Module 6: Dissociative Disorders Study Guide

Clinical Presentation of Dissociative Disorders

• Dissociative disorders are a group of disorders characterized by symptoms of disruption and/or discontinuity in consciousness, memory, identity, emotion, body representation, perception, motor control, and behavior (APA, 2022).
• Symptoms typically appear following a significant stressor or years of ongoing stress, such as abuse (Maldonadao & Spiegel, 2014).
• Temporary dissociative symptoms can occur due to lack of sleep or ingestion of a substance, but these are not diagnosed as dissociative disorders because they do not involve a lack of impairment in functioning.
• Comparison with Stress Disorders:     - Individuals with Acute Stress Disorder and PTSD often experience dissociative symptoms like amnesia, numbing, flashbacks, and depersonalization/derealization.     - These individuals meet criteria for stress disorders rather than dissociative disorders due to the presence of an identifiable stressor and the lack of additional specific dissociative symptoms.
• The three main types of dissociative disorders include:     - Dissociative Identity Disorder (DID).     - Dissociative Amnesia.     - Depersonalization/Derealization Disorder.

Dissociative Identity Disorder (DID)

• Core Diagnostic Criteria (Criteria A): The presence of two or more distinct personality states or an experience of possession.
• Presentation of Personalities:     - Personalities can be overt or covert depending on psychological motivation, stress level, cultural context, emotional resilience, and internal conflicts/dynamics (APA, 2022).     - Prolonged stress may lead to sustained periods of identity confusion or alteration.     - In possession-form cases (and a small portion of non-possession cases), alternate identities are readily observable.     - In most non-possession-form cases, identities are not overtly displayed or only subtly displayed. Subtle manifestations include differences in names, hairstyles, handwriting, wardrobes, accents, or sense of agency.     - If identities are not observable, their presence is identified through sudden alterations in the sense of self and recurrent dissociative amnesias.
• Amnestic Gaps (Criteria B):     - Individuals must have a gap in the recall of events, information, or trauma due to the switching of personalities.     - These gaps exceed typical forgetting from lack of attention.     - Gaps manifest as lapses in autobiographical memory, loss of well-learned skills or recent events, and finding possessions for which there is no recollection of ownership.
• Possession-Form Identities:     - Often manifest as a spirit or supernatural being taking control.     - The individual acts or speaks in a distinctly different way.     - These must be recurrent, involuntary, unwanted, and cause significant distress or impairment (Criteria C).     - Cultural/Religious Exception: Possession states that are part of broadly accepted cultural or religious practices should not be diagnosed as DID (Criteria D).
• Structure of Subpersonalities:     - There is generally a dominant or primary personality present most of the time.     - Individuals have several subpersonalities. Research identifies average numbers: $15$ subpersonalities for women and $8$ for men (APA, 2000).
• Switching and Relationships:     - Shifting between personalities can range from appearing to fall asleep to dramatic, excessive bodily movements.     - Switching is often triggered by a significant stressor, as the subpersonality best equipped for the stressor will present.     - Relationships vary: some individuals are aware of other personalities, while others have a one-way amnesic relationship (unaware of other personalities).

Dissociative Amnesia

• Definition: The inability to recall important autobiographical information, usually of a traumatic or stressful nature.
• Nature of the Amnesia:     - Unlike permanent amnesia, the information is successfully stored in memory but cannot be freely recollected.     - It is a reversible memory retrieval deficit.     - Permanent amnesia often has a neurobiological cause, whereas dissociative amnesia does not (APA, 2022).
• Types of Dissociative Amnesia:     - Localized Amnesia: The most common type; inability to recall events during a specific period. The duration can range from the time immediately surrounding a traumatic event to years (common in abuse or combat).     - Selective Amnesia: A component of localized amnesia where the individual recalls some, but not all, details of a specific period. Example: A soldier deployed may forget combat but remember a holiday dinner with their unit.     - Systematized Amnesia: Failure to recall a specific category of information (e.g., memories of a specific room in a childhood home).     - Generalized Amnesia: A rare and frightening complete loss of memory for most or all of one's life history, identity, previous world knowledge, and well-learned skills.
• Deficits in Generalized Amnesia:     - Includes semantic knowledge (e.g., losing the ability to identify letters, colors, or numbers).     - Includes procedural knowledge (e.g., forgetting how to tie shoes or drive a car).     - Onset is acute; individuals are often found in a state of disorientation, sometimes by law enforcement.
• Functional Impact:     - Varies based on the history of traumatization.     - Some are chronically impaired in forming attachments, while others may be highly successful in occupations through compulsive overwork.     - A subgroup develops a chronic autobiographical memory deficit not fixed by relearning, leading to poor overall functioning (APA, 2022).

