Dissociative disorder

Dissociative disorder
Classification and external resources
ICD-10 F44
ICD-9 300.12-300.14
MeSH D004213

Dissociative disorders (DD) are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception. People with dissociative disorders use dissociation, a defense mechanism, pathologically and involuntarily. Dissociative disorders are thought to primarily be caused by psychological trauma.

The dissociative disorders listed in the American Psychiatric Association's DSM-5 are as follows:[1]

Both dissociative amnesia and dissociative fugue usually emerge in adulthood and rarely occur after the age of 50. The ICD-10 classifies conversion disorder as a dissociative disorder[4] while the DSM-IV classifies it as a somatoform disorder.

Diagnosis and prevalence

The lifetime prevalence of dissociative disorders varies from 10% in the general population to 46% in psychiatric inpatients.[5] Diagnosis can be made with the help of structured interviews such as the Dissociative Disorders Interview Schedule (DDIS) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), or with the Dissociative Experiences Scale (DES) which is a self-assessment questionnaire.[5] Some diagnostic tests have also been adapted and/or developed for use with children and adolescents such as the Children's Version of the Response Evaluation Measure (REM-Y-71), Child Interview for Subjective Dissociative Experiences, Child Dissociative Checklist (CDC), Child Behavior Checklist (CBCL) Dissociation Subscale, and the Trauma Symptom Checklist for Children Dissociation Subscale.[6]

There are problems with classification, diagnosis and therapeutic strategies of dissociative and conversion disorders which can be understood by the historic context of hysteria. Even current systems used to diagnose DD such as the DSM-IV and ICD-10 differ in the way the classification is determined.[7] In most cases mental health professionals are still heistant to diagnosing patients with Dissociative Disorder, because before they are considered to be diagnosed with Dissociative Disorder these patients have more than likely been diagnosed with major depression, anxiety disorder, and most often post-traumatic disorder[8]


An important concern in the diagnosis of dissociative disorders is the possibility that the patient may be feigning symptoms in order to escape negative consequences. Young criminal offenders report much higher levels of dissociative disorders, such as amnesia. In one study it was found that 1% of young offenders reported complete amnesia for a violent crime, while 19% claimed partial amnesia.[9] There have also been incidences in which people with dissociative identity disorder provide conflicting testimonies in court, depending on the personality that is present.[10]

Children and adolescents

Dissociative disorders (DD) are widely believed to have roots in traumatic childhood experience (abuse or loss), but symptomology often goes unrecognized or is misdiagnosed in children and adolescents.[6][11][12][13] There are several reasons why recognizing symptoms of dissociation in children is challenging: it may be difficult for children to describe their internal experiences;[13] caregivers may miss signals or attempt to conceal their own abusive or neglectful behaviors;[13] symptoms can be subtle or fleeting;[6] disturbances of memory, mood, or concentration associated with dissociation may be misinterpreted as symptoms of other disorders.[6]

In addition to developing diagnostic tests for children and adolescents (see above), a number of approaches have been developed to improve recognition and understanding of dissociation in children. Recent research has focused on clarifying the neurological basis of symptoms associated with dissociation by studying neurochemical, functional and structural brain abnormalities that can result from childhood trauma.[11] Others in the field have argued that recognizing disorganized attachment (DA) in children can help alert clinicians to the possibility of dissociative disorders.[12]

Clinicians and researchers also stress the importance of using a developmental model to understand both symptoms and the future course of DDs.[6][11] In other words, symptoms of dissociation may manifest differently at different stages of child and adolescent development and individuals may be more or less susceptible to developing dissociative symptoms at different ages. Further research into the manifestation of dissociative symptoms and vulnerability throughout development is needed.[6][11] Related to this developmental approach, more research is required to establish whether a young patient’s recovery will remain stable over time.[14]

Current debates and the DSM-5

A number of controversies surround DD in adults as well as children. First, there is ongoing debate surrounding the etiology of dissociative identity disorder (DID). The crux of this debate is if DID is the result of childhood trauma and disorganized attachment.[11][15] A second area of controversy surrounds the question of whether or not dissociation as a defense versus pathological dissociation are qualitatively or quantitatively different. Experiences and symptoms of dissociation can range from the more mundane to those associated with posttraumatic stress disorder (PTSD) or acute stress disorder (ASD) to dissociative disorders.[6] Mirroring this complexity, it is still being decided whether the DSM-5 will group dissociative disorders with other trauma/stress disorders.[16]

