Dissociative Disorders

 

What is a dissociative disorder?

When individuals feel detached from themselves or their surroundings, almost as if they are dreaming or living in slow motion, they are having dissociative experiences. 

These kind of experiences can be divided into two types-

1. Depersonalization: your perception alters so that you temporarily lose the sense of your own reality as if you were in a dream and you were watching yourself. 
2. Derealization: your sense of reality of the external world is lost. Things may seem to change shape or size; people may seem dead or mechanical.

These sensations of unreality are characteristic of dissociative disorders because, in a sense, they are a psychological mechanism whereby one 'dissociates' from reality. 

Causes of Dissociative Disorders (Etiology): 

ENVIORNMENTAL:-

Interpersonal physical and sexual abuse.

Prevalence of childhood abuse and neglect. 

Other: childhood medical and surgical procedures, war, childhood prostitution, terrorism. 

Influence of social and cultural factors.

Stress, illicit drug use. 

TEMPERAMENTAL:- 

Characterized by harm avoidant temperament, immature defenses.

Disconnection: reflects defectiveness, and emotional inhibition and subsume themes of abuse, neglect and deprivation. 

Over connection: involve impaired autonomy with themes of dependency, vulnerability and incompetence.  

COURSE MODIFIERS:- 

Ongoing abuse, late-life retraumatization, comorbidity with mental disorders, several medical illness, delay in treatment. 

Treatment: 

DRUG:-

Little evidence is shown for antidepressant drugs.

PSYCHOLOGICAL TREATMENT:-

Long-term Psychotherapy: Therapeutic resolution of the distressing situations and increasing the strength of personal coping mechanisms. It focuses on recalling what happened during the amnesic or fugue states, often with the help of friends and family who know what happened, so the patient can confront the information and integrate it into their conscious experience. 

Hypnosis is often used to access unconscious memories and bring various alters into awareness. 

Below you will find a list of different Dissociative Disorders:

1. Depersonalization-Derealization Disorder (DDD) 

When feelings of unreality are so severe and frightening that they dominate an individual's life and prevent normal functioning. 

Diagnostic Criteria:

A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:

1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one's thoughts, feelings, sensations, body, or actions (e.g.. perceptual alterations, distorted sense of time, unreal or absent self, emotional and/ or physical numbing).
2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, life- less, or visually distorted).

B. During the depersonalization or derealization experiences, reality testing remains intact.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).

E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.

Diagnostic features: 

Abbreviated description- 

• surrounding seem unreal
• looking at the world through a fog
• body does not belong to one
• did not hear part of conversation
• finding familiar place strange and unfamiliar
• staring off into space; unaware of time
• can't remember if just did something or thought it
• do usually difficult things with ease/spontaneity
• act so differently/feel like two different people
• talk out loud to oneself when alone

1.    Diminished sense of agency (e.g., feeling robotic, like an automaton, lacking control of one's speech or movements)

2.    The unitary symptom of "depersonalization" consists of several symptom factors: anomalous body experiences (i.e., unreality of the self and perceptual alterations); emotional or physical numbing; and temporal distortions with anomalous subjective recall. 

3.   Derealization is commonly accompanied by subjective visual distortions, such as blurriness, heightened acuity, widened or narrowed visual field, two-dimensionality or flatness, exaggerated three-dimensionality, or altered distance or size of objects (i.e., macropsia or micropsia). 

4.    Auditory distortions can also occur, whereby voices or sounds are muted or heightened. 

5.    May think they are "crazy" or "going crazy". 

6.    Fear of irreversible brain damage. 

7.    Subjectively altered sense of time (i.e., too fast or too slow).

8.   Subjective difficulty in vividly recalling past memories and owning them as personal and emotional.

9.    Individuals may suffer extreme rumination or obsessional preoccupation (e.g., constantly obsessing about whether they really exist, or checking their perceptions to determine whether they appear real).

10.    Varying degrees of anxiety and depression are also common associated features. 

Prevalence:

In general, approximately one-half of all adults have experienced at least one lifetime episode of depersonalization/derealization. However, symptomatology that meets full criteria for depersonalization/derealization disorder is markedly less common than transient symptoms. Lifetime prevalence in U.S. and non-U.S. countries is approximately 2% (range of 0.8% to 2.8%). The gender ratio for the disorder is 1:1.

Development and Course:

The mean age at onset- 16 years, 

Start in early or middle childhood. 

