6.3 Understanding Dissociation

The DSM-5 defines dissociation as
"a disruption and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control and behavior"
(American Psychiatric Association, 2013, p. 291).
Distinction between dissociative states and dissociative traits
- State Dissociation: Viewed as a transient symptom (lasting a few minutes or hours).
- Example: Dissociation during a traumatic event.
- Trait Dissociation: Integral aspect of personality.

Dissociative symptoms can occur in both patients and the general population.
Commonly conceptualized on a continuum from nonsevere manifestations (e.g., daydreaming) to severe disturbances typical of dissociative disorders.
Reference: Bernstein & Putnam, 1986.

Dissociative Amnesia:
- Does not imply permanent memory loss; rather a hypothetical disconnection of memories from conscious inspection.
- The memory still exists, but is inaccessible.
Depersonalization:
- Experience of feeling like a robot or devoid of feelings.
Derealization:
- Defined as "an alteration in the perception of one's surroundings so that a sense of reality of the external world is lost"
  (Steinberg, 2001, p. 101).
- Imagery: Experiencing the world as if living in a movie or looking through fog.
Identity Confusion:
- Described as “thoughts and feelings of uncertainty and conflict a person has related to [their] identity"
  (Steinberg, 2001, p. 101).
Identity Alteration:
- Behavioral manifestation of identity confusion.
- Reference: Bernstein & Putnam, 1986.

Dissociative disorders are more common than expected.
Prevalence estimated between 4%-29% in clinical populations (Ross, Anderson, Fleischer, & Norton, 1991; Sar, Tutkun, Alyanak, Bakim, & Baral, 2000; Tutkun et al., 1998).
Lower prevalence found in the general population, typically around 1%-3% (Lee, Kwok, Hunter, Richards, & David, 2010; Rauschenberger & Lynn, 1995; Sandberg & Lynn, 2006).
Individuals with schizophrenia may also display heightened levels of dissociation (Allen & Coyne, 1995; Merckelbach, à Campo, Hardy, & Giesbrecht, 2005; Yu et al., 2010).

The DES is the most widely used self-report measure of dissociation (Bernstein & Putnam, 1986; Carlson & Putnam, 2000; Wright & Loftus, 1999).
Self-report measure involves completing a survey/questionnaire, possibly with investigator assistance.
Key items in the DES include:
- (a) “Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something, and they actually see themselves as if they were looking at another person.”
- (b) “Some people find that sometimes they are listening to someone talk, and they suddenly realize that they did not hear part or all of what was said.”

The DES is primarily a screening tool.
A high level of dissociation on the DES does not necessarily indicate a dissociative disorder but suggests the need for further investigation of symptoms.
A structured clinical interview to further assess symptoms is known as the Structured Clinical Interview for DSM-4 Dissociative Disorders (Steinberg, 1994).
An updated version was created following the DSM-5 publication.

Individuals with dissociative disorders frequently report a history of childhood trauma, with some reports corroborated through medical or legal records (Cardeña & Gleaves, 2006).
Research suggests that about 95% of individuals with Dissociative Identity Disorder (DID) were physically and/or sexually abused as children (Ross et al., 1990).
Caution is advised as not all reports of childhood abuse are reliable, but there is strong evidence indicating that traumatic experiences can precipitate states of dissociation.
The dissociative states and adoption of multiple personalities may act as important psychological coping mechanisms in response to threats and danger (Dalenberg et al., 2012).