Dissociative disorder

Dissociative disorders
Video explanation
SpecialtyPsychiatry
SymptomsDisruption of memory, awareness, identity, or perception[1][2]
TypesDissociative identity disorder
Dissociative amnesia
Depersonalization-derealization disorder
Other specified dissociative disorder
Unspecified dissociative disorder[1]
Risk factorsPsychological trauma[1]
Differential diagnosisEffects of medication, sleep disorders, PTSD, acute stress disorder, diseases of the nervous system[1][2]

Dissociative disorders (DD) are a group of mental disorders that involve disruption or breakdown of memory, awareness, identity, or perception.[1][2] Symptoms may include lose of memory (amnesia), different personality states, or feelings of experiences being not real.[1] The symptoms are not under voluntary control and occur to a degree that functioning is disrupted.[1][2] These conditions often are associated with psychological trauma.[1]

The DSM-5 list the following types:[1]

Diagnosis involves ruling out other possible causes such as the effects of medication, sleep disorders, PTSD, acute stress disorder, and diseases of the nervous system.[1][2] The ICD-11 classifies conversion disorder as a dissociative disorder,[2] while the DSM-V classifies it as a somatic symptom and related disorder.[1] DID effects about 1.5% of people, dissociative amnesia about 1.8%, and DPDR about 2%.[1] While dissociative amnesia is more common in females, DID and DPDR occur equally frequently in both sexes.[1]

Cause

Dissociative identity disorder

Dissociative identity disorder is caused by ongoing childhood trauma that occurs before the ages of six to nine.[4][5] People with dissociative identity disorder usually have close relatives who have also had similar experiences.[6]

Dissociative amnesia

A way to cope with trauma. Dissociative 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.[7]

Depersonalization disorder

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; however, this disorder can also acutely form due to severe traumas such as war or the death of a loved one.

Diagnosis

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.[8][9] 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.[9] 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.[9] Some diagnostic tests have also been adapted or developed for use with children and adolescents such as the Adolescent Dissociative Experiences Scale,[10] 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.[11]

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.[12] 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 depression, anxiety disorder, and most often post-traumatic disorder.[13]

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. There have also been cases in which people with dissociative identity disorder provide conflicting testimonies in court, depending on the personality that is present.[14]

Current debates

A number of controversies surround DD in adults as well as children. First, there is ongoing debate surrounding the cause of dissociative identity disorder (DID). The crux of this debate is if DID is the result of childhood trauma and disorganized attachment.[15][16] 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.[11] Mirroring this complexity, the DSM-5 workgroup considered grouping dissociative disorders with other trauma/stress disorders,[17] but instead decided to put them in the following chapter to emphasize the close relationship.[1] The DSM-5 also introduced a Dissociative subtype of PTSD.[1]

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.[18] 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.[19][20] 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."[21]

Treatment

As mentioned earlier, anti-anxiety, antidepressants and tranquilizers are treatment medications that do not cure, but may help control the symptoms of dissociative disorders.

Dissociative identity disorder

Long-term psychotherapy to improve a person's quality of life.

Dissociative amnesia

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.[22] However, the medication Pentothal can sometimes help to restore the memories.[6] 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.


Psychotherapy is helpful for the person who has traumatic, past events to resolve.[6] Once dissociative fugue is discovered and treated, many people recover quickly. The problem may never happen again.[6]

Depersonalization disorder

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.[6]


Epidemiology

The lifetime prevalence of dissociative disorders varies from 10% in the general population to 46% in psychiatric inpatients.[8]

Children

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.[11][15][23] 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; symptoms can be subtle or fleeting;[11] disturbances of memory, mood, or concentration associated with dissociation may be misinterpreted as symptoms of other disorders.[11]

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.[15] Others in the field have argued that recognizing disorganized attachment (DA) in children can help alert clinicians to the possibility of dissociative disorders.[23]

Clinicians and researchers also stress the importance of using a developmental model to understand both symptoms and the future course of DDs.[11][15] 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.[11][15] Related to this developmental approach, more research is required to establish whether a young patient's recovery will remain stable over time.[24]

