L6 Dissociative Disorder PDF

Dissociative Disorder Ms. Aimee B. Maloles, RPsy, RPm  Dissociative disorders are mental disorders that involve experiencing a disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity. People with dissociative disorders escape reality in ways th...

Dissociative Disorder Ms. Aimee B. Maloles, RPsy, RPm  Dissociative disorders are mental disorders that involve experiencing a disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity. People with dissociative disorders escape reality in ways that are involuntary and unhealthy and cause problems with functioning in everyday life. Dissociative disorders involve problems with memory, identity, emotion, perception, behavior and sense of self. Dissociative symptoms can potentially disrupt every area of mental functioning (APA). Examples of dissociative symptoms include the experience of detachment or feeling as if one is outside one’s body, and loss of memory or amnesia. Dissociative disorders are frequently associated with previous experience of trauma.  There are three main types of dissociative disorders: Dissociative Identity Disorder Dissociative identity disorder is associated with overwhelming experiences, traumatic events and/or abuse that occurred in childhood. Dissociative identity disorder was previously referred to as multiple personality disorder. Symptoms of dissociative identity disorder (criteria for diagnosis) include: The existence of two or more distinct identities (or “personality states”). The distinct identities are accompanied by changes in behavior, memory and thinking. The signs and symptoms may be observed by others or reported by the individual. Ongoing gaps in memory about everyday events, personal information and/or past traumatic events. The symptoms cause significant distress or problems in social, occupational or other areas of functioning. In addition, the disturbance must not be a normal part of a broadly accepted cultural or religious practice. As noted in the DSM-5, in many cultures around the world, experiences of being possessed are a normal part of spiritual practice and are not dissociative disorders.  The attitude and personal preferences (for example, about food, activities, clothes) of a person with dissociative identity disorder may suddenly shift and then shift back. The identities happen involuntarily and are unwanted and cause distress. People with dissociative identity disorder may feel that they have suddenly become observers of their own speech and actions, or their bodies may feel different (e.g., like a small child, like the opposite gender, huge and muscular). The Sidran Institute notes that a person with dissociative identity disorder “feels as if she has within her two or more entities, each with its own way of thinking and remembering about herself and her life. It is important to keep in mind that although these alternate states may feel or appear to be very different, they are all manifestations of a single, whole person.” Other names used to describe these alternate states including “alternate personalities,” “alters,” “states of consciousness” and “identities.”  Risk Factors and Suicide Risk People who have experienced physical and sexual abuse in childhood are at increased risk of dissociative identity disorder. The vast majority of people who develop dissociative disorders have experienced repetitive, overwhelming trauma in childhood. Among people with dissociative identity disorder in the United States, Canada and Europe, about 90 percent had been the victims of childhood abuse and neglect. Suicide attempts and other self-injurious behavior are common among people with dissociative identity disorder. More than 70 percent of outpatients with dissociative identity disorder have attempted suicide  Dissociative Amnesia Dissociative amnesia is a type of dissociative disorder that involves inability to recall important personal information that would not typically be lost with ordinary forgetting. It is usually caused by trauma or stress. Diagnosis is based on history after ruling out other causes of amnesia. Although the forgotten information may be inaccessible to consciousness, it sometimes continues to influence behavior (eg, a woman who was raped in an elevator refuses to ride in elevators even though she cannot recall the rape). The amnesia appears to be caused by traumatic or stressful experiences endured or witnessed (e.g. physical or sexual abuse, rape, combat, genocide, natural disasters, death of a loved one, serious financial troubles) or by tremendous internal conflict (eg, turmoil over guilt-ridden impulses or actions, apparently unresolvable interpersonal difficulties, criminal behaviors). Symptoms and Signs of Dissociative Amnesia Localized amnesia involves being unable to recall a specific event or events or a specific period of time; these gaps in memory are usually related to trauma or stress. Selective amnesia involves forgetting only some of the events during a certain period of time or only part of a traumatic event. For example, a soldier may experience dissociative amnesia during the time they were deployed, yet still have some memories of positive experiences such as celebrating Thanksgiving dinner or Christmas dinner with their unit.  