

• Social environment (i.e., family, development) contribute to dissociation​

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-Fantasy proneness and inaccurate trauma reports​

• Trauma and stress levels might increase dissociation​

• Comorbid conditions can make dissociation symptoms persistent ​

• Trauma might predispose and enhance fantasy proneness (escape) and increase vulnerability to DID elaborations​

• Find consensus (goal is to understand dissociation-> better methods in providing treatment​

• Genetic correlation of dissociation​

• Explore history without looking for evidence​

  • Clinician be as removed, unbiased as possible​

• Social environment important in understanding dissociation​

• Fantasy proneness and inaccurate trauma reports​

  • Most of the time not accurate​

• Comorbid conditions can make dissociation symptoms persistent ​

  • BPD, AD, DD​

• Trauma might predispose and enhance fantasy proneness (escape) and increase vulnerability to DID elaborations​

• Not much data on the disorder (low prevalence, no double blind study done)​

Transdiagnostic Model ​

• SLEEP and dissociation​

  • Causal relationship​

  • Disruptions in sleep cycles: ​

    • Impairs memory and cognitive control​

    • Reduced cognitive control in emotional contexts​

    • Increased anxiety​

  • TTM and regulatory systems​

    • Disruption in regulation​

    • Disruption in regulating intrusive thoughts​

    • Lack of emotional awareness, regulation​

    • Avoidance/issues with reality monitoring​

Treatment of Dissociative Disorders​

• Pharmacotherapy not promising​

  • Benzodiazepines worsen symptoms, but some promise with antiseizure meds​

  • Placebo and psychotherapy show promise for dissociation​

  • Some case studies show promise for family therapy, paradoxical interventions, flooding). ​

  • Lack of randomized trials​

  • Promise for CBT: ​focus on not reinforcing the behaviour, psychoeducation (help them understand)​

• Don’t know much about Dissociative disorder, don’t receive much attention​

• Dissociative symptoms and comorbid anxieties, Benzodiazepines worsen symptoms, but some promise with antiseizure meds​

• Family therapy: treat in context of interactions with family members​

• Flooding: exposing person to most feared factor​

• No double blind randomized trials​

• Clinician knows existence of symptoms, overreport on those symptoms (implicit bias)​