Dissociative Disorder

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Dissociative Disorder

• Chapter 10
• John F. Kihlstrom
• Presentation By
• Jennifer Keller

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Introduction

• The category of dissociative disorders includes a
  wide variety of syndromes whose common core is an
  alteration in consciousness that affects memory
  and identity (APA, 1994).
• Impairments of memory and consciousness are
  often observed in the organic brain syndromes,
  but dissociative disorders are functional they
  are attributable to instigating events or
  processes that do not result in insult, injury,
  or disease to the brain, and produce more
  impairment than would normally occur in the
  absence of this instigating event or process
  (Kihlstrom Schacter, 2000).

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Dissociative Disorders from DSM IV

• 300.12 Dissociative Amnesia (formerly Psychogenic
  Amnesia)
• A. The predominant disturbance is one or more
  episodes of inability to recall important
  personal information, usually of a traumatic or
  stressful nature, that is too extensive to be
  explained by ordinary forgetfulness
• .B. The disturbance does not occur exclusively
  during the course of Dissociative Identity
  Disorder, Dissociative Fugue, Post traumatic
  Stress Disorder, Acute Stress Disorder, or
  Somatization Disorder and is not due to the
  direct physiological effects of a substance
  (e.g., a drug of abuse, a medication) or a
  neurological or other general medical condition
  (e.g., Amnestic Disorder Due to Head Trauma).
• C. The symptoms cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.

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• 300.13 Dissociative Fugue (formerly Psychogenic
  Fugue)
• A. The predominant disturbance is sudden,
  unexpected travel away from home or one's
  customary place of work, with inability to recall
  one's past
• .B. Confusion about personal identity or
  assumption of a new identity (partial or
  complete).
• C. The disturbance does not occur exclusively
  during the course of Dissociative Identity
  Disorder and is not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication) or a general medical
  condition (e.g., temporal lobe epilepsy).
• D. The symptoms cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning

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• 300.14 Dissociative Identity Disorder (formerly
  Multiple Personality Disorder)
• A. The presence of two or more distinct
  identities or personality states (each with its
  own relatively enduring pattern of perceiving,
  relating to, and thinking about the environment
  and self).
• B. At least two of these identities or
  personality states recurrently take control of
  the person's behavior.
• C. Inability to recall important personal
  information that is too extensive to be explained
  by ordinary forgetfulness.
• D. The disturbance is not due to the direct
  physiological effects of a substance (e.g.,
  blackouts or chaotic behavior during Alcohol
  Intoxication) or a general medical condition
  (e.g., complex partial seizures). In children,
  the symptoms are not attributable to imaginary
  playmates or other fantasy play.

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• 300.6 Depersonalization Disorder
• A. Persistent or recurrent experiences of feeling
  detached from, and as if one is an outside
  observer of, one's mental processes or body
  (e.g., feeling like one is in a dream).
• B. During the depersonalization experience,
  reality testing remains intact.
• C. The depersonalization causes clinically
  significant distress or impaintient in social,
  occupational, or other important areas of
  functioning.
• D. The depersonalization experience does not
  occur exclusively during the course of another
  mental disorder,such as Schizophrenia, Panic
  Disorder, Acute Stress Disorder, or another
  Dissociative Disorder, and is not due to the
  direct physiological effects of a substance(e.g.,
  a drug of abuse, a medication) or a general
  medical condition (e.g., temporal lobe epilepsy).

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• 300.15 Dissociative Disorder Not Otherwise
  Specified
• This category is included for disorders in which
  the predominant feature is a Dissociative symptom
  (i.e., a disruption in the usually integrated
  functions of consciousness, memory, identity, or
  perception of the environment) that does not meet
  the criteria for any specific Dissociative
  Disorder. Examples include
• 1. Clinical presentations similar to Dissociative
  Identity Disorder that fail to meet full criteria
  for this disorder.Examples include presentations
  in which a) there are not two or more distinct
  personality states, or b) amnesia for important
  personal information does not occur.
• 2. Derealization unaccompanied by
  depersonalization in adults.

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• 3 -States of dissociation that occur in
  individuals who have been subjected to periods of
  prolonged and intense coercive persuasion (e.g.,
  brainwashing, thought re- form, or indoctrination
  while captive).
• 4. Dissociative trance disorder single or
  episodic disturbances in the state of
  consciousness, identity, or memory that are
  indigenous to particular locations and cultures.
• Dissociative trance involves narrowing of
  awareness of immediate surroundings or
  stereotyped behaviors or movements that are
  experienced as being beyond one's control.
• Possession trance involves re placement of the
  customary sense of personal identity by a new
  identity, attributed to the influence of a
  spirit, power, deity, or other person, and
  associated with stereotyped "involuntary"
  movements or amnesia.
• Examples include amok (Indonesia), bebainan
  (Indonesia), latab (Malaysia), pibloktoq
  (Arctic), ataque de nervios (Latin America), and
  possession (India).
• The Dissociative or trance disorder is not a
  normal part of a broadly accepted collective
  cultural or religious practice.

