Dissociative disorders (DD) are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception. People with dissociative disorders use
dissociation
Dissociation, in the wide sense of the word, is an act of disuniting or separating a complex object into parts. Dissociation may also refer to:
* Dissociation (chemistry), general process in which molecules or ionic compounds (complexes, or salts) ...
as a
defense mechanism
In psychoanalytic theory, a defence mechanism (American English: defense mechanism), is an unconscious psychological operation that functions to protect a person from anxiety-producing thoughts and feelings related to internal conflicts and o ...
, pathologically and involuntarily. The individual experiences these dissociations to protect themselves. Some dissociative disorders are triggered by
psychological trauma
Psychological trauma, mental trauma or psychotrauma is an emotional response to a distressing event or series of events, such as accidents, rape, or natural disasters. Reactions such as psychological shock and psychological denial are typical. ...
, but
depersonalization-derealization disorder may be preceded only by stress,
psychoactive substances
A psychoactive drug, psychopharmaceutical, psychoactive agent or psychotropic drug is a chemical substance, that changes functions of the nervous system, and results in alterations in perception, mood, consciousness, cognition or behavior.
T ...
, or no identifiable trigger at all.
The dissociative disorders listed in the
American Psychiatric Association
The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are involve ...
's
DSM-5
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
are as follows:
*
Dissociative identity disorder
Dissociative identity disorder (DID), better known as multiple personality disorder or multiple personality syndrome, is a mental disorder characterized by the presence of at least two distinct and relatively enduring personality states.
The di ...
(formerly multiple personality disorder): the alternation of two or more distinct personality states with impaired recall among personality states. In extreme cases, the host personality is unaware of the other, alternating personalities; however, the alternate personalities can be aware of all the existing personalities.
[Schacter, D. L., Gilbert, D. T., & Wegner, D.M. (2011). ''Psychology: Second Edition'', pages 572-573 New York, NY: Worth.]
*
Dissociative amnesia
Psychogenic amnesia or dissociative amnesia is a memory disorder characterized by sudden retrograde episodic memory loss, said to occur for a period of time ranging from hours to years to decades. More recently, "dissociative amnesia" has been d ...
(formerly psychogenic amnesia): the temporary loss of recall memory, specifically
episodic memory
Episodic memory is the memory of everyday events (such as times, location geography, associated emotions, and other contextual information) that can be explicitly stated or conjured. It is the collection of past personal experiences that occurred ...
, due to a traumatic or stressful event. It is considered the most common dissociative disorder amongst those documented. This disorder can occur abruptly or gradually and may last minutes to years depending on the severity of the trauma and the patient.
Dissociative fugue was previously a separate category but is now treated as a specifier for dissociative amnesia.
*
Depersonalization-derealization disorder: periods of detachment from self or surrounding which may be experienced as "unreal" (lacking in control of or "outside" self) while retaining awareness that this is only a feeling and not a reality.
* The old category of
dissociative disorder not otherwise specified is now split into two: other specified dissociative disorder, and unspecified dissociative disorder. These categories are used for forms of pathological dissociation that do not fully meet the criteria of the other specified dissociative disorders; or if the correct category has not been determined; or the disorder is transient.
The
ICD-11
The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World H ...
lists dissociative disorders as:
* Dissociative neurological symptom disorder
* Dissociative amnesia
* Dissociative amnesia with
dissociative fugue
Dissociative fugue (), formerly called a fugue state or psychogenic fugue, is a mental disorder, mental and Abnormal behavior, behavioral Disorder (medicine), disorderDrs; that is nosology, classified variously as a dissociative disorder,Dissoci ...
* Trance disorder
* Possession trance disorder
* Dissociative identity disorder
* Partial dissociative identity disorder
* Depersonalization-derealization disorder
Cause and treatment
Dissociative identity disorder
Cause: Dissociative identity disorder is caused by ongoing
childhood trauma
Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and ...
that occurs before the ages of six to nine. People with dissociative identity disorder usually have close relatives who have also had similar experiences.
Treatment: Long-term
psychotherapy
Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome pro ...
to improve the patient's quality of life.
Dissociative amnesia
Cause: A way to cope with trauma.
