35: Dissociative Disorders

Published on 24/05/2015 by admin

Filed under Psychiatry

Last modified 22/04/2025

Print this page

This article have been viewed 2498 times

CHAPTER 35 Dissociative Disorders

Steven C. Schlozman, MD, Ruta M. Nonacs, MD, PhD

KEY POINTS

• Dissociative disorders are a heterogeneous set of psychiatric conditions that are characterized by the lack of a fully integrated consciousness.

• Although dissociative disorders remain controversial, they represent an often unconsidered and therefore missed diagnostic category of diagnoses.

• A large segment of the general population will endorse dissociative symptoms in the absence of significant psychopathology, suggesting that these symptoms exist along a spectrum from normal to pathological.

• Dissociative disorders are most often associated with a history of trauma.

• The etiology of dissociation is likely multifactorial, involving neurobiological responses to significant external stressors.

OVERVIEW

Dissociative disorders are among the most controversial, as well as the most intriguing, psychiatric conditions. Central to the conceptualization of dissociation is the understanding that a person’s consciousness may not be fully integrated. Thus, a patient may experience a distinct alteration in personality or experience, in which thoughts, feelings, or actions are not logically integrated with other self-referential experiences.¹ Furthermore, although the concept of dissociation is more than 100 years old, there continues to exist great debate as to the validity of the symptoms of dissociation itself, as to whether the symptoms of dissociative disorders are better accounted for as subsets of different psychiatric conditions (e.g., anxiety disorders, posttraumatic stress disorder [PTSD], brief traumatic reactions, psychotic disorders, and attachment disorders), and as to the extent to which political and even cinematic agendas have contributed to the current conceptualization of dissociative syndromes. Certainly, the most famous of the dissociative conditions, dissociative identity disorder (DID), is featured in more than a half a dozen popular films and is sometimes mentioned in the now somewhat discounted “epidemic” of ritual satanic cults said to spawn new cases of dissociative disorder in the 1980s.

Nevertheless, most clinicians continue to view the concept of dissociation as a rare, albeit possible, response to horrific and traumatic events and experiences. To this extent, dissociative phenomena are often discussed in the setting of trauma studies, and case reports of dissociation detail those who have suffered a single, horrifying event, as well as those who have suffered the repeated neglect and abuse that characterizes early poor attachment. However, it is not the case that trauma is a necessary etiological factor in the development of dissociation. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is careful to avoid any etiological hypotheses when describing dissociative behavior, and there certainly exist case reports that involve individuals with significant dissociative symptoms that occur in the absence of an identifiable stressor. Given the heterogeneous nature of the syndromes and those who suffer from them, it is no wonder that dissociative disorders are the subject of at times intense controversy.

Finally, there are a number of dissociative conditions described in the DSM-IV. In addition to DID, these include dissociative amnesia, dissociative fugue, depersonalization disorder, and dissociative disorder not otherwise specified (NOS).² Additionally, one must remain vigilant against individuals who feign dissociative symptoms for secondary gain or to assume the sick role. These are best characterized as factitious disorders or malingering and are not true dissociative phenomena. This distinction, however, is made difficult by the possibility that many who feign dissociative symptoms might also have true dissociative disorders. Thus, even the differential diagnosis can be contentious.

This chapter defines the overall concept of dissociation, gives brief summaries of the main dissociative conditions, and discusses etiology and treatment.

HISTORICAL PERSPECTIVE

Dissociative phenomena have been observed and described for hundreds of years. In the late eighteenth century, Franz Mesmer explored the concept of dissociation from the perspective of hypnosis, and indeed was likely the first clinician to document the relationship between those who are easily hypnotized and those who are prone to dissociation.^3,⁴ Nearly a century later, Pierre Janet, building on the work of Sigmund Freud, suggested that the ego fragments in the setting of traumatic events, leading to dissociative states. Importantly, this theory represents a departure from Freud’s primary notions regarding trauma and dissociation. While Janet felt that it was primarily a fragile ego that collapsed under the weight of horrifying trauma, thus yielding dissociative symptoms, Freud conceptualized dissociation as the work of a powerful ego defense, in which individuals wall off intense emotional pain as something separate from the self and left to be expressed only in dissociative states.⁵ Finally, in the early 1900s, Morton Prince wrote “The Dissociation of a Personality,” a lengthy case study that documented his patient, Sally Beauchamp, as “The Saint, the Devil, the Woman.” This was the first in-depth analysis of what is today known as DID.^6,⁷

As mentioned, dissociative disorders became a much discussed subject in psychiatry during the 1980s, in which presumed victims of satanic ritual abuse were often diagnosed with DID and discovered their past via hypnosis and the reclamation of lost memories. Much has been written about the huge recent increase in recovered memories that is often tied to dissociative states, with some clinicians feeling that these cases represent a barely touched-on epidemic of dissociation, whereas others feel strongly that these cases were instead the result of suggestible patients being led to express symptoms and memories that had little basis in the suggested etiology of their predicaments. It is clear that controversy still exists regarding these cases.⁸