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• 5. Loss of consciousness, stupor, or coma not
  attributable to a general medical condition.
• 6. Ganser syndrome the giving of approximate
  answers to questions (e.g., "2 plus 2 equals 5")
  when not associated with Dissociative Amnesia or
  Dissociative Fugue

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• Dissociative amnesia
• The patient suffers a loss of autbiographical
  memory for certain past experiences
• Dissociative Fugue
• The amnesia is much more extensive and covers the
  whole of the individuals past life
• It is coupled with a loss of personal identity
• And often physical movement to another location
• Dissociative Identity Disorder
• A single individual appears to manifest 2 or more
  distinct identities.
• Each personality alternates in control over
  conscious experience, thought, and action and is
  separated by some degree of amnesia from the
  other(s).
• Depersonalization Disorder
• The person believes that he or she has changed in
  some way, or is somehow unreal (derealization).

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The Evolution of the Concept

• Three Theorist
• Pierre Janet
• One or more automatisms could split off from the
  rest, thus functioning outside of awareness,
  independent of voluntary control or both.
• Neodissociation (Hilgard)
• Links within the brain would be disrupted or
  isolated from phenomenal awareness and the
  experience of intentionality.
• Woody and Bowers
• The phenomena of dissociation reflect the failure
  of these modules to be integrated at higher
  levels of the system.
• Dissociation is a natural state, to some degree.

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The Evolution of a Diagnosis

• DSM I
• Classified as Psychoneurotic Disorders
• Anxiety is either directly felt and expressed
  orunconsciously and automatically controlled by
  various defense mechanisms (p. 32).
• DSM II
• Hysterical Neurosis and Dissociative Type were
  defined as disorders of the special senses or the
  voluntary nervous system.

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• DSM III III-R
• Abandoned both neurosis and hysteria as
  technical terms.
• The essential feature of the dissociative
  disorders was a disturbance in the normally
  integrative functions of identity, memory, or
  consciousness in the absence of brain insult,
  injury, or disease
• DSM IV
• Returned an explicit criterion of amnesia to the
  diagnostic criteria MPD, which was renamed
  Dissociative Identity Disorder (DID).
• Dissociative Disorder NOS, resembles DID without
  amnesia, and also covers derealization with the
  absence of depersonalization and trance states.

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Dissociative (Psychogenic) Amnesia

• Also known as limited functional amnesia and
  entails a loss of personal memory that cannot be
  accounted for by ordinary forgetting or by brain
  insult, injury, or disease.
• This amnesia is commonly retrograde, in that it
  covers a period of time before the precipitating
  event.
• Research is needed exploring the symptoms that
  differentiate organic and functional amnesias.

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Dissociative (Psychogenic) Fugue

• Also called functional retrograde amnesia.
• Fugue adds a loss of identity to the loss of
  personal memory observed in psychogenic amnesia
  and sometimes physical relocation.
• Fugue is associated with physical or mental
  trauma, depression, problems with the legal
  system, or other personal difficulty.
• Fugue impairs semantic memory for personal
  information, as well as episodic memory for
  personal experiences

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Dissociative Identity (Multiple Personality)
Disorder

• There is an alteration of both memory and
  identity.
• Ellenbergers 3 Categories of DID
• Successive multiple personalities (usual case),
  with symmetrical or asymmetrical amnesias.
• Simultaneous multiple personalities (very rare)
• Personality clusters
• Primary Personality
• A tendency to identify the primary personality
  with the ego-state that displays the most
  conventional qualities.
• However researchers have argued that there are no
  clear pattern of normality or pathology that
  distinguishes the primary personality from the
  alter egos.

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Videos of Howie

• Session 1
• http//www.youtube.com/watch?vP9RcFyAoQTsmodere
  latedsearch
• Session 13
• http//www.youtube.com/watch?vm2uMhHDe4Qsmodere
  latedsearch

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DID within Laboratory Studies

• DID may involve a dissociation between explicit
  and implicit memory
• Explicit memory refers to the persons conscious,
  intentional recollection of some previous
  episode, most commonly reflected in recall and
  recognition.
• Implicit memory, or memory without awareness, is
  reflected in any change in the persons
  experience, thought, or action which is
  attributable to some prior episode of experience,
  but which cannot be accounted for by explicit
  memory of an event.