Treatment: Psychotherapy (e.g. talk therapy) counseling or psychosocial therapy which involves talking about your disorder and related issues with a mental health provider. Psychotherapy often involves hypnosis (help you remember and work through the trauma); creative art therapy (using creative process to help a person who cannot express his or her thoughts); cognitive therapy (talk therapy to identify unhealthy and negative beliefs/behaviors); and medications (antidepressants, anti-anxiety medications, or sedatives). These medications help control the symptoms associated with the dissociative disorders, but there are no medications yet that specifically treat dissociative disorders. However, the medication
pentothal
Sodium thiopental, also known as Sodium Pentothal (a trademark of Abbott Laboratories), thiopental, thiopentone, or Trapanal (also a trademark), is a rapid-onset short-acting barbiturate general anesthetic. It is the thiobarbiturate analog of ...
can sometimes help to restore the memories.
The length of an event of dissociative amnesia may be a few minutes or several years. If an episode is associated with a traumatic event, the amnesia may clear up when the person is removed from the traumatic situation.
Dissociative fugue
Dissociative fugue (), formerly called a fugue state or psychogenic fugue, is a mental disorder, mental and Abnormal behavior, behavioral Disorder (medicine), disorderDrs; that is nosology, classified variously as a dissociative disorder,Dissoci ...
was a separate category but is now listed as a specifier for dissociative amnesia.
Depersonalization-derealization disorder
Cause: Dissociative disorders usually develop as a way to cope with trauma. The disorders most often form in children subjected to chronic physical, sexual or emotional abuse or, less frequently, a home environment that is otherwise frightening or highly unpredictable; however, this disorder can also acutely form due to severe traumas such as war or the death of a loved one.
Treatment: Same treatment as dissociative amnesia. An episode of depersonalization-derealization disorder can be as brief as a few seconds or continue for several years.
Dissociative disorders, especially dissociative identity disorder (DID), while being the result of extraordinary abuse and trauma in childhood, it should not be attributed exotic status. DID would be better examined through a more holistic lens, taking into considering the social, cognitive, and neural components, and how they interact with one another.
Medications
There are no medications to treat dissociative disorders, however, drugs to treat anxiety and depression that may accompany the disorders can be given.
Diagnosis and prevalence
The lifetime prevalence of dissociative disorders varies from 10% in the general population to 46% in psychiatric inpatients.
Diagnosis can be made with the help of structured clinical interviews such as the Dissociative Disorders Interview Schedule (DDIS) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R), and behavioral observation of dissociative signs during the interview.
Additional information can be helpful in diagnosis, including the
Dissociative Experiences Scale
The Dissociative Experiences Scale (DES) is a psychological self-assessment questionnaire that measures dissociative symptoms.
Background
It contains twenty-eight questions and returns an overall score as well as four sub-scale results.
DES is ...
or other questionnaires, performance-based measures, records from doctors or academic records, and information from partners, parents, or friends.
A dissociative disorder cannot be ruled out in a single session and it is common for patients diagnosed with a dissociative disorder to ''not'' have a previous dissociative disorder diagnosis due to a lack of clinician training.
Some diagnostic tests have also been adapted or developed for use with children and adolescents such as the Adolescent Dissociative Experiences Scale,
Children's Version of the Response Evaluation Measure (REM-Y-71), Child Interview for Subjective Dissociative Experiences, Child Dissociative Checklist (CDC),
Child Behavior Checklist The Child Behavior Checklist (CBCL) is a widely used caregiver report form identifying problem behavior in children.Achenbach, T.M., & Rescorla, L. A. (2001). ''Manual for the ASEBA School-Age Forms and Profiles.'' Burlington, VT: University of Verm ...
(CBCL) Dissociation Subscale, and the Trauma Symptom Checklist for Children Dissociation Subscale.
Dissociative disorders have been found to be quite prevalent in outpatient populations, as well as within low-income communities. One study found that in a population of poor inner-city outpatients, there was a 29% prevalence of dissociative disorders.
There are problems with classification, diagnosis and therapeutic strategies of dissociative and conversion disorders which can be understood by the historic context of
hysteria
Hysteria is a term used colloquially to mean ungovernable emotional excess and can refer to a temporary state of mind or emotion. In the nineteenth century, hysteria was considered a diagnosable physical illness in women. It is assumed that ...