Symptoms and Signs of Dissociative Amnesia Generalized amnesia where they have a complete loss of memory of their entire life history, including their own identity. While generalized amnesia is extremely rare, it is also extremely frightening. The onset is acute, and the individual is often found wandering in a state of disorientation. Many times, these individuals are brought into emergency rooms by law enforcement following a dangerous situation such as an individual wandering on a busy road. Dissociative fugue is considered to be the most extreme type of dissociative amnesia. Not only does an individual forget personal information, but they also flee to a different location (APA, 2013). Diagnosis of Dissociative Amnesia Clinical criteria Diagnosis of dissociative amnesia is clinical, based on presence of the following criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5): Patients cannot recall important personal information (usually trauma- or stress- related) that would not typically be lost with ordinary forgetting. Symptoms cause significant distress or significantly impair social or occupational functioning. Also, the symptoms cannot be better accounted for by the effects of a drug or another disorder (eg, partial complex seizures, substance use disorder, traumatic brain injury, posttraumatic stress disorder, another dissociative disorder).  Diagnosis requires a medical and psychiatric examination to rule out other possible causes. Initial evaluation should include MRI to rule out structural causes EEG to rule out a seizure disorder Blood and urine tests to rule out toxic causes, such as illicit drug use Psychological testing can help better characterize the nature of the dissociative experiences Take aways: Dissociative amnesia is characterized by the inability to recall important autobiographical information, whether during a specific period (localized) or one’s entire life (generalized) or forgetting personal information and fleeing to a different location (fugue). Depersonalization/Derealization Disorder Depersonalization/Derealization disorder is categorized by recurrent episodes of depersonalization and/or derealization. Depersonalization can be defined as a feeling of unreality or detachment from oneself. Individuals describe this feeling as an out-of- body experience where you are an observer of your thoughts, feelings, and physical being. Furthermore, some patients report feeling as though they lack speech or motor control, thus feeling at times like a robot. Distortions of one’s physical body have also been reported, with various body parts appearing enlarged or shrunken. Emotionally, one may feel detached from their feelings, lacking the ability to feel emotions despite knowing they have them  Symptoms of derealization include feelings of unreality or detachment from the world—whether it be individuals, objects, or their surroundings. For example, an individual may feel as though they are unfamiliar with their surroundings, even though they are in a place they have been to many times before. Feeling emotionally disconnected from close friends or family members whom they have strong feelings for is another common symptom experienced during derealization episodes. Sensory changes have also been reported, such as feeling as though your environment is distorted, blurry, or even artificial. Distortions of time, distance, and size/shape of objects may also occur.  These episodes can last anywhere from a few hours to days, weeks, or even months (APA, 2013). The onset is generally sudden, and like the other dissociative disorders, is often triggered by intense stress or trauma. As one can imagine, depersonalization/derealization disorder can cause significant emotional distress, as well as impairment in one’s daily functioning (APA, 2013). Depersonalization – experiences of unreality or detachment from one’s mind, self or body. People may feel as if they are outside their bodies and watching events happening to them. Derealization – experiences of unreality or detachment from one’s surroundings. People may feel as if things and people in the world around them are not real. Comorbidity Many dissociative disorders have been found to have a high comorbidity with PTSD and depressive disorders. Somatic symptom and conversion disorders, as well as some personality disorders, have also been found to be comorbid Treatment of Dissociative Disorder Treatment for dissociative disorders is limited for a few reasons. First, with respect to dissociative amnesia, many individuals recover on their own without any intervention. Occasionally treatment is sought out after recovery due to the traumatic nature of memory loss. Second, the rarity of these disorders has offered limited opportunities for research on both the development and effectiveness of treatment methods. Due to the differences between dissociative disorders, treatment options will be discussed specific to each disorder. Treatment typically involves psychotherapy. Therapy can help people gain control over the dissociative process and symptoms. The goal of therapy is to help integrate the different elements of identity. Therapy may be intense and difficult as it involves remembering and coping with past traumatic experiences. Cognitive behavioral therapy and dialectical behavioral therapy are two commonly used types of therapy. Hypnosis has also been found to be helpful in treatment of dissociative identity disorder. There are no medications to directly treat the symptoms of dissociative identity disorder. However, medication may be helpful in treating related conditions or symptoms, such as the use of antidepressants to treat symptoms.