CAUSES OF DISSOCIATION

Virtually all explorations of dissociation involve trauma. The majority of academic writing that discusses dissociation occurs in the trauma literature, and scholars have even defined trauma itself as a threat to one’s personal integrity. This is in fact one of the main reasons some believe that dissociative behavior is more a subset of PTSD, with the symptoms of disconnection representing the flashbacks, reexperiencing, and numbing that are central to the diagnosis of PTSD.^9,¹⁰

Additionally, those who are more easily hypnotized are also more prone to dissociation. As younger people and especially children are also more easily hypnotized, this finding is perhaps tied to the fact that younger individuals are also more likely to dissociate. Finally, to the extent that deficiencies in early attachment have been tied to dissociation, it may be that children are more prone to dissociation simply because they have more recently experienced the challenges to secure attachment that have been suggested as etiological to dissociation.^11,¹²

From a more biological perspective, dissociative-like states have long been observed in patients who are given dissociative anesthetics (such as midazolam), or who use illicit substances such as lysergic acid diethylamide (LSD).^11,¹³ These findings suggest irregular serotonin activity as playing some role in dissociative phenomena. Additionally, many patients with brain injury, and especially patients with complex partial seizures, have displayed dissociative behavior.¹⁴^–¹⁷ These findings suggest that multiple triggers, both biological and psychological in origin, mingle in the formation of dissociation as a pathological state.

However, community samples also document a relatively high degree of dissociation in the general population. Although the reasons for this finding are not clear, dissociation has more recently been characterized as akin to state-dependent learning, in which certain information is more easily retrieved from some individuals in specific states of self. As with many psychiatric phenomena, dissociation may exist along a spectrum, with some expressions of dissociation more closely tied to normal states and other symptoms more obviously representative of significant pathology.¹¹

THE EPIDEMIOLOGY OF DISSOCIATION

Estimates as to the prevalence of dissociation vary widely. The overall rate of dissociative disorders is thought to be approximately 10%, based primarily on standardized assessments (such as the Dissociative Experience Scale [DES] and the Structured Clinical Interview for Dissociative Disorders [SCID-D]). Importantly, these assessments have face validity only; therefore, caution must be exercised in interpreting data that stem from these investigations. Additionally, the prevalence of dissociative experiences in the general population is estimated by some to be as high as 75%. It is not clear how to interpret these findings when drawing conclusions regarding the epidemiology of dissociation.¹¹

Nevertheless, some important demographic features have emerged from these investigations. First, as already noted, younger people and especially children are more likely to suffer both dissociative events and to meet criteria for dissociative disorders. Second, for symptoms of general dissociation, there appear to be equal male-to-female ratios. However, specific dissociative syndromes have different gender profiles. While dissociative fugue is more common in men, DID is found more often in women.

DIFFERENT DISSOCIATIVE DISORDERS

The DSM-IV lists dissociative amnesia (formerly called psychogenic amnesia), dissociative fugue, DID (formerly called multiple personality disorder), depersonalization disorder, and dissociative disorder NOS among the dissociative disorders. Tables 35-1 through 35-5 summarize important findings for each of these syndromes.

Table 35-1 Dissociative Amnesia (DSM-IV Criteria and Exclusions)

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, posttraumatic 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 function.

Table 35-2 Dissociative Fugue (DSM-IV Criteria and Exclusions)

A. The predominant disturbance is sudden, unexpected travel away from home or one’s customary place of work, with an inability to recall one’s past.

B. There is confusion about personal identity or an 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 function.

Table 35-3 Dissociative Identity Disorder (DSM-IV Criteria and Exclusions)

A. There are 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. There is an 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.

Table 35-4 Depersonalization Disorder (DSM-IV Criteria and Exclusions)

A. There is a persistent or recurrent experience 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 impairment in social, occupational, or other important areas of function.

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).

Table 35-5 Dissociative Disorder NOS (DSM-IV Criteria and Exclusions)

1. Clinical presentations are similar to dissociative identity disorders 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 may be unaccompanied by depersonalization in adults.

3. States of dissociation may occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion (e.g., brainwashing, thought reform, 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 replacement 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), latah (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.

5. Loss of consciousness, stupor, or coma is not attributable to a general medical condition.

6. Ganser syndrome involves the giving of approximate answers to questions (e.g., “2 plus 2 equals 5”) when not associated with dissociative amnesia or dissociative fugue.

Dissociative amnesia has been defined in DSM-IV as “an inability to recall important personal information, usually of a traumatic nature, that is too extensive to be explained by normal forgetfulness.” (Table 35-1 lists the DSM-IV criteria of this condition and exclusions to it.) Dissociative amnesia may be global, involving a total loss of important personal information, or it may be more localized, in which patients cannot recall specific episodes of behavior or traumatic experiences. These experiences may include self-mutilation, criminal or sexual behaviors, traumatic events, or even marital or financial crises.

The incidence in men and women appears to be equal, and large segments of the general population may suffer brief amnestic periods following a significant large-scale disaster.