. Even current systems used to diagnose DD such as the DSM-IV and ICD-10 differ in the way the classification is determined. In most cases mental health professionals are still hesitant to diagnose patients with Dissociative Disorder, because before they are considered to be diagnosed with Dissociative Disorder these patients have more than likely been diagnosed with
major depressive disorder
Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introdu ...
,
anxiety disorder
Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal function are significantly impaired. Anxiety may cause physi ...
, and most often
post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
. It has been found from interviews with those who may be afflicted with dissociative disorders may be more effective at getting an accurate diagnosis than self-scoring assessments and scales.
The prevalence of dissociative disorders is not completely understood due to the many difficulties in diagnosing dissociative disorders. Many of these difficulties stem from a misunderstanding of dissociative disorders, from an unfamiliarity diagnosis or symptoms to disbelief in some dissociative disorders entirely. Due to this it has been found that only 28% to 48% of people diagnosed with a dissociative disorder receive treatment for their mental health.
Patients who are misdiagnosed are often those more likely to be hospitalised repeatedly, and lack of treatment can result in intensive outpatient treatment and higher rates of disability.
An important concern in the diagnosis of dissociative disorders in forensic interviews is the possibility that the patient may be feigning symptoms in order to escape negative consequences. Young criminal offenders report much higher levels of dissociative disorders, such as amnesia. In one study it was found that 1% of young offenders reported complete amnesia for a violent crime, while 19% claimed partial amnesia. There have also been cases in which people with dissociative identity disorder provide conflicting testimonies in court, depending on the personality that is present.
The world-wide prevalence of dissociative disorders is not well understood due to different cultural beliefs surrounding human emotions and the human brain.
Children and adolescents
Dissociative disorders (DD) are widely believed to have roots in
adverse childhood experiences Adverse childhood experiences (ACEs) encompass various forms of physical and emotional abuse, neglect, and household dysfunction experienced in childhood. The harms of ACEs can be long-lasting, affecting people even in their adulthood. ACEs have ...
including abuse and loss, but the symptoms often go unrecognized or are misdiagnosed in children and adolescents.
However, a recent western Chinese study showed an increase in awareness of dissociative disorders present in children These studies show that DD's have an intricate relationship with the patient's mental, physical and socio-cultural environments. This study suggested that dissociative disorders are more common in Western, or developing countries, however, some cases have been seen in both clinical and non-clinical Chinese populations. There are several reasons why recognizing symptoms of dissociation in children is challenging: it may be difficult for children to describe their internal experiences; caregivers may miss signals or attempt to conceal their own abusive or neglectful behaviors; symptoms can be subtle or fleeting; disturbances of memory, mood, or concentration associated with dissociation may be misinterpreted as symptoms of other disorders.
Another resource, Beacon House, informs us of dissociative disorder in children, suggesting that it is a survival mechanism that often goes unnoticed in children that have been traumatised. Dr. Shoshanah Lyons suggests that traumatised children often continue to dissociate even though they might not be in any danger, and that they are often unaware that they are dissociating. In addition to developing diagnostic tests for children and adolescents (see above), a number of approaches have been developed to improve recognition and understanding of dissociation in children. Recent research has focused on clarifying the neurological basis of symptoms associated with dissociation by studying neurochemical, functional and structural brain abnormalities that can result from childhood trauma. Others in the field have argued that recognizing disorganized attachment (DA) in children can help alert clinicians to the possibility of dissociative disorders. In their 2008 article, Rebecca Seligman and Laurence Kirmayer suggest the existence of evidence of linkages between trauma experienced in childhood and the capacity for dissociation or depersonalisation. They also suggest that individuals who are able to utilise dissociative techniques are able to keep this as an extended strategy to cope with stressful situations.
Clinicians and researchers stress the importance of using a developmental model to understand both symptoms and the future course of DDs.[ In other words, symptoms of ]dissociation
Dissociation, in the wide sense of the word, is an act of disuniting or separating a complex object into parts. Dissociation may also refer to:
* Dissociation (chemistry), general process in which molecules or ionic compounds (complexes, or salts) ...
may manifest differently at different stages of child and adolescent development and individuals may be more or less susceptible to developing dissociative symptoms at different ages. Further research into the manifestation of dissociative symptoms and vulnerability throughout development is needed. Related to this developmental approach, more research is required to establish whether a young patient's recovery will remain stable over time.
