Title: Dissociative Disorder
1Dissociative Disorder
- Chapter 10
- John F. Kihlstrom
- Presentation By
- Jennifer Keller
2Introduction
- 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).
3Dissociative 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.
4- 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
5- 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.
6- 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).
7- 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.
8- 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.
9- 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
10- 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).
11The 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.
12The 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.
13- 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.
14Dissociative (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.
15Dissociative (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
16Dissociative 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.
17Videos of Howie
- Session 1
- http//www.youtube.com/watch?vP9RcFyAoQTsmodere
latedsearch - Session 13
- http//www.youtube.com/watch?vm2uMhHDe4Qsmodere
latedsearch
18DID 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.
19- 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.
20Sociocultural 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?
21- Kenny (1986) after an ethnographic analysis of
DID, argues that DID is a response to changing
conditions in American culture.
22Depersonalization 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.
23Diagnosis 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
24Assessments 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.
25Forensic 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.
26Etiology 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.
27Etiology of Dissociative Disorder cont.
- At this point, the traumatic etiology for
dissociative identity disorder and other
dissoicative disorders must be considered a
hypothesis.
28Treatment 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.
29Treatment 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
30Challenges 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
31The 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?