Dissociative Disorder

1. Dissociative Disorder Chapter #10 John F. Kihlstrom Presentation By: Jennifer Keller

2. Introduction • 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).

3. Dissociative 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 individual’s 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).

11. The 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.

12. The Evolution of a Diagnosis • DSM I • Classified as Psychoneurotic Disorders • Anxiety is either “directly felt and expressed or…unconsciously 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.

14. Dissociative (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.

15. Dissociative (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

16. Dissociative Identity (Multiple Personality) Disorder • There is an alteration of both memory and identity. • Ellenberger’s 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.

17. Videos of Howie • Session #1 • http://www.youtube.com/watch?v=P9RcFyAoQTs&mode=related&search= • Session #13 • http://www.youtube.com/watch?v=m2uMhHDe4Qs&mode=related&search=

18. DID within Laboratory Studies • DID may involve a dissociation between explicit and implicit memory • Explicit memory refers to the person’s 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 person’s 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.

20. Sociocultural 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.

22. Depersonalization 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.

23. Diagnosis 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

24. Assessments 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.

25. Forensic 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.

26. Etiology 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.

27. Etiology of Dissociative Disorder cont. • At this point, the traumatic etiology for dissociative identity disorder and other dissoicative disorders must be considered a hypothesis.

28. Treatment 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.

29. Treatment 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

30. Challenges 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

31. The 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?