| Dissociative disorder | |
|---|---|
| Specialty | Psychiatry, psychology |
Dissociative disorders (DD) are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception. People with dissociative disorders use dissociation as a defense mechanism, pathologically and involuntarily. Some dissociative disorders are triggered by psychological trauma, but dissociative disorders such as depersonalization/derealization disorder may be preceded only by stress, psychoactive substances, or no identifiable trigger at all.
The dissociative disorders listed in the American Psychiatric Association's DSM-5 are as follows:
- Dissociative identity disorder
(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. This category now includes the old derealization disorder category.
- Dissociative amnesia (formerly psychogenic amnesia): the temporary loss of recall memory, specifically episodic memory, 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 (formerly psychogenic fugue) is now subsumed under the dissociative amnesia category. It is described as reversible amnesia for personal identity, usually involving unplanned travel or wandering, sometimes accompanied by the establishment of a new identity. This state is typically associated with stressful life circumstances and can be short or lengthy.
- Depersonalization 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.
- Dissociative seizures also known as psychogenic non-epileptic seizures: seizures that are often mistaken for epilepsy but are not caused by electrical pulses in the brain and are in fact another form of dissociation.
- 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.
Cause and treatment
Dissociative identity disorder
Cause: Dissociative identity disorder is caused by ongoing childhood trauma 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 to improve the patients 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
tranquilizers). These medications help control the mental health
symptoms associated with the disorders, but there are no medications
that specifically treat dissociative disorders. However, the medication Pentothal 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
Cause: A stressful event that happens in adulthood.
Treatment: Hypnosis is often used to help patient recall
true identity and remember events of the past. Psychotherapy is helpful
for the person who has traumatic, past events to resolve. Once dissociative fugue is discovered and treated, many people recover quickly. The problem may never happen again.
Depersonalization 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, and
same drugs. An episode of depersonalization disorder can be as brief as a
few seconds or continue for several years.
Specific psychopharmacology
As
mentioned earlier, anti-anxiety, antidepressants and tranquilizers are
treatment medications that do not cure, but may help control the
symptoms of dissociative disorders.
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 interviews such as
the Dissociative Disorders Interview Schedule (DDIS) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), or with the Dissociative Experiences Scale (DES) which is a self-assessment questionnaire.
Some diagnostic tests have also been adapted or developed for use with
children and adolescents such as the Children's Version of the Response
Evaluation Measure (REM-Y-71), Child Interview for Subjective
Dissociative Experiences, Child Dissociative Checklist (CDC), Child Behavior Checklist (CBCL) Dissociation Subscale, and the Trauma Symptom Checklist for Children Dissociation Subscale.
There are problems with classification, diagnosis and therapeutic
strategies of dissociative and conversion disorders which can be
understood by the historic context of hysteria. 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 depression, anxiety
disorder, and most often post-traumatic disorder.
An important concern in the diagnosis of dissociative disorders
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.
Children and adolescents
Dissociative
disorders (DD) are widely believed to have roots in traumatic childhood
experience (abuse or loss), but symptomology often goes unrecognized or
is misdiagnosed in children and adolescents.
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.
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.
Clinicians and researchers also stress the importance of using a
developmental model to understand both symptoms and the future course of
DDs. In other words, symptoms of dissociation
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 of dissociative identity disorder (DID). The crux of this debate is if DID is the result of childhood trauma and disorganized attachment.
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 can range from the more mundane to those associated with posttraumatic stress disorder (PTSD) or acute stress disorder (ASD) to dissociative disorders.
Mirroring this complexity, it is still being decided whether the DSM-5
will group dissociative disorders with other trauma/stress disorders.
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 Freudian notions of repression. Even the claimed
etiological link between trauma/abuse and dissociation has been
questioned. An alternative model proposes a perspective on dissociation
based on a recently established link between a labile sleep–wake cycle
and memory errors, cognitive failures, problems in attentional control,
and difficulties in distinguishing fantasy from reality."