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®) (5th ed.). American Psychiatric Pub. pp. 291–307. ISBN 978-0-89042-557-2. Archived from the original on 2021-08-28. Retrieved 2021-02-25.
  2. 1 2 3 4 5 6 "ICD-11 - Mortality and Morbidity Statistics". icd.who.int. Archived from the original on 1 August 2018. Retrieved 25 February 2021.
  3. 1 2 Beidel, Deborah C.; Frueh, B. Christopher; Hersen, Michel (2014). Adult psychopathology and diagnosis (Seventh ed.). Hoboken, N.J.: Wiley. pp. 414–422. ISBN 9781118657089. Archived from the original on 2021-05-16. Retrieved 2021-02-25.
  4. ↑ Spigel, David; et al. "Dissociative disorders in DSM5DMS". Archived from the original on 17 November 2020. Retrieved 3 January 2018.
  5. ↑ Salter, Micahel; Dorahy, Martin; Middleton, Warwick. "Dissociative identity disorder exists and is the result of childhood trauma". The Conversation. Archived from the original on 12 November 2020. Retrieved 3 January 2018.
  6. 1 2 3 4 5 Miller, John L. (February 3, 2014). "Dissociative Disorders". athealth.com. Archived from the original on October 19, 2020. Retrieved December 14, 2016.
  7. ↑ Schacter, D. L., Gilbert, D. T., & Wegner, D.M. (2011). Psychology: Second Edition, pages 572-573 New York, NY: Worth.
  8. 1 2 Ross; et al. (2002). "Prevalence, Reliability and Validity of Dissociative Disorders in an Inpatient Setting". Journal of Trauma and Dissociation. 3: 7–17. doi:10.1300/J229v03n01_02.
  9. 1 2 3 Bailey, Tyson D.; Boyer, Stacey M.; Brand, Bethany L. (2019). "Dissociative Disorders". In Segal, Daniel L. (ed.). Diagnostic Interviewing (5th ed.). Springer. ISBN 978-1-4939-9127-3. Archived from the original on 2020-08-12. Retrieved 2021-01-17.
  10. ↑ "Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents: International Society for the Study of Dissociation" (PDF). Journal of Trauma & Dissociation. 5 (3): 119–150. 2004-10-04. doi:10.1300/J229v05n03_09. ISSN 1529-9732. Archived (PDF) from the original on 2021-06-25. Retrieved 2020-07-24.
  11. 1 2 3 4 5 6 7 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 (2): 231–249. doi:10.1016/s1056-4993(02)00103-7. PMID 12725010.
  12. ↑ Splitzer, C; Freyberger, H.J. (2007). "Dissoziative Störungen (Konversionsstörungen)". Psychotherapeut.
  13. ↑ [Nolen-Hoeksema, S. (2014). Somatic Symptom and Dissociative Disorders. In (ab)normal Psychology (6th ed., p. 164). Penn, Plaza, New York: McGraw-Hill.]
  14. ↑ Haley, J. (2003). "Defendant's wife testifies about his multiple personas". Bellingham Herald: B4.
  15. 1 2 3 4 5 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 (2): 79–91. doi:10.1080/08039480510022963. PMID 16195104.
  16. ↑ Boysen, Guy A. (2011). "The Scientific Status of Childhood Dissociative Identity Disorder: A Review of Published Research". Psychotherapy and Psychosomatics. 80 (6): 329–34. doi:10.1159/000323403. PMID 21829044.
  17. ↑ Brand, Bethany L.; Lanius, Ruth; Vermetten, Eric; Loewenstein, Richard J.; Spiegel, David (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 & Dissociation. 13 (1): 9–31. doi:10.1080/15299732.2011.620687. PMID 22211439.
  18. ↑ 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.
  19. ↑ Maldonado, R.J.; Spiegel, D. (2019). "Dissociative Disorders". In Weiss Roberts, Laura; Hales, Robert E.; Yudofsky, Stuart C. (eds.). The American Psychiatric Publishing Board Review Guide for Psychiatry (7th ed.). American Psychiatric Pub. ISBN 978-1-61537-150-1. Archived from the original on 2020-08-12. Retrieved 2020-07-24.
  20. ↑ Heim, Gerhard; Bühler, Karl-Ernst (2019-04-03). Craparo, Giuseppe; Ortu, Francesca; van der Hart, Onno (eds.). Pierre Janet’s views on the etiology, pathogenesis, and therapy of dissociative disorders 1. Rediscovering Pierre Janet (1 ed.). Routledge. pp. 178–199. doi:10.4324/9780429201875-14. ISBN 978-0-429-20187-5. Archived from the original on 2021-08-28. Retrieved 2020-07-24.
  21. ↑ 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.
  22. ↑ (Mayo, 2011, p.11) (3 Mar 2011). Mayo Clinic. 1-12. Retrieved May 5, 2015, from http://www.mayoclinic.com/health/dissociative-disorders/DS00574 Archived 2014-01-02 at the Wayback Machine
  23. 1 2 Waters, F. (July–August 2005). "Recognizing dissociation in preschool children". The International Society for the Study of Dissociation News. 23 (4): 1–4.
  24. ↑ Jans, Thomas; Schneck-Seif, Stefanie; Weigand, Tobias; Schneider, Wolfgang; Ellgring, Heiner; Wewetzer, Christoph; Warnke, Andreas (2008). "Long-term outcome and prognosis of dissociative disorder with onset in childhood or adolescence". Child and Adolescent Psychiatry and Mental Health. 2 (1): 19. doi:10.1186/1753-2000-2-19. PMC 2517058. PMID 18651951.
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