Dissociative disorders

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Dissociative disorders
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Dissociative disorders (DDs) are a range of conditions characterized by significant disruptions or fragmentation "in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior." Dissociative disorders involve involuntary dissociation as an unconscious defense mechanism, wherein the individual with a dissociative disorder experiences separation in these areas as a means to protect against traumatic stress. Some dissociative disorders are caused by major psychological trauma, though the onset of depersonalization-derealization disorder may be preceded by less severe stress, by the influence of psychoactive substances, or occur without any discernible trigger. [1]

Contents

The dissociative disorders listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are as follows: [2]

The ICD-11 lists dissociative disorders as: [7]

Causes and treatment

Dissociative disorders most often develop as a way to cope with psychological trauma. People with dissociative disorders were commonly subjected to chronic physical, sexual, or emotional abuse as children (or, less frequently, an otherwise frightening or highly unpredictable home environment). Some categories of DD, however, can form due to trauma that occurs later in life and is unrelated to abuse, such as war or the death of a loved one.

Dissociative disorders, especially dissociative identity disorder (DID), should not be treated with an extraordinary or supernatural status. DDs would be better examined and treated through the lens of any other psychological disorder. [8]

Dissociative identity disorder

Cause: The cause of dissociative identity disorder is contentious; it is most often considered to be caused either by ongoing childhood trauma that occurs before the ages of six to nine, [9] [10] or as an unintentional product of therapy, fantasy, or other sociogenic factors. [11]

Treatment: Long-term psychotherapy to improve the patient's quality of life. Psychotherapy often involves hypnosis (to help a patient remember and work through the trauma), creative art therapy (using creative process to help a person who cannot express their thoughts), cognitive therapy (talk therapy to identify unhealthy and negative beliefs or behaviors), and medications (antidepressants, anti-anxiety medications, or sedatives). These medications can help control the symptoms associated with DID and other DD, but there are no medications yet that specifically treat dissociative disorders. [12]

Dissociative amnesia

Cause: Psychological trauma. While a history of child abuse is common in patients, it is not a necessary factor in determining if a person will develop dissociative amnesia. [13]

Treatment: Psychotherapy counseling or psychosocial therapy which involves talking about the disorder and related issues with a mental health provider. The medication pentothal can sometimes help to restore the memories. [14] 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.

Depersonalization-derealization disorder

Cause: While not as strongly linked as other dissociative disorders, there is a correlation between depersonalization-derealization disorder and childhood trauma, especially emotional abuse or neglect. It can also be caused by other forms of stress such as sudden death of a loved one. [15]

Treatment: Same treatment as dissociative amnesia. An episode of depersonalization-derealization disorder can be as brief as a few seconds or continue for several years. [14]

Neuroscience

Differences in brain activity

Dissociative disorders are characterized by distinct brain differences in the activation of various brain regions including the inferior parietal lobe, prefrontal cortex, and limbic system. [16]

Those with dissociative disorders have higher activity levels in the prefrontal lobe and a more inhibited limbic system on average than healthy controls. [16] Heightened corticolimbic inhibition is associated with distinctly dissociative symptoms such as depersonalization and derealization. [16] The function of these symptoms is thought to be a coping mechanism employed in extremely threatening or traumatic events. [17] By inhibiting structures in the limbic system, such as the amygdala, the brain is able to reduce extreme levels of arousal. [16] In the dissociative subtype of PTSD, there is both excessive control of emotions through suppressed limbic structures and insufficient control of emotions in the hyperactivity of the medial prefrontal cortex. Increased activity in the medial prefrontal cortex is associated with non-dissociative symptoms such as re-experiencing and hyperarousal. [16]

Differences in volume of brain structures

There are notable differences in the volume of certain areas of the brain such as reduced cortical and subcortical volumes in the hippocampus and amygdala. [18] Reduced volume of the amygdala may account for the lessened emotional reactivity observed during dissociation. [18] The hippocampus is associated with learning and the formation of memory, and its reduced volume is associated with impairments in memory for those with DID and PTSD. [19] Brain-imaging studies demonstrating the link between reduced hippocampal volume and DID as well as PTSD have added to empirical support for the existence of the disorder, as additional brain-imaging studies have demonstrated a negative correlation between hippocampal volume and early childhood trauma (which is hypothesized to be a potential etiological factor for dissociative symptoms). [20] [21] [22]

