Dissociative Disorders

dissociative disorders

• Disruption of the usual functions of consciousness, memory, identity, or perception

• Not all dissociation is pathological (daydreaming, time passing while driving)

• DSM-5 diagnoses:

  • Dissociative amnesia

  • Dissociative identity disorder

  • Depersonalization disorder

dissociative amnesia

• A. Inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary
  forgetfulness

• Specifier: With dissociative fugue

• Memory for non-personal information is usually intact

• Memory usually returns within a few days, but can be chronic

• Subtypes of amnesia:

  • Localized – specific time period

  • Selective – parts of the trauma but not others

  • Generalized – all personal information from past

  • Continuous – all personal information from a certain point in the past

• One-year prevalence of around 1-2%

• Many differential diagnoses, including: DID, PTSD, neurocognitive disorders, substance-abuse, seizure disorders, factitious disorder, malingering, ADHD, learning disability, anxiety

• There is an ongoing debate about the etiology, prevalence, cultural importance, and even veracity of these disorders

  • Pope et al (2006) – No evidence of dissociative amnesia before 1800, suggesting it is a culturally bound syndrome

  • Malingered (faked) amnesia is probably common

  • “Repressed memories”

  • DSM criteria assume mind/body dualism

dissociative fugue specifier (dissociative amnesia)

• It involves a temporary loss of personal identity and memory, often leading individuals to travel unexpectedly or assume a new identity

• Amnesia plus apparently purposeful travel or bewildered wandering

• subtype of dissociative amnesia

• Several cultures recognize disorders that include “running”

  • Pibloktoq

  • Grisi siknis

  • Amok

• Prevalence of dissociative fugue is known to increase during times of stress, such as war or natural disaster

• Lifetime prevalence of <0.2%

depersonalization disorder

• A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body (e.g., feeling like one is in a dream).

• B. During the depersonalization experience, reality testing remains
  intact.

• Feeling of being an “automaton”, watching self in a movie, or being outside own body

• Perceived lack of control over motor behaviour, speech, affective responses

• Reality testing is intact

  • Patient knows that they are not actually an automaton

  • In contrast to a delusion, in which the patient is convinced of the reality of their belief

• “Derealization” is also common in depersonalization disorder

  • Feeling of disconnection with or unreality of the outside
    world

• Depersonalization experiences are extremely common

  • Up to 50% of people will experience an episode at some
    point in their life

  • 1/3 of people when exposed to life-threatening danger

  • Lifetime prevalence of the disorder is around 1.5% in
    women, unknown in men

• Depersonalization occurs in other mental illnesses (it is only a disorder when it is persistent or recurrent)

dissociative identity disorder diagnostic criteria

• A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).

• B. At least two of these identities or personality states recurrently take control of the person's behavior.

• C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

• D. The disturbance is not due to the direct physiological effects
  of a substance (e.g., blackouts or chaotic behavior during Alcohol
  Intoxication) or a general medical condition (e.g., complex partial
  seizures). Note: In children, the symptoms are not attributable to
  imaginary playmates or other fantasy play.

dissociative identity disorder

• One personality is considered to be the “host”, while others are the “alters”

• Alters may differ from the host in age, gender, allergies, possibly even brain functioning (eg: EEG patterns)

• Average number appears to be 13 to 16 (but the number can range up to >100)

• Switching often occurs in response to stressful events

  • May or may not be noticed by others, depending on how significant the difference between the host and alter

• Age at diagnosis is around 29-35 years, and DID is much more common in women than in men

• Prevalence is unclear (<1% lifetime prevalence, Sar et al, 2007)

• Co-morbidity is extremely common

  • Self-harm behaviour, suicide thoughts/attempts, insomnia, s*xual dysfunction, anxiety, paranoia

  • Depression, PTSD, substance abuse, eating disorders, personality disorders

  • Most people are diagnosed with DID only after several
    years of contact with the system and several other
    diagnoses

is dissociative identity disorder a culturally bound condition?

• Huge spike in diagnoses in the 1970's and 80's

• Occurs outside of North America and Europe but more rarely

• Recognition of and willingness to diagnosis the disorder are also inseparable from culture; similar subjective experience is probably described in different ways across times/places

• Sense of self is not a completely stable trait for anyone

  • So why would it be hard to imagine some percentage
    of the population having such an extremely variable
    sense of self that they experience being different
    people?

dissociative identity disorder models

• Trauma model

  • Results from severe childhood trauma, causing the patient to
    use dissociation as an effective coping strategy (defense mechanism)

  • Escaping pain and abuse, even temporarily, would be very
    reinforcing

  • Diathesis might include suggestibility, proneness to fantasy, or
    disorganized attachment style

  • Supported by the very high percentage of DID sufferers with
    trauma histories

• Social-cognitive model

  • DID is essentially role-playing, and reinforced by therapists and society

  • Suggestibility again represents diathesis, but in this case is considered to make some people more likely to learn to behave according to therapist's expectations

  • Prevalence is related to movies or news stories about the condition (ie: ritual satanic abuse)

  • DID is rarely observed in children, even though the trauma model suggested that childhood when the behaviour develops

false-memory syndrome

• You may hear about or read this term in the context of DID,
  but it is not a DSM diagnosis and is extremely controversial!

• Memories from childhood that are repressed by dissociative
  amnesia are experienced as being “re-discovered” in therapy in adulthood

• Simple false memories can be easily implanted experimentally and often there is no objective way to confirm or dismiss recovered memories

• Individuals with recovered memories are usually highly suggestible, and there is evidence that clinicians whose clients uncover memories use leading questions and other techniques

• The prevalence of most psychological disorders has increased since the 1980s. However, scientific publications regarding
  dissociative amnesia peaked in the mid-1990s but then declined steeply through 2003. In addition, no fictional or nonfictional description of individuals showing dissociative amnesia following a trauma exists prior to 1800.