Dissociative Disorders

Overview of Dissociative Disorders

  • Defined by severe maladaptive disruptions or alterations of identity, memory, and consciousness.

  • These alterations are experienced as being beyond one’s control.

  • Dissociation: A lack of normal integration of thoughts, feelings, and experiences in consciousness and memory.

Types of Dissociative Disorders

  • Dissociative Amnesia & Fugue

  • Depersonalization/Derealization Disorder

  • Dissociative Identity Disorder (DID)

Dissociative Amnesia

  • Generalized Amnesia: Inability to remember anything, including personal identity.

  • Localized Amnesia: Inability to remember specific events, usually traumatic.

  • Typical onset is in adulthood.

Diagnostic Criteria for Dissociative Amnesia

A. Inability to recall important autobiographical information, typically traumatic or stressful, inconsistent with ordinary forgetting.
B. Symptoms cause clinically significant distress or impairment in social, occupational, or other critical areas of functioning.
C. Disturbance is not attributable to physiological effects of a substance or a medical condition (e.g., complex seizures).
D. Not explained by other mental disorders such as DID or PTSD.

  • Specify: If with dissociative fugue (involves purposeful travel or bewildered wandering associated with amnesia for identity or autobiographical information).

Dissociative Fugue

  • Subtype of dissociative amnesia characterized not only by loss of memory of past and personal identity but also sudden travel.

Depersonalization-Derealization Disorder

  • Features severe feelings of detachment; individuals feel like outside observers of their own body or mind.

    • Depersonalization: Losing sense of one’s own reality.

    • Derealization: Losing sense of the reality of the external world.

  • Experiences cause significant distress or impairment in emotions and perception.

  • Often comorbid with panic disorder; rare onset usually follows a traumatic event.

Cognitive and Perceptual Deficits in Depersonalization-Derealization Disorder

  • Deficits include:

    • Tunnel vision

    • Mind emptiness

    • Dysregulated emotion particularly affecting the HPA axis.

Diagnostic Criteria for Depersonalization-Derealization Disorder

A. Presence of persistent or recurrent experiences of depersonalization, derealization, or both:

  1. Depersonalization: Experiences of detachment or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions. This includes perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing.

  2. Derealization: Experiences of unreality or detachment with respect to surroundings; individuals or objects appear unreal, dreamlike, foggy, lifeless, or visually distorted.
    B. Reality testing remains intact during episodes.
    C. Symptoms cause clinically significant distress or impairment in important areas of functioning.
    D. Symptoms are not attributable to the physiological effects of substances or another medical condition.
    E. Symptoms are not explained by another mental disorder (e.g., schizophrenia, panic disorder).

Epidemiology of Dissociative Disorders

  • Prevalence rates vary by sample:

    • 0.8% for depersonalization

    • 1.8% for dissociative amnesia

    • 1.5% for Dissociative Identity Disorder

  • Comorbidity with depression, PTSD, anxiety disorders is common; affects both genders equally.

  • Average age of onset:

    • 15.9-22.8 years for depersonalization.

Functional Impairment

  • Limited data available on the impact of dissociative disorders due to the presence of comorbid disorders.

Treatment of Dissociative Disorders

  • Dissociative Amnesia: Often resolves without treatment; few controlled trials for derealization.

  • Some clinical reports suggest antidepressants may be beneficial; Cognitive Behavioral Therapy (CBT) approaches show potential effectiveness but mechanism is unclear.

  • CBT is confirmed as effective for depersonalization.

Dissociative Identity Disorder (DID)

  • Formerly known as Multiple Personality Disorder; characterized by co-existence of multiple identities.

  • Average of 15 identities; typically diagnosed in childhood.

  • Often comorbid with other disorders.

Characteristics of Dissociative Identity Disorder

  • Host Identity: The primary identity that seeks treatment.

  • Alters: The different identities or personalities.

  • Switch: Instantaneous transition from one personality to another; 37% report changes in handedness during the switch.

Diagnostic Criteria for Dissociative Identity Disorder

A. Disruption of identity characterized by two or more distinct personality states with alterations in self and sense of agency, along with related changes in affect, behavior, consciousness, memory, perception, and sensory-motor functioning. Signs and symptoms may be observable by others or reported by the individual.
B. Recurrent gaps in recalling everyday events, important personal information, or traumatic events inconsistent with ordinary forgetting.
C. Symptoms cause significant distress or impairment in social, occupational, or other areas of functioning.
D. Disturbance is not a normal part of a cultural or religious practice.
E. Symptoms not attributable to the effects of a substance or another medical condition such as seizures.

Etiology of Dissociative Identity Disorder

  • Posttraumatic Model: Suggests DID is the result of severe childhood trauma, particularly abuse; individuals create different identities to escape unbearable pain.

  • Criticism notes that childhood sexual abuse increases general adult psychopathology risk but does not directly predict DID specifically.

  • Suggestibility: People may utilize dissociation as a coping mechanism; individuals with high suggestibility can dissociate against trauma, while less suggestible persons tend to develop PTSD.

  • Studies remain inconclusive.

Can Therapy Cause DID?

  • Increasing prevalence of DID correlates with media portrayal in books and movies.

  • 80-100% of patients are unaware of their alters before therapy; number of alters may increase with therapy.

  • Greater therapist belief in DID diagnosis correlates with more diagnoses; potential for leading questions and false memories during therapy.

Biological Factors in Dissociative Identity Disorder

  • Debate over the roles of heredity and environment in DID.

  • Temporal lobe seizures are occasionally associated with dissociative symptoms.

  • Sleep deprivation can worsen symptoms.

Memory Issues in Dissociative Identity Disorder

  • Real and false memories can stem from traumatic experiences.

  • Suggestion from therapists can create false memories, complicating treatment and diagnosis.

Treatment of Dissociative Identity Disorder

  • Long-term psychotherapy aimed at reintegrating separate personalities shows a 22% success rate.

  • Treatment for associated trauma follows similar pathways as post-traumatic stress disorder treatments.