The Amygdala Amygdala small.gif
The Amygdala
The Hippocampus Hippocampus small.gif
The Hippocampus
The Prefrontal Cortex Prefrontal cortex (left) animation.gif
The Prefrontal Cortex

Medications

There are no medications to cure or completely treat dissociative disorders, however, drugs to treat anxiety and depression that may accompany the disorders can be given. [23]

Diagnosis and prevalence

The lifetime prevalence of dissociative disorders varies from 10% in the general population to 46% in psychiatric inpatients. [24] Diagnosis can be made with the help of structured clinical interviews such as the Dissociative Disorders Interview Schedule (DDIS) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R), and behavioral observation of dissociative signs during the interview. [24] [25] Additional information can be helpful in diagnosis, including the Dissociative Experiences Scale or other questionnaires, performance-based measures, records from doctors or academic records, and information from partners, parents, or friends. [25] A dissociative disorder cannot be ruled out in a single session and it is common for patients diagnosed with a dissociative disorder to not have a previous dissociative disorder diagnosis due to a lack of clinician training. [25] Some diagnostic tests have also been adapted or developed for use with children and adolescents such as the Adolescent Dissociative Experiences Scale, [26] 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. [27]

Dissociative disorders have been found to be quite prevalent in outpatient populations, as well as within low-income communities. One study found that in a population of poor inner-city outpatients, there was a 29% prevalence of dissociative disorders. [28]

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. [29] In most cases mental health professionals are still hesitant 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 depressive disorder, anxiety disorder, and most often post-traumatic stress disorder. [30] It has been found from interviews with those who may be afflicted with dissociative disorders may be more effective at getting an accurate diagnosis than self-scoring assessments and scales. [28]

The prevalence of dissociative disorders is not completely understood due to the many difficulties in diagnosing dissociative disorders. Many of these difficulties stem from a misunderstanding of dissociative disorders, from an unfamiliarity diagnosis or symptoms to disbelief in some dissociative disorders entirely. [31] Due to this it has been found that only 28% to 48% of people diagnosed with a dissociative disorder receive treatment for their mental health. [32] Patients who are misdiagnosed are often those more likely to be hospitalised repeatedly, and lack of treatment can result in intensive outpatient treatment and higher rates of disability. [32]

An important concern in the diagnosis of dissociative disorders in forensic interviews 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. [33] There have also been cases in which people with dissociative identity disorder provide conflicting testimonies in court, depending on the personality that is present. [34] [ better source needed ] The world-wide prevalence of dissociative disorders is not well understood due to different cultural beliefs surrounding human emotions and the human brain. [35]

Children and adolescents

Dissociative disorders (DD) are widely believed to have roots in adverse childhood experiences including abuse and loss, but the symptoms often go unrecognized or are misdiagnosed in children and adolescents. [27] [36] [37] [ verification needed ] However, a recent western Chinese study showed an increase in awareness of dissociative disorders present in children. [38] These studies show that DD's have an intricate relationship with the patient's mental, physical and socio-cultural environments. [38] This study suggested that dissociative disorders are more common in Western, or developing countries, [38] however, some cases have been seen in both clinical and non-clinical Chinese populations. [38] There are several reasons why recognizing symptoms of dissociation in children is challenging: it may be difficult for children to describe their internal experiences; caregivers may miss signals or attempt to conceal their own abusive or neglectful behaviors;[ citation needed ] symptoms can be subtle or fleeting; [27] disturbances of memory, mood, or concentration associated with dissociation may be misinterpreted as symptoms of other disorders. [27]

Another resource, Beacon House, informs us of dissociative disorder in children, suggesting that it is a survival mechanism that often goes unnoticed in children that have been traumatised. [39] Dr. Shoshanah Lyons suggests that traumatised children often continue to dissociate even though they might not be in any danger, and that they are often unaware that they are dissociating. [39] 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. [36] Others in the field have argued that recognizing disorganized attachment (DA) in children can help alert clinicians to the possibility of dissociative disorders. [37] In their 2008 article, Rebecca Seligman and Laurence Kirmayer suggest the existence of evidence of linkages between trauma experienced in childhood and the capacity for dissociation or depersonalisation. [40] They also suggest that individuals who are able to utilise dissociative techniques are able to keep this as an extended strategy to cope with stressful situations. [40]

Clinicians and researchers[ who? ] stress the importance of using a developmental model to understand both symptoms and the future course of DDs. [27] [36] 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. [27] [36] Related to this developmental approach, more research is required to establish whether a young patient's recovery will remain stable over time. [41]