Less than 20% of individuals experience onset after age 20 years and only 5% after age 25 years. 

Onset can range from extremely sudden to gradual. 

Duration- vary greatly, from brief (hours or days) to prolonged (weeks, months, or years). 

2. Dissociative Amnesia (DA) 

Dissociative Amnesia is different from Amnesia in Cognitive Disorder. DA is caused by psychological trauma or extreme stress while Amnesia is a result of medical disorder or physical cause. 

Diagnostic Criteria:

A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.

    Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/traumatic brain injury, other neurological condition). 

D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.

    Coding note: The code for dissociative amnesia without dissociative fugue is 300.12 (F44.0). The code for dissociative amnesia with dissociative fugue is 300.13 (F44.1).

    Specify if: 300.13 (F44.1) With dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information.

Diagnostic features: 

Localized/selective Amnesia: a failure to recall specific events, usually traumatic, that occur during a specific period. Minimize the importance of their memory loss and may become uncomfortable when prompted to address it. 

Generalized Amnesia: a failure to remember anything, including who they are, one's life history. May be lifelong or extend from a period in the more recent past, such as 6 months or a year previously. 

Systematized Amnesia: the individual loses memory for a specific category of information (e.g., all memories relating to one's family, a particular person, or childhood sexual abuse). 

Continuous Amnesia: the individual forgets each new even as it happens. 

1. Chronically impaired in their ability to form and sustain satisfactory relationships. 
2. Histories of trauma, child abuse, and victimization are common. 
3. Report dissociative flashbacks (i.e., behavioral reexperiencing of traumatic events). 
4. History of self- mutilation, suicide attempts, and other high-risk behaviors. 
5. Depressive and functional neurological symptoms are common. 
6. Sexual dysfunctions are common. 
7. Mild traumatic brain injury may precede dissociative amnesia.

Prevalence:

The 12-month prevalence for dissociative amnesia among adults in a small U.S. commu- nity study was 1.8% (1.0% for males; 2.6% for females).

Development and Course:

Onset- usually sudden. 

Less is known because seldom evident, even to the individual. 

Onset may be delayed for hours, days, or longer.

The duration of the forgotten events can range from minutes to decades. 

Some episodes of dissociative amnesia resolve rapidly (e.g.. when the person is removed from combat or some other stressful situation), whereas other episodes persist for long periods of time. 

Dissociative amnesia has been observed in young children, adolescents, and adults. 

3. Dissociative Identity Disorder (DID) 

Earlier called as Multiple personality disorder, in this disorder people may adopt as many as 100 new identities, all simultaneously coexisting, although the average number is closer to 15. These identities are partially independent with a few distinct characteristics like behavior, tone of voice, physical gestures. 

Diagnostic Criteria:

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.

B. Recurrent gaps in the recall of everyday events, important personal information, and/ or traumatic events that are inconsistent with ordinary forgetting.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.

    Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.

E. The symptoms are not attributable to the physiological effects of a substance (e.g.. blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Diagnostic features: 

1. Report feeling like that they have become depersonalized observers of their 'own' speech and actions, which they may feel powerless to stop. 

2. May report perception of voices: voices are multiple, perplexing, independent thought streams. 

3. They often conceal or are not fully aware of, disruptions in consciousness, amnesia or other dissociative symptoms. 

4. Report multiple type of interpersonal maltreatment during childhood and adulthood. 

5. Present with comorbid depression, anxiety, substance abuse, self-injury, non-epileptic seizures, or other common symptoms. 

Prevalence:

The 12-month prevalence of dissociative identity disorder among adults in a small U.S. community study was 1.5%. The prevalence across genders in that study was 1.6% for males and 1.4% for females.

Development and Course:

• The full disorder may first manifest at al- most any age (from earliest childhood to late life). 
• Problems in children: memory, concentration, attachment, and traumatic play. 
• Problems in adolescence: adolescent turmoil or the early stages of another mental disorder. 
• Problems in older individuals: late-life mood disorders, obsessive-compulsive disorder, paranoia, psychotic mood disorders, or even cognitive disorders due to dissociative amnesia. 

Psychological decompensation and overt changes in identity may be triggered by 1) removal from the traumatizing situation (e.g., through leaving home); 2) the individual's children reaching the same age at which the individual was originally abused or traumatized; 3) later traumatic experiences, even seemingly inconsequential ones, like a minor motor vehicle accident; or 4) the death of, or the onset of a fatal illness in, their abuser(s).