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• Biological Processes
• Brain imaging techniques used in one study found
  that genuine alter egos showed greater
  differences in amplitude and latency than
  simulated ones.
• Another study by Mathew, Jack and West reported a
  shift in regional cerebral blood flow, toward the
  right temporal lobe, in a single patient.
• No follow up studies have been conducted to
  explore these biological findings.

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Sociocultural Influences

• Loosening of diagnostic criteria which is
  influenced by popular culture.
• The common practice of eliciting alter egos
  through hypnosis, instead of observing them
  emerge spontaneously.
• Could DID be a strategic social enactment in
  which an individual disavows responsibility for
  certain actions by attributing them to some
  indwelling entity other than the self?
• If so, could it be shaped by either the client,
  therapist, or both?

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• Kenny (1986) after an ethnographic analysis of
  DID, argues that DID is a response to changing
  conditions in American culture.

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Depersonalization and Derealization

• People experience themselves as totally
  different, and the world as strange and new.
• Commonly described as isolated, lifeless,
  strange, and unfamiliar behaving mechanically
  without initiative or self-control.
• Depersonalization self
• Derealization world
• Also seen as symptoms in anxiety, depression,
  obsession.

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Diagnosis and Assessment of Dissociation

• The actual incidence and prevalence of
  dissociative disorders is hard to estimate.
• Assessments
• Structured Clinical Interview for DSM IV
  Dissociative Disorders (SCID-D)
• Diagnosis these syndromes according to the rules
  of DSM IV

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Assessments continued

• Dissociative Experiences Scale (DES)
• A diagnostic screening too that locates high
  scoring subjects who might be at risk for
  dissociative disorder
• Assesses levels of dissoication on a trait-like
  continuum from low to high.
• Clinician-Administered Dissoicative States Scale
  (CADSS)
• Was developed to measure episodic dissoiative
  states and is suitable for measuring changes in
  symptoms.
• Focuses on symptoms of depersonalization and
  derealization instead of the disruptions of
  memory and identity.

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Forensic Aspects of Dissociative Disorder

• Disociative disorders have created substantial
  difficulties for the legal system.
• Hillside Strangler
• Murdered and raped ten women in LA and two in
  Bellingham, WA
• Faked DID with two alter egos Steve Walker and
  Billy.

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Etiology of Dissociative Disorder

• Stress, acute or chronic, is an extremely
  prominent feature in dissoicative disorders.
• Research indicates a strong relationship between
  DID and a history of childhood physical and
  sexual abuse.
• Horevitz and Loewenstein(1994), characterized DID
  as a traumatically induced developmental
  disorder of childhood.
• Most of these studies are retrospective and
  prospective research failed to find evidence of
  any specific impact of child sexual abuse on
  adult personality and psychopathology.

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Etiology of Dissociative Disorder cont.

• At this point, the traumatic etiology for
  dissociative identity disorder and other
  dissoicative disorders must be considered a
  hypothesis.

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Treatment of Dissociative Disorders

• Other than DID, little has been written about the
  treatment of dissoicative disorders.
• Most cases of psychogenic amnesia and fugue
  resolve themselves spontaneously.
• Clients recover their memories and identities
  unaided.
• A clinician can promote these recoveries by
  contact with family and friends or by hints
  generated through free associations or dream
  reports
• Some cases report recovery was stimulated by
  induction of hypnosis or sedation by intravenous
  barbiturates.
• No studies have had concurring results with these
  stimulatants.

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Treatment cont.

• Drug treatment
• Benzodiazepines and other psychoactive drugs
• Act on the anxiety and depression, in which
  depersonalization and derealization occur, rather
  than directly on the feelings of unreality.
• DID
• Psychodynamic uncovering, abreaction, and working
  through of the trauma and other conflictual
  issues presumed to underlie the disorder,
  followed by an attempt at integrating the
  personalities into a single identity.
• Working to achieve theraputic alliance among the
  egos
• Insight-oriented therapy
• Some tries at CBT

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Challenges to Treatment

• Secondary gain for both client and clinician
• Countertransference of reactions of anger,
  exasperation, aggression (sexual attraction)
• Suggestibility
• The integration of confabulations and other
  distortions into memory

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The Dissociative Spectrum

• Dissociative disorders constitute only a portion
  of what was formerly described as hysteria.
• Dissociative disorders were separated from
  conversion disorders in the DSM II-R, the author
  believes this to be a mistake.
• What are your thoughts?