The differential diagnosis includes organic syndromes (secondary to brain injuries, lesions, or seizures), as well as factitious disorders and malingering, and the treatment for dissociative amnesia is aimed at the restoration of missing memories, sometimes through psychotherapy and free association, but at times using hypnosis or an amytal interview. Generally speaking, patients with dissociative amnesia recover quickly and completely. However, many patients continue to display a propensity toward amnesia in the setting of trauma.¹⁸

Dissociative Fugue

Dissociative fugue is probably the rarest of the dissociative disorders and is characterized in the DSM-IV as “the sudden unexpected travel away from one’s place of daily activities, with inability to recall some or all of one’s past.” Often, patients suffering from dissociative fugue will assume entirely new identities during their fugue episode. (Table 35-2 lists the DSM-IV criteria of this condition and exclusions to it.) Like dissociative amnesia, fugue is typically triggered by a traumatic event and thus appears to be more common during wartime or after natural disasters. Patients suffering from dissociative fugue may appear normal, though they often become confused and distressed when asked questions about their personal history.

Dissociative fugue occurs primarily in adults, usually between the second and fourth decades of life. While men appear to be affected as often as women, during war, the incidence of men suffering from dissociative fugue increases. While fugues may last several years, most episodes last from a few days to a few months. Alternative diagnoses include brain pathology leading to fugue states, drug-induced fugues secondary to alcoholic or drug-related blackouts, and factitious disorders or malingering. In addition, some cultural syndromes (e.g., amok and latah) may mimic fugue states.

The treatment for dissociative fugue is similar to that for dissociative amnesia; the patient is helped to recall the events preceding the fugue, typically with psychotherapy but sometimes through hypnosis or an amytal interview. The prognosis varies. When fugue states are of short duration, they tend to spontaneously resolve. Longer-lasting episodes, however, may be intractable.^11,¹⁹

Dissociative Identity Disorder

Among the dissociative disorders, DID has received the most attention over the last two decades and has endured considerable controversy. The positive aspects of this controversy involve an ongoing debate regarding the interplay of society on psychiatric nosology, as well as a careful reexamination of all dissociative phenomena and their relationship to consciousness and pathology. DID is defined in the DSM-IV as “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 the self).” In addition, the DSM specifies that “at least two of these identities” must periodically “take control of the person’s behavior.” Finally, there must be a demonstrated “inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.” (Table 35-3 lists the DSM-IV criteria of this condition and exclusions to it.)

An essential aspect of DID is the amnestic quality for alternate personalities displayed by the primary personality. However, in many instances different personality states have varying levels of awareness of other personalities (often called alters) and often a dominant personality state exists that is cognizant of all of the various personalities. The term co-consciousness has been used to describe the simultaneous experience of multiple entities at one time. Thus, one personality may be aware of another’s feelings regarding an ongoing experience.

DID is characterized by high rates of co-morbid depression, and often by affective symptoms that constitute the presenting complaint. In addition, from one-third to one-half of cases of DID experience auditory hallucinations. Some researchers have suggested that these hallucinations are described as “inner voices,” helping to differentiate these symptoms from the external voices heard by those suffering from schizophrenia and other psychotic disorders. Also, in contrast to individuals suffering from schizophrenia, patients with DID are unusually hypnotizable and do not display evidence of a formal thought disorder.

DID is reported more commonly in women than in men, and the mean number of distinct personalities is approximately 13. The prevalence rate is estimated at 1%, with co-morbid conditions (such as depression and borderline personality disorder) being relatively common. Additionally, somatic symptoms (including headaches, gastrointestinal distress, and genitourinary disturbances) are also frequent, as well as increased rates of corresponding conversion symptoms, factitious disorders, and malingering. It is in fact this somewhat messy compilation of diagnoses that contributes to some of the controversy that surrounds DID in general.

DID is usually diagnosed in the third or fourth decade, though those suffering from DID usually report symptoms during childhood and adolescence. Most case series document a chronic, fluctuating course, characterized by relapse and remission. Making the diagnosis of DID in a particular patient is not without controversy. Some clinicians have proposed that the diagnosis must be persistently pursued if a patient’s symptoms even subtly hint at the possibility of dissociation. These clinicians describe patients who are either unaware of, or who wish to hide, their disorder, and therefore need to be “educated” about DID. Critics contend that patients with DID are highly suggestible and that clinicians “create” such patients by “suggesting” symptoms. The critics emphasize that clinicians who show interest and enthusiasm in the multiplicity of personalities reinforce the symptoms.

Extended psychotherapy remains the treatment of choice, although approaches vary widely and remain controversial. Some clinicians describe specialized treatment for DID, including delineating and mapping the alters, inviting each to participate in the treatment, and facilitating communication between the various alters. Through careful exploration of all alternate identities, clinicians attempt to understand past episodes of trauma as experienced by each personality. Hypnosis is sometimes employed to reach dissociated states. Other clinicians focus on the function of the dissociative process in the here-and-now of the patient’s life and the ongoing treatment. They help patients become aware of using dissociation to manage feelings and thoughts within themselves and to manage the closeness and distance within relationships. All approaches seek to increase affect tolerance and to integrate the dissociated states within the patient.

Psychopharmacological treatments (such as antidepressants and anxiolytics) are often useful in treating the common accompanying complaints of depression and anxiety. However, no pharmacological treatment has been found to reduce dissociation, per se. Benzodