Dissociative Disorders

At the most basic level …

• Disorders dealing with disruptions or interruptions of typical consciousness

• Patients lose track of who, where, and why with respect to identity and self-awareness

• Also, profound memory deficits

• Assumed to arise from stressful experiences but don’t involve typical anxiety symptoms

Dissociation

• A process in which some or all of our mental processes are separated from the main stream of consciousness, or

• When our actions lose their connection with the rest of our personality

Dissociative Disorders - Overview

• Three types recognized in DSM 5• All involve caused by dissociation which leads

to some aspects of cognition, memory, or experience to be inaccessible consciously

• Consciousness fails to perform its essential task, the seamless integration of our thoughts, emotions, motivations, and other aspects into our experience

On the other hand …

• Mild forms of dissociation are everyday experiences

• Automatization – to perform a task without conscious awareness

• You suddenly find yourself in your driveway without any memory of your trip

• But for these disorders, the dissociation is much more severe

Why?

• Both the behavioral and psychodynamic theorists think that these severe levels of disconnectedness arise from an avoidance response

• Protects person from experiencing significant fear and/or anxiety

• Soldiers involved in intense military survival training report many brief instances

A lot we don’t know

• Lots of uncertainty • We just don’t know much about these

disorders• Worse yet, there are major disputes regarding

risk factors and treatment• Another reason arises from their scarcity• One in a thousand?• Even less?

Is it just repression?

• Psychodynamic theorists have an easy explanation

• Some people, when placed under great stress, repress (purposefully forget) experiences, traumatic events, even their identity

• But much evidence shows that trauma causes enhanced memory of the essential features of the threat

Dissociative Amnesia

• The inability to recall important personal information, usually concerning a bad experience

• This problem cannot be explained by ordinary forgetfulness

• These memories are unavailable during the amnesia episode

• But they can be retrieved once it episode passes

Fugue

• Now a subtype of Dissociative Amnesia• Rare but fascinating• More severe than typical dissociative

amnesias• Can involve limited but seemingly purposeful

travel• Recovery usually complete except for what

happened under fugue state

Memory Distinctions

• Dissociative Amnesia involves, by definition, problems with memory

• But while explicit memory (memories we express in words) is disrupted ….

• Implicit memory (memories based on experiences without conscious awareness) is not

Depersonalization/Derealization

• Depersonalization – a disconnection from your mental processes or body

• You feel like a robot, like you have been lifted from your body and are observing yourself

• Derealization – a disconnection from your surroundings

• Nothing is real, everyone is a robot, the “world” of the Matrix

Characteristics

• Does not involve memory problems• Usually begins in adolescence and then

persists• Comorbidity is common, 2/3s experience

depression and anxiety• Childhood trauma is often found

Dissociative Identity Disorder (DID)

• DSM 5 1) at least two separate personalities (alters) 2) they have unique personalities, including

differing and distinct: a) cognition b) behavior c) emotions d) memories, etc.

More DID criteria

3) these alters may be seen by others , or reported by the patient

4) gaps in memory that are beyond simple forgetting’

5) condition must be chronic 6) can’t be explained by cultural influences,

drugs or religious beliefs.

Alters

• Differing personalities• Behaviors. • Handedness• Memories• Allergies• Eye glasses prescriptions• Foods

Miscellaneous

• More women than men• Begins as kids but generally not diagnosed til

early adulthood• More severe than other Dissociative disorders• Tougher and longer for treatment • Often found with PTSD, major depressive

disorder and somatic • Often physiological symptoms

Why are some skeptical?

• Startling increases in diagnosis• No cases prior to 1800• Few between 1920 and the 70’s• Huge uptick after Sybil and The Three Faces of

Eve in the mid-70’s• But very few cases in China and other places• Are some therapists merely finding what they

were looking for?

Posttraumatic model

• Some people are predisposed to dissociation• If they experience severe childhood trauma• Alters develop to cope with the trauma

• But the condition is so rare, there are no studies

Are some just role-playing?

• Maybe some people just jump into the culturally composed role of the “Multiple Personality Patient”

• This is prompted by the work of therapists who suggest the existences of the alters then use hypnosis to “confirm” that they are real

• Well publicized media reports provide a template

Support for “role playing”

• Some traumatized have considerable experience with fantasy lives

• They may deeply wish they were someone else• They are also eager to please their therapist• Many therapeutic techniques do reward

patients for revealing alters• People can readily invent alternate personalities

Are the alters really distinct?

• Clever studies demonstrate that alters share implicit memories

• In another study it was established that alters also share explicit memories

• The uniqueness of each alter seems more apparent than real

Reliability ?

• A disproportionate number of DID diagnoses come from a small number of clinicians

• In Switzerland, 66% of diagnoses came from 10% of psychiatrists

• In some clinics, DID is never indicated

Does DID develop in treatment?

• Usually, evidence of DID only develops during therapy – patients had no awareness of alters earlier

• Were they suggested by overeager clinicians?

• But a study of murders found some DID symptoms (trances, differing handwriting) in childhood

Treatment

• All therapists take a gentle, empathetic approach

• Goal – to function as a completely integrated person

• This is done by teaching strategies to effectively deal with stress

• Meds don’t influence the presence of the alters

Psychodynamics & DID treatment

• Most popular therapeutic approach• But still very few• Great efforts to reverse the effects of

repression• Since DID are highly hypnotizable, it is used to

go back to the childhood abuse through age regression

• Controversial and harmful