Dissociative Disorders

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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
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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?
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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

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