Depersonalization/Derealization Disorder

• Definition: Categorized by recurrent episodes of depersonalization, derealization, or both.
• Depersonalization:     - Feeling of unreality or detachment from oneself; an out-of-body experience where one is an observer of their own thoughts and physical being.     - Reports include feeling like a "robot" (lacking motor or speech control).     - Physical distortions: body parts appearing enlarged or shrunken.     - Emotional numbing: feeling detached from feelings despite being aware they have them.
• Derealization:     - Feeling of unreality or detachment from the world (individuals, objects, surroundings).     - Surroundings may feel unfamiliar even if well-known.     - Feeling emotionally disconnected from close friends or family.     - Sensory/Environmental distortions: environments appearing distorted, blurry, or artificial. Distortions of time, distance, and the size/shape of objects.
• Clinical Signs and Impact:     - Episodes can last hours, days, weeks, or months.     - Onset is usually sudden and triggered by intense stress or trauma.     - Individuals often fear they are "going crazy" or have irreversible brain damage.     - Associated with major morbidity and impairment in interpersonal and occupational spheres due to hypoemotionality, difficulty focusing, and a sense of life-disconnectedness (APA, 2022).

Epidemiology of Dissociative Disorders

• General Prevalence: Once thought to be rare, research suggests higher prevalence in the general population.
• Dissociative Identity Disorder (DID):     - Estimated prevalence in U.S. adults: $1.5\%$.     - Women predominate in adult clinical settings.     - Few gender differences in symptom profiles or trauma history, though women show higher rates of somatization.
• Dissociative Amnesia:     - Occurs in approximately $1.8\%$ of the U.S. population.
• Depersonalization/Derealization Disorder:     - Transient symptoms are common: approximately $50\%$ of adults have experienced at least one episode of depersonalization/derealization in their lifetime.     - Symptomology meeting full diagnostic criteria is less common.     - One-month prevalence in the United Kingdom: approximately $1-2\%$ (APA, 2022).
• Onset Patterns:     - Generally late adolescence to early adulthood.     - DID Exception: Symptoms are believed to begin in early childhood due to repeated abuse exposure, though full onset is often not noticed until adolescence (Sar et al., 2014).

Comorbidity

• Trauma-Related: High comorbidity with PTSD, although the comorbidity of Depersonalization/Derealization Disorder with PTSD is noted as low.
• Mood Disorders: Depressive disorders are commonly found alongside dissociative disorders due to social and emotional functioning impacts.
• Dissociative Amnesia Specifics:     - Emotional distress often emerges once the amnesia episode is in remission (APA, 2022), contributing to depressive episodes.     - Evidence of comorbid Somatic Symptom Disorder and Conversion Disorder.     - Comorbid Personality Traits/Disorders: Dependent, Obsessive-Compulsive, Avoidant, and Borderline.     - Evidence of comorbid substance-related, feeding, and eating disorders.
• Depersonalization/Derealization Specifics:     - Common comorbidities include Anxiety Disorders and unipolar Depressive Disorder.

Etiology: Perspectives on Cause

• Biological Perspective:     - Heritability rates for dissociation are estimated between $50-60\%$ (Pieper et al., 2011).     - Combination of genetics and environmental factors is considered most influential.
• Cognitive Perspective:     - Focuses on a memory retrieval deficit, particularly in Dissociative Amnesia.     - Theory (Kopelman, 2000): Stress and biopsychosocial predispositions affect the frontal lobe's executive system, hindering autobiographical memory retrieval.     - Neuroimaging shows deficits in prefrontal regions (Picard et al., 2013).     - In DID, neuroimaging shows differences in hippocampus activation between subpersonalities (Tsai et al., 1999). The hippocampus converts short-term to long-term memory and may be responsible for generating dissociative states (Staniloiu & Markowitsch, 2010).
• Sociocultural Perspective:     - Influenced by Lilienfeld et al. (1999): Mass media provide a model for individuals to learn about and engage in dissociative behaviors.     - Rise in DID cases after media portrayals like Sybil (the story of a woman with $16$ subpersonalities).     - Media may influence clinical practice by causing therapists to use leading questions or techniques that evoke dissociative symptoms.
• Psychodynamic Perspective:     - Caused by repression of unpleasant or traumatic thoughts and feelings (Richardson, 1998).     - Repression serves as a subconscious protection from painful memories.     - DID results from repeated traumatic exposure (abuse, neglect, abandonment). Children develop subpersonalities to "flee" the dangerous situation (Dalenberg et al., 2012).     - Note: Individuals with DID have the highest rate of childhood psychological trauma compared to all other psychiatric disorders (Sar, 2011).