Current debates and the DSM-5
A number of controversies surround DD in adults as well as children. First, there is ongoing debate surrounding the etiology
Etiology (pronounced ; alternatively: aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek (''aitiologÃa'') "giving a reason for" (, ''aitÃa'', "cause"); and ('' -logÃa''). More completely, e ...
of dissociative identity disorder
Dissociative identity disorder (DID), better known as multiple personality disorder or multiple personality syndrome, is a mental disorder characterized by the presence of at least two distinct and relatively enduring personality states.
The di ...
(DID). The crux of this debate is if DID is the result of childhood trauma and disorganized attachment. A proposed view is that dissociation has a physiological basis, in that it involves automatically triggered mechanisms such as increased blood pressure and alertness, that would, as Lynn contends, imply its existence as a cross-species disorder. A second area of controversy surrounds the question of whether or not dissociation as a defense versus pathological dissociation are qualitatively or quantitatively different. Experiences and symptoms of dissociation
Dissociation, in the wide sense of the word, is an act of disuniting or separating a complex object into parts. Dissociation may also refer to:
* Dissociation (chemistry), general process in which molecules or ionic compounds (complexes, or salts) ...
can range from the more mundane to those associated with posttraumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
(PTSD) or acute stress disorder (ASD) to dissociative disorders. Mirroring this complexity, the DSM-5 workgroup considered grouping dissociative disorders with other trauma/stress disorders, but instead decided to put them in the following chapter to emphasize the close relationship. The DSM-5 also introduced a dissociative subtype of PTSD.
A 2012 review article supports the hypothesis that current or recent trauma may affect an individual's assessment of the more distant past, changing the experience of the past and resulting in dissociative states. However, experimental research in cognitive science continues to challenge claims concerning the validity of the dissociation construct, which is still based on Janetian notions of structural dissociation. Even the claimed etiological link between trauma/abuse and dissociation has been questioned. Links observed between trauma/abuse and DD are largely only present from a Western cultural context. For non-Western cultures dissociation "may constitute a "normal" psychological capacity". An alternative model proposes a perspective on dissociation based on a recently established link between a labile
Lability refers to something that is constantly undergoing change or is likely to undergo change.
Biochemistry
In reference to biochemistry, this is an important concept as far as kinetics is concerned in metalloproteins. This can allow for th ...
sleep–wake cycle and memory errors, cognitive failures, problems in attentional control, and difficulties in distinguishing fantasy from reality."
Debates around DD also stem from Western versus non-Western lenses of viewing the disorder, and associated views of causes of DD. DID was initially believed to be specific to the West, until cross-cultural studies indicated its occurrence worldwide. Conversely, anthropologists have largely done little work on DD in the West relating to its perceptions of possession syndromes that would be present in non-Western societies. While dissociation has been viewed and catalogued by anthropologists differently in the West and non-Western societies, there are aspects of each that show DD has universal characteristics. For example, while shamanic and rituals of non-Western societies may hold dissociative aspects, this is not exclusive as many Christian sects, such as "possession by the Holy Ghost" share similar qualities to those of non-Western trances.
See also
* Complex post-traumatic stress disorder
Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder that is theorized to develop in response to exposure to a series of traumatic events in a context in which the individual perceive ...
References
External links
Dissociative disorders
€”Mayo Clinic
The Mayo Clinic () is a nonprofit American academic medical center focused on integrated health care, education, and research. It employs over 4,500 physicians and scientists, along with another 58,400 administrative and allied health staff, ...
Depersonalization Disorder
€”Cleveland Clinic
Cleveland Clinic is a nonprofit American academic medical center based in Cleveland, Ohio. Owned and operated by the Cleveland Clinic Foundation, an Ohio nonprofit corporation established in 1921, it runs a 170-acre (69 ha) campus in Cleveland, ...
International Society for the Study of Trauma and Dissociation
{{Authority control
Dissociative disorders