Module 6: Dissociative Disorders Study Notes

Overview of Dissociative Disorders

• Definition and General Presentation: Dissociative disorders consist of a group of disorders characterized by a disruption or discontinuity in several key functional areas including memory, identity, consciousness, emotion, body representation, perception, motor control, and behavior (APA, 2022).

• Etiological Triggers: Symptoms often manifest following a significant stressor or as a result of long-term, ongoing stress, such as years of abuse (Maldonadao & Spiegel, 2014).

• Differential Exclusions:     * Temporary Symptoms: One may experience temporary dissociative symptoms due to ingestion of a substance or lack of sleep; however, these are not classified as dissociative disorders if there is no functional impairment.     * Stress-Related Disorders: Symptoms like amnesia, flashbacks, numbing, and depersonalization/derealization are frequent in PTSD and acute stress disorder. These are diagnosed as stress disorders rather than dissociative disorders when there is a clearly identifiable stressor and a lack of the specific additional symptoms required for dissociative categories.

Dissociative Identity Disorder (DID)

• Core Diagnostic Criteria (Criteria A): The primary diagnostic indicator for DID is the presence of $2$ or more distinct personality states or the experience of being possessed (APA, 2022).

• Presentation Variations:     * Personalities may be overt or covert, influenced by factors such as emotional resilience, stress level, psychological motivation, internal conflicts, and cultural context.     * Possession-form: Alternate identities (often presenting as spirits or demons) are typically readily observable.     * Non-possession-form: Identities are usually subtle and not overtly displayed in the majority of individuals. When observable, they manifest as changes in hairstyle, name, handwriting, accent, or wardrobe.

• Internal Disruptions: If identities are covert, they are identified through sudden disruptions in the sense of self and agency, and recurrent dissociative amnesia.

• Memory Gaps (Criteria B): There must be excessive gaps in the recall of trauma, information, or events due to personality switching.     * These gaps exceed typical forgetting and include lapses in autobiographical memory, forgetting well-learned skills, or discovering items that the individual has no recollection of acquiring.     * Gaps can occur for everyday events, not just traumatic ones.

• Cultural Consideration (Criteria D): Possession states that are part of broadly accepted religious or cultural practices should not be diagnosed as DID.

• Subpersonalities:     * There is usually a dominant or primary personality present most of the time.     * On average, women have $15$ subpersonalities, while men have $8$ (APA, 2000).

• The Switching Process: Switching between personalities can be subtle (appearing as if the person fell asleep) or dramatic (involving excessive body movements). Sudden switches are usually precipitated by significant stress, bringing forward the subpersonality best equipped to handle the situation.

• Intrasystem Relationships: Personalities may be mutually aware, or they may have a "one-way amnesic relationship," where the primary personality is unaware of the others, leading to episodes of amnesia.

• Functional Impact (Criteria C): Impairment ranges from minimal (e.g., high-functioning professionals) to profound. Minimal impairment often affects parenting, marital, and family life more than professional performance.

Dissociative Amnesia

• Definition: The inability to recall important autobiographical information, usually of a stressful or traumatic nature.

• Nature of the Memory Loss: Unlike permanent amnesia, which often has a neurobiological cause, dissociative amnesia is a reversible memory retrieval deficit. Information was successfully stored but cannot be freely recollected (APA, 2022).

• Specific Types of Dissociative Amnesia:     * Localized Amnesia: The most common form; an inability to recall any events during a specific period. This can last from the brief moments surrounding a trauma to several years (e.g., combat or abuse).     * Selective Amnesia: A component of localized amnesia where some, but not all, details of a specific period are recalled. Example: A soldier remembering unit dinners but not combat deployment details.     * Systematized Amnesia: The failure to recall a specific category of information, such as memories of a specific room in a childhood home.     * Generalized Amnesia: A rare and frightening form where individuals lose most or all of their life history, including identity and general world knowledge.

• Generalized Amnesia Deficits:     * Semantic Knowledge: Loss of common knowledge (e.g., numbers, colors, letters).     * Procedural Knowledge: Loss of learned skills (e.g., driving a car, tying shoes).     * Onset: Often acute; individuals may be found wandering in a state of disorientation and are sometimes brought to emergency rooms by law enforcement.

• Long-term Impairment: Some individuals develop chronic autobiographical memory deficits that are not fixed by relearning their history, leading to poor functioning in most domains (APA, 2022).

Depersonalization/Derealization Disorder

• Depersonalization: Feelings of unreality or detachment from oneself.     * Described as an "out-of-body experience" or being an observer of one's own thoughts and feelings.     * Symptoms include feeling like a "robot" (lacking motor or speech control) and physical distortions (body parts appearing shrunken or enlarged).     * Emotional Numbing: Feeling detached from emotions despite knowing they exist.

• Derealization: Feelings of unreality or detachment from the world (people, objects, or surroundings).     * Symptoms include feeling unfamiliar with well-known places or emotionally disconnected from close family/friends.     * Sensory/Perceptual Distortions: Environment may look blurry, artificial, or distorted. Distortions in time, distance, and the size/shape of objects are common.

• Psychological Distress: Individuals often fear they are "going crazy" or have irreversible brain damage. They may have an altered sense of time and obsessions regarding their own existence.

