Dissociative Disorders PDF

Dissociative Disorders Learning objectives Be familiar with symptoms of the various dissociative disorders. Be able to discuss the issues surrounding the concept of dissociation Be able to discuss the models of Dissociative Identity Disorder...

Dissociative Disorders Learning objectives Be familiar with symptoms of the various dissociative disorders. Be able to discuss the issues surrounding the concept of dissociation Be able to discuss the models of Dissociative Identity Disorder 1  DSM-5 Emphasis on dissociation per se “disruption in usually integrated functions of consciousness, memory, identity or perception of environment”  involuntary Often assumed to be a coping mechanism triggered by exposure to extreme stress/trauma Issues related to Dissociation Uniqueness of clinical phenomena? Normal absorption versus completely altered states of consciousness Some forms are widespread- Depersonalization Disorder Dissociation linked to suggestibility, fantasy proneness & false memories in lab tasks (van den Klout et al, 2013) Links to sleep loss (Lynn et al, 2012) 2  Research limitations Small ns Dimensional approach Combine different disorders Flawed treatment studies Dissociative Disorders DSM-5 Depersonalization Disorder Dissociative Amnesia Dissociative Fugue Dissociative Identity Disorder (DID) 3  Depersonalization/Derealization Disorder Depersonalization: Persistent experiences of feeling detached from one’s mental processes or body May feel like outside observers Derealization: Experiences of unreality or detachment to surroundings Reality testing intact Clinical picture Mild, transient episodes: 50%  Severe chronic DPD: 0.8-2.8%  Higher in young people Little research Often follows stressful life event Tendency to selectively inhibit emotions May mark inhibitory control of emotion circuits 4  Dissociative amnesia Inability to recall important personal information Usually of a traumatic nature Greater than normal forgetting Generalized- less common Localized and selective Dissociative amnesia Dissociative fugue- Amnesia plus travel rare Trance & possession are common parts of some traditional religious and cultural movement Not considered pathological Must be considered pathological by people in that culture 5  Clinical Picture Prevalence: perhaps 1.8%-7.3%  50% mild, intermittent or single episode Onset: Sudden Emotion modulation: Evidence of inhibition of the hippocampus & occipital cortex (memory circuits) Some evidence of excessive control of limbic regions by prefrontal cortical regions “hard-wired inhibitory response” Rule Out Organic brain disorder  Often difficult to distinguish  Subthreshold brain injury Post-concussion amnesia Substance-induced disorders Malingering 6 DSM-5 Dissociative Identity Disorder (DID) Disruption of identity (sense of self) Recurrent dissociative amnesias “Coming to” – find self in unfamiliar places Finding unfamiliar objects Not consistent with broadly accepted cultural or religious practices Etiology Complex traumas  Combat  Cult abuse  Childhood trauma/abuse  Less common among older people Effects of trauma on fragile minds: An unintegrated mind 7  Clinical Picture Prevalence: accurate figures unknown Twin studies: Heritability factor of 50% Inconsistent data Onset: Adolescence or early adult 90% report childhood trauma Research on trauma is often flawed Presenting complaint often depression with headaches Chronic in absence of treatment Rule Out Schizophrenia and other psychotic disorders  Relationship with BPD unclear  Some researchers view DID as extreme BPD or PTSD  30% don’t meet BPD criteria Malingering for financial or forensic gain Factitious Disorder Socially-created symptoms 8  Models of DID Biological 1. Epilepsy-like condition – only minority of pts. 2. Blocking of memory circuits 3. Emotional Over-modulation  No convergent neuroimaging evidence Trauma model Coping response to childhood trauma Recall: Complex PTSD Alters reflect aspects of personality being dissociated Most common is sexual 9 Critiques of trauma model Dissociation associated with other conditions- panic disorder, PTSD Trauma history  Corroboration can be missing  Cross-sectional designs  Family maladjustment better predictor  Selection and referral biases Critiques of trauma model Dramatic increase from 1970s to 2000 Greater prevalence in USA Leading questions in assessment & treatment Many DID pts show few signs of condition prior to psychotherapy Most DID diagnoses derive from approximately 200 mental health specialists in DID 10 Critiques of trauma model Links to sleep disturbance & other sleep-loss conditions  Longitudinal study (van der Kloet et al., 2012)  Sleep hygiene treatment reduced dissociative symptoms Socio-cognitive model (e.g., Lynn et al, 2014) Role enactment in suggestible individual suffering from intense emotional symptoms Not malingering Constructed through suggestion “Recovered memory” phenomena 11  Social-cultural Disorder of self- Vulnerabilities influences understanding Biological Ambiguous psychological Self-reports of vulnerabilities symptoms trauma Dysfunctional family Sleep disruption False memories of trauma High negative Highly aversive events emotionality Acceptance of Suggestive influences implicit & explicit Fantasy proneness leading questions suggestions repeated questioning Suggestibility hypnosis Dissociative symptoms Media & sociocultural influences being suggested that something occur Conclusions DID remains a complex and controversial diagnosis Lack of research and clear definitions of dissociation contribute to skepticism in many professionals but a group of professionals champion the diagnosis 12