Dissociative disorder

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]

• Dissociative identity disorder (formerly multiple personality disorder): the alternation of two or more distinct personality states with impaired recall among personality states. In extreme cases, the host personality is unaware of the other, alternating personalities; however, the alternate personalities are aware of all the existing personalities.^[2] This category now includes the old derealization disorder category.
• Dissociative amnesia (formerly psychogenic amnesia): the temporary loss of recall memory, specifically episodic memory, due to a traumatic or stressful event. It is considered the most common dissociative disorder amongst those documented. This disorder can occur abruptly or gradually and may last minutes to years depending on the severity of the trauma and the patient.^[3]
• Dissociative fugue (formerly psychogenic fugue) is now subsumed under the Dissociative amnesia category. It is described as reversible amnesia for personal identity, usually involving unplanned travel or wandering, sometimes accompanied by the establishment of a new identity. This state is typically associated with stressful life circumstances and can be short or lengthy.^[2]
• Depersonalization disorder: periods of detachment from self or surrounding which may be experienced as "unreal" (lacking in control of or "outside of" self) while retaining awareness that this is only a feeling and not a reality.
• The old category of dissociative disorder not otherwise specified is now split into two: Other specified dissociative disorder, and unspecified dissociative disorder. These categories are used for forms of pathological dissociation that do not fully meet the criteria of the other specified dissociative disorders, or if the correct category has not been determined.

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.

Cause and treatment

Dissociative identity disorder (multiple personality disorder)

Cause: People with dissociative identity disorder usually have close relatives who have also had similar experiences.^[5]

Treatment: Long-term psychotherapy that helps the patient merge his/her multiple personalities into one personality. “The trauma of the past has to be explored and resolved with proper emotional expression. Hospitalization may be required if behavior becomes bizarre or destructive”.^[6] Dissociative identity disorder has a tendency to recur over a period of several years, and may become less of a problem after mid-life.^[6]

Dissociative amnesia

Cause: A way to cope with trauma.

Treatment: Psychotherapy (e.g. talk therapy) counseling or psychosocial therapy which involves talking about your disorder and related issues with a mental health provider. Psychotherapy often involves hypnosis (help you remember and work through the trauma); creative art therapy (using creative process to help a person who cannot express his or her thoughts); cognitive therapy (talk therapy to identify unhealthy and negative beliefs/behaviors); and medications (antidepressants, anti-anxiety medications or tranquilizers). These medications help control the mental health symptoms associated with the disorders, but there are no medications that specifically treat dissociative disorders.^[7] However, the medication Penthothal can sometimes help to restore the memories.^[8] The length of an event of dissociative amnesia may be a few minutes or several years. If an episode is associated with a traumatic event, the amnesia may clear up when the person is removed from the traumatic situation.

Dissociative fugue

Cause: A stressful event that happens in adulthood.

Treatment: Hypnosis is often used to help patient recall true identity and remember events of the past. Psychotherapy is helpful for the person who has traumatic, past events to resolve.^[9] Once dissociative fugue is discovered and treated, many people recover quickly. The problem may never happen again.^[9]

Depersonalization disorder

Cause: Dissociative disorders usually develop as a way to cope with trauma. The disorders most often form in children subjected to chronic physical, sexual or emotional abuse or, less frequently, a home environment that is otherwise frightening or highly unpredictable.

Treatment: Same treatment as dissociative amnesia, and same drugs. An episode of depersonalization disorder can be as brief as a few seconds or continue for several years.^[9]

Specific psychopharmacology

As mentioned earlier, anti-anxiety, antidepressants and tranquilizers are treatment medications that do not cure, but help control the symptoms of dissociative disorders. The accepted mode of treatment are atypical neuroleptics such as Abilify, Zyprexa, Seroquel and Geodon. Newer-generation anticonvulsants are also highly effective. Quetiapine is initiated at 25–50 mg PO bid and increased by 50 mg PO bid q3d until symptom resolution is achieved. The higher dose should be administered nightly due to the strong sedation effects of the medicine. Other medications such as SSRIs and SNRIs may reduce the anxiety and apprehension of the dissociation.

Keppra may be effective in treating dissociation. Doses are usually kept much lower than for the treatment of seizure disorders. Lamotrigine started at 25 mg and increased by 25 mg every 2 weeks is another option. The effects of these novel anticonvulsants is thought to be secondary to GABA modulation.^[10]

Risk factors People who experience chronic physical, sexual or emotional childhood abuse are at a greater risk of developing dissociative disorders. Children and adults experiencing other traumatic events (including war, natural disasters, kidnapping, torture and invasive medical procedures) also may develop these conditions.^[11]

Diagnosis and prevalence

The lifetime prevalence of dissociative disorders varies from 10% in the general population to 46% in psychiatric inpatients.^[12] 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.^[12] 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.^[13]

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.^[14] In most cases mental health professionals are still heistant to diagnose 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^[15]

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.^[16] There have also been incidences in which people with dissociative identity disorder provide conflicting testimonies in court, depending on the personality that is present.^[17]

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.^{[13][18][19][20]} There are several reasons why recognizing symptoms of dissociation in children is challenging: it may be difficult for children to describe their internal experiences;^[20] caregivers may miss signals or attempt to conceal their own abusive or neglectful behaviors;^[20] symptoms can be subtle or fleeting;^[13] disturbances of memory, mood, or concentration associated with dissociation may be misinterpreted as symptoms of other disorders.^[13]

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.^[18] Others in the field have argued that recognizing disorganized attachment (DA) in children can help alert clinicians to the possibility of dissociative disorders.^[19]

Clinicians and researchers also stress the importance of using a developmental model to understand both symptoms and the future course of DDs.^[13][18] 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.^[13][18] Related to this developmental approach, more research is required to establish whether a young patient’s recovery will remain stable over time.^[21]

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.^[18][22] 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.^[13] Mirroring this complexity, it is still being decided whether the DSM-5 will group dissociative disorders with other trauma/stress disorders.^[23]

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.^[24] 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."^[25]

See also

• Complex post-traumatic stress disorder
• Dissociative identity disorder in fiction

References

External links

• Mayo Clinic - http://www.mayoclinic.org/diseases-conditions/dissociative-disorders/basics/tests-diagnosis/con-20031012
• Cleveland Clinic - http://my.clevelandclinic.org/disorders/dissociative_disorders/hic_depersonalization_disorder.aspx
• International Society for the Study of Trauma and Dissociation - http://www.isst-d.org/
• Sidran Institute - http://www.sidran.org/sub.cfm?sectionID=4