Current debates and the DSM-5

A number of aspects of dissociative disorders are currently in active debate. 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 or disorganized attachment. [36] [42] A proposed view is that dissociation has a physiological basis, in that it involves automatically triggered mechanisms such as increased blood pressure and alertness, that would, as Lynn contends, imply its existence as a cross-species disorder. [43] A second area of discussion surrounds the question of whether there is a qualitative or quantitative difference between dissociation as a defense versus pathological dissociation. Experiences and symptoms of dissociation can range from the more mundane to those associated with post traumatic stress disorder (PTSD) or acute stress disorder (ASD) to dissociative disorders. [27] Mirroring this complexity, the DSM-5 workgroup considered grouping dissociative disorders with other trauma/stress disorders, [44] but instead decided to put them in the following chapter to emphasize the close relationship. [45] The DSM-5 also introduced a dissociative subtype of PTSD. [45]

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. [46] However, experimental research in cognitive science continues to challenge claims concerning the validity of the dissociation construct, which is still based on Janetian notions of structural dissociation. [4] [47] Even the claimed etiological link between trauma/abuse and dissociation has been questioned. Links observed between trauma/abuse and DD are largely only present from a Western cultural context. For non-Western cultures dissociation "may constitute a "normal" psychological capacity".[ citation needed ] 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." [48]

Debates around DD also stem from Western versus non-Western lenses of viewing the disorder, and associated views of causes of DD. DID was initially believed to be specific to the West, until cross-cultural studies indicated its occurrence worldwide. [43] Conversely, anthropologists have largely done little work on DD in the West relating to its perceptions of possession syndromes that would be present in non-Western societies.[ citation needed ] While dissociation has been viewed and catalogued by anthropologists differently in the West and non-Western societies, there are aspects of each that show DD has universal characteristics. For example, while shamanic and rituals of non-Western societies may hold dissociative aspects, this is not exclusive as many Christian sects, such as "possession by the Holy Ghost" share similar qualities to those of non-Western trances.[ citation needed ]

See also

Related Research Articles

<span class="mw-page-title-main">Dissociative fugue</span> Dissociative disorder

Dissociative fugue, formerly called a fugue state or psychogenic fugue, is a rare psychiatric phenomenon characterized by reversible amnesia for one's identity in conjunction with unexpected wandering or travel. This is sometimes accompanied by the establishment of a new identity and the inability to recall personal information prior to the presentation of symptoms. Dissociative fugue is a mental and behavioral disorder that is classified variously as a dissociative disorder, a conversion disorder, and a somatic symptom disorder. It is a facet of dissociative amnesia, according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Dissociative identity disorder (DID), previously known as multiple personality disorder (MPD), is one of multiple dissociative disorders in the DSM-5, ICD-11, and Merck Manual. It has a history of extreme controversy.

<span class="mw-page-title-main">Post-traumatic stress disorder</span> Mental disorder associated with trauma

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event and can include triggers such as misophonia. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

<span class="mw-page-title-main">Depersonalization</span> Anomaly of self-awareness

Depersonalization is a dissociative phenomenon characterized by a subjective feeling of detachment from oneself, manifesting as a sense of disconnection from one's thoughts, emotions, sensations, or actions, and often accompanied by a feeling of observing oneself from an external perspective. Subjects perceive that the world has become vague, dreamlike, surreal, or strange, leading to a diminished sense of individuality or identity. Sufferers often feel as though they are observing the world from a distance, as if separated by a barrier "behind glass". They maintain insight into the subjective nature of their experience, recognizing that it pertains to their own perception rather than altering objective reality. This distinction between subjective experience and objective reality distinguishes depersonalization from delusions, where individuals firmly believe in false perceptions as genuine truths. Depersonalization is also distinct from derealization, which involves a sense of detachment from the external world rather than from oneself.

Dissociation is a concept that has been developed over time and which concerns a wide array of experiences, ranging from a mild emotional detachment from the immediate surroundings, to a more severe disconnection from physical and emotional experiences. The major characteristic of all dissociative phenomena involves a detachment from reality, rather than a false perception of reality as in psychosis.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones generally with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se. Examples of distressing events include violence, rape, or a terrorist attack.

Adjustment disorder is a maladaptive response to a psychosocial stressor. It is classified as a mental disorder. The maladaptive response usually involves otherwise normal emotional and behavioral reactions that manifest more intensely than usual, causing marked distress, preoccupation with the stressor and its consequences, and functional impairment.