• Clinical Presentation: Associated with "hypoemotionality with others" and difficulty focusing or retaining information (APA, 2022). Episodes can last for hours, days, weeks, or months.

Epidemiology of Dissociative Disorders

• Dissociative Identity Disorder (DID): Estimated prevalence of $1.5\%$ in U.S. adults. Women predominate in adult clinical settings and show higher rates of somatization, though childhood trauma histories are similar across genders.

• Dissociative Amnesia: Prevalence of approximately $1.8\%$ in the U.S. population.

• Depersonalization/Derealization Disorder:     * Approximately $50\%$ of all adults have experienced at least one transient episode in their lifetime.     * Full symptomatic criteria are markedly less common.     * In the United Kingdom, a one-month prevalence of $1$-$-2\% \text{ was reported}$ (APA, 2022).

• Onset Patterns: Typically occurs in late adolescence to early adulthood.     * In DID, symptoms likely begin in early childhood due to abuse, but the full disorder is often not recognized until adolescence (Sar et al., 2014).

Comorbidity

• PTSD: High comorbidity with most dissociative disorders, though notably low specifically for depersonalization/derealization disorder.

• Depressive Disorders: Common across all categories due to the negative impact on social and emotional functioning.

• Dissociative Amnesia Remission: Once an episode of amnesia clears, a wide range of intense emotions often surfaces, frequently triggering a depressive episode.

• Somatic and Personality Disorders:     * Somatic symptom disorder and conversion disorder are found in those with dissociative amnesia.     * Comorbid personality traits include dependent, obsessive-compulsive, avoidant, and borderline.

• Other Disorders: DID and dissociative amnesia show links to feeding, eating, and substance-related disorders. Anxiety disorders are common in depersonalization/derealization disorder.

Etiology

• Biological Perspective:     * Heritability rates for dissociation are suggested to be between $50$-$-60\%$.     * Theory suggests a combination of genetic and environmental factors is more influential than genetics alone (Pieper et al., 2011).

• Cognitive Perspective:     * Memory Retrieval Deficit: Theories by Kopelman (2000) suggest psychological stress and biopsychosocial predispositions impair the frontal lobes' executive system in retrieving autobiographical memories.     * Neuroimaging: Shows deficits in prefrontal regions responsible for memory retrieval (Picard et al., 2013).     * DID and the Hippocampus: Research shows different levels of hippocampus activation between subpersonalities (Tsai et al., 1999). The hippocampus, which converts short-term to long-term memory, is hypothesized to be responsible for dissociative states (Staniloiu & Markowitsch, 2010).

• Sociocultural Perspective:     * Mass Media Influence: Lilienfeld and colleagues (1999) argued that media portrayals provide a model for individuals to learn and engage in dissociative behaviors.     * The "Sybil" Effect: Case numbers of DID increased significantly after the publication of Sybil, detailing a woman with $16$ subpersonalities (Goff & Simms, 1993).     * Clinician Influence: Media can influence therapists to use questions or techniques that unconsciously evoke dissociative symptoms in patients.

• Psychodynamic Perspective:     * Repression: Disorders are caused by the subconscious blocking of unpleasant thoughts or traumatic feelings to protect the individual from pain (Richardson, 1998).     * Escape Mechanism: In DID, repeated exposure to childhood abuse or neglect leads children to develop different personalities to "flee" the situation mentally.     * Individuals with DID have the highest rates of childhood psychological trauma among all psychiatric disorders (Sar, 2011).

Treatment Options

• Challenges to Treatment: Many individuals with dissociative amnesia recover spontaneously. The rarity of these disorders also limits extensive research on treatment efficacy.

• Dissociative Identity Disorder Treatment:     * Ultimate Goal: Integration of subpersonalities into a single unified self, termed "final fusion" (Chu et al., 2011).     * Process of Integration: Includes psychoeducation to help the individual acknowledge subpersonalities. The clinician must build rapport with the primary personality and then encourage communication and coordination between subpersonalities.     * Fusion: This occurs when two or more alternate identities join, resulting in a complete loss of separateness.     * Alternatives to Fusion: Final fusion may not be desirable for those with severe stressors, advanced age, or medical comorbidities. In these cases, the goal is "resolution" or sufficient coordination for independent functioning.     * Maintenance: Relapse risk is high for those who do not achieve final fusion. Treatment focuses on social and positive coping skills to process trauma and prevent future relapses.

• Dissociative Amnesia Treatment:     * Hypnosis: Used to modulate symptoms and allow controlled recall of memories. Clinicians walk the patient through events occurring during the amnesic period to reorient them (Maldonadao & Spiegel, 2014).     * Barbiturates: Known as "truth serums," drugs like barbiturates are sometimes used to reduce anxiety enough to allow the recall and processing of unpleasant memories (Ahern et al., 2000).

• Depersonalization/Derealization Disorder Treatment:     * Diagnosis as Therapy: Simply receiving a diagnosis can reduce symptom intensity by alleviating anxiety about "going crazy" (Medford et al., 2005).     * Pharmacotherapy: SSRIs can be effective for managing comorbid mood symptoms.     * Cognitive-Behavioral Therapy (CBT): The psychological treatment of preference; it addresses negative attributions and catastrophic appraisals of stress that contribute to dissociative symptoms (Medford et al., 2005).