Treatment Options

• Limitations in Treatment:     - Many individuals with Dissociative Amnesia recover naturally.     - Rarity of disorders limits research on treatment effectiveness.
• Dissociative Identity Disorder Treatment:     - Ultimate Goal: Integration of subpersonalities to the point of final fusion (Chu et al., 2011).     - Integration: Ongoing process of merging subpersonalities. Requires psychoeducation and acknowledging the various personalities.     - Process:         1. Build rapport with the primary personality.         2. Encourage communication and coordination between subpersonalities.         3. Address conflicts between personalities.     - Fusion: When two or more identities join to lose separateness.     - Final Fusion: All subpersonalities are fused into one unified self.     - Challenges: Final fusion is difficult to obtain. Some patients (due to age, history, or comorbid disorders) find it undesirable. Alternative goal: "Resolution" (sufficient integration for independent functioning).     - Maintenance: Post-fusion treatment focuses on social and positive coping skills to prevent relapse.
• Dissociative Amnesia Treatment:     - Hypnosis: Based on the theory that amnesia is self-hypnosis. Clinicians use it to reduce amnesia symptom intensity and walk the patient through memories just before the amnesic period to reorient them (Maldonadao & Spiegel, 2014).     - Barbiturates: Use of "truth serums" to reduce anxiety surrounding memories, allowing them to be processed in a safe environment (Ahern et al., 2000).     - Phasic Therapy: Also used to produce positive effects.
• Depersonalization/Derealization Disorder Treatment:     - Diagnosis alone can be effective by relieving anxiety about the nature of the symptoms.     - Goal: Alleviate secondary health symptoms (anxiety/depression).     - Combined Method: Use of SSRIs for mood improvement along with Cognitive Behavioral Therapy (CBT).     - CBT: Addresses negative attributions and catastrophic appraisals that contribute to symptoms. Reducing overall anxiety subsequently reduces depersonalization/derealization (Medford et al., 2005).

Questions & Discussion

• What is the difference between depersonalization and derealization?     - Depersonalization is a feeling of detachment from oneself (being an observer of one's body/thoughts), while derealization is a feeling of detachment from the world or surroundings (objects/people appearing artificial or unfamiliar).
• Identify the diagnostic criteria for each of the three dissociative disorders. How are they similar? How are they different?     - DID involves distinct personalities and amnesia; Dissociative Amnesia involves memory loss only; Depersonalization/Derealization involves feelings of unreality. They are similar in that they involve disruptions of consciousness and are often trauma-triggered.
• What are the types of amnesia within dissociative amnesia?     - Localized, Selective, Systematized, and Generalized (which includes semantic and procedural deficits).
• What are the prevalence rates for dissociative disorders?     - DID: $1.5\%$. Dissociative Amnesia: $1.8\%$. Depersonalization/Derealization: Transient symptoms in $50\%$ of adults but full criteria prevalence is around $1-2\%$ in targeted studies (UK).
• What are some identified barriers in determining prevalence rates of these disorders?     - Rarity, lack of extensive research, and the fact that some symptoms (like amnesia) are temporary or naturally recovering.
• What are the common comorbid diagnoses for individuals with dissociative disorders?     - PTSD, Depressive disorders, Anxiety disorders, and occasionally Personality or Somatic Symptom disorders.
• How do the biological, cognitive, sociocultural, and psychodynamic perspectives differ in their explanation of the development of dissociative disorders?     - Biological: Focuses on genes (50-60% heritability).     - Cognitive: Focuses on memory retrieval deficits and hippocampal activity.     - Sociocultural: Focuses on media influence and clinician suggestion.     - Psychodynamic: Focuses on repression of trauma and subpersonalities as a defense mechanism to "flee" abuse.
• What is the treatment goal for dissociative identity disorder? How is it achieved?     - Final fusion; achieved through rapport building, communication between alters, addressing conflicts, and merging identities.
• What are the treatment options for dissociative amnesia and depersonalization/derealization disorder?     - Amnesia: Hypnosis, barbiturates, and phasic therapy.     - Depersonalization/Derealization: Diagnosis, CBT, and SSRIs.