Ganser syndrome is a rare dissociative disorder characterized by nonsensical or wrong answers to questions and other dissociative symptoms such as fugue, amnesia or conversion disorder, often with visual pseudohallucinations and a decreased state of consciousness. The syndrome has also been called nonsense syndrome, balderdash syndrome, syndrome of approximate answers, hysterical pseudodementia or prison psychosis.

Depersonalization-derealization disorder is a mental disorder in which the person has persistent or recurrent feelings of depersonalization and/or derealization. Depersonalization is described as feeling disconnected or detached from one's self. Individuals may report feeling as if they are an outside observer of their own thoughts or body, and often report feeling a loss of control over their thoughts or actions. Derealization is described as detachment from one's surroundings. Individuals experiencing derealization may report perceiving the world around them as foggy, dreamlike, surreal, and/or visually distorted.

Dysphoria is a profound state of unease or dissatisfaction. It is the semantic opposite of euphoria. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation.

Acute stress reaction (ASR), also known as psychological shock, mental shock, or simply shock, and acute stress disorder (ASD), is a psychological response to a terrifying, traumatic, or surprising experience. Combat stress reaction (CSR) is a similar response to the trauma of war. The reactions may include but are not limited to intrusive or dissociative symptoms, and reactivity symptoms such as avoidance or arousal. It may be exhibited for days or weeks after the traumatic event. If the condition is not correctly addressed, it may develop into post-traumatic stress disorder (PTSD).

<span class="mw-page-title-main">Emotional detachment</span> Inability and/or disinterest in emotionally connecting to others

In psychology, emotional detachment, also known as emotional blunting, is a condition or state in which a person lacks emotional connectivity to others, whether due to an unwanted circumstance or as a positive means to cope with anxiety. Such a coping strategy, also known as emotion-focused coping, is used when avoiding certain situations that might trigger anxiety. It refers to the evasion of emotional connections. Emotional detachment may be a temporary reaction to a stressful situation, or a chronic condition such as depersonalization-derealization disorder. It may also be caused by certain antidepressants. Emotional blunting, also known as reduced affect display, is one of the negative symptoms of schizophrenia.

<span class="mw-page-title-main">Complex post-traumatic stress disorder</span> Psychological disorder

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

A spectrum disorder is a disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".

<span class="mw-page-title-main">DSM-5</span> 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In 2022, a revised version (DSM-5-TR) was published. In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. However, some providers instead rely on the International Statistical Classification of Diseases and Related Health Problems (ICD), and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions. The DSM-5 is the only DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the only living document version of a DSM.

Derealization is an alteration in the perception of the external world, causing those with the condition to perceive it as unreal, distant, distorted or in other words falsified. Other symptoms include feeling as if one's environment is lacking in spontaneity, emotional coloring, and depth. It is a dissociative symptom that may appear in moments of severe stress.

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

<span class="mw-page-title-main">Dissociative disorder not otherwise specified</span> Medical condition

Dissociative disorder not otherwise specified (DDNOS) was a mental health diagnosis for pathological dissociation that matched the DSM-IV criteria for a dissociative disorder, but did not fit the full criteria for any of the specifically identified subtypes, and the reasons why the previous diagnoses were not met are specified. The International Statistical Classification of Diseases and Related Health Problems (ICD-10) refers to the diagnosis as "Other dissociative and conversion disorders". Under the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), it is known as "Other specified dissociative disorder" (OSDD).

Other specified dissociative disorder (OSDD) is a mental health diagnosis for pathological dissociation that matches the DSM-5 criteria for a dissociative disorder, but does not fit the full criteria for any of the specifically identified subtypes, which include dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder, and the reasons why the previous diagnoses were not met are specified. "Unspecified dissociative disorder" is given when the clinician does not give a reason. The International Statistical Classification of Diseases and Related Health Problems (ICD-10) refers to the diagnosis as "Other dissociative and conversion disorders". Under the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), it was known as "Dissociative disorder not otherwise specified" (DDNOS).

The Multiscale Dissociation Inventory (MDI) is a comprehensive, self-administered, multiscale instrument developed by Paul F. Dell. It is designed to assess the domain of dissociative phenomena. The MDI measures 14 major facets of pathological dissociation and uses 23 scales to diagnose dissociative disorders.

References

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