A 2012 review article supports the hypothesis that current or recent trauma may affect an individual's assessment of the more distant past, changing the experience of the past and resulting in dissociative states.[17] However, experimental research in cognitive science continues to challenge claims concerning the validity of the dissociation construct, which is still based on Freudian notions of repression. Even the claimed etiological link between trauma/abuse and dissociation has been questioned. An alternative model proposes a perspective on dissociation based on a recently established link between a labile sleep–wake cycle and memory errors, cognitive failures, problems in attentional control, and difficulties in distinguishing fantasy from reality."[18]

See also

References

  1. ↑ American Psychiatric Association (2000). DSM-IV-TR (4th ed.). American Psychiatric Press. p. 543. ISBN 0-89042-025-4.
  2. ↑ 2.0 2.1 Schacter, D. L., Gilbert, D. T., & Wegner, D.M. (2011). Psychology: Second Edition, pages 572-573 New York, NY: Worth.
  3. ↑ Maldonando R.J. and Spiegel D. (2009). Dissociative Disorders. In The American Psychiatric Publishing: Board Review Guide for Psychiatry(Chapter 22). Retrieved from http://books.google.ca/books?hl=en&lr=&id=RFazteXMaj8C&oi=fnd&pg=PA397&dq=Maldonado+JR,+et+al.+Dissociative+disorders.&ots=OOPwzv6IN4&sig=Xo7WlHv6pGUxMBwdpRNN3HnqBCo#v=onepage&q=Maldonado%20JR%2C%20et%20al.%20Dissociative%20disorders.&f=false
  4. ↑ International Statistical Classification of Diseases and Related Health Problems, 10th Revision. F44.9
  5. ↑ 5.0 5.1 Ross et al. (2002). "Prevalence, Reliability and Validity of Dissociative Disorders in an Inpatient Setting". Journal of Trauma and Dissociation: pp.7–17. doi:10.1300/J229v03n01_02.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Steiner, H.; Carrion, V.; Plattner, B.; Koopman, C. (2002). "Dissociative symptoms in posttraumatic stress disorder: diagnosis and treatment". Child and Adolescent Psychiatric Clinics North America 12: 231–249. doi:10.1016/s1056-4993(02)00103-7.
  7. ↑ Splitzer, C; Freyberger, H.J. (2007). "Dissoziative Störungen (Konversionsstörungen)". Psychotherapeut.
  8. ↑ [Nolen-Hoeksema, S. (2014). Somatic Symptom and Dissociative Disorders. In (ab)normal Psychology (6th ed., p. 164). Penn, Plaza, New York: McGraw-Hill.]
  9. ↑ Evans, C., Mezey, G., & Ehlers, A. (2009). "Amnesia for violent crime among young offenders". Journal of Forensic Psychology (20): 85–106.
  10. ↑ Haley, J. (2003). "Defendent's wife testifies about his multiple personas". Bellingham Herald: B4.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Diseth, T. (2005). "Dissociation in children and adolescents as reaction to trauma - an overview of conceptual issues and neurobiological factors". Nordic Journal of Psychiatry 59: 79–91. doi:10.1080/08039480510022963.
  12. ↑ 12.0 12.1 Waters, F. (July–August 2005). "Recognizing dissociation in preschool children". The International Society for the Study of Dissociation News 23 (4): 1–4.
  13. ↑ 13.0 13.1 13.2 James, B. (1992). "The dissociatively disordered child". Unpublished paper.
  14. ↑ Jans, T.; Schneck-Seif, S., Weigand, T., Schneider, W., Ellgring, H., Wewetzer, C., Warnke, A., (23 July 2008). "Long-term outcome and prognosis of dissociative disorder with onset in childhood or adolescence". Child and Adolescent Psychiatry and Mental Health 2.
  15. ↑ Boysen, G. (August 2011). "The scientific status of childhood dissociative identity disorder: A review of published research". Psychotherapy and Psychosomatics 80: 329–334. doi:10.1159/000323403. PMID 21829044.
  16. ↑ Brand, B.; Lanius, B.; Vermetten, E.; Loewenstein, R. (2012). "Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5". Journal of Trauma and Dissociation 13: 9–31. doi:10.1080/15299732.2011.620687.
  17. ↑ Stern DB (January 2012). "Witnessing across time: accessing the present from the past and the past from the present". The Psychoanalytic Quarterly 81 (1): 53–81. doi:10.1002/j.2167-4086.2012.tb00485.x. PMID 22423434.
  18. ↑ Lynn, SJ et al. (2012). "Dissociation and dissociative disorders: challenging conventional wisdom". Current Directions in Psychological Science 21 (1): 48–53. doi:10.1177/0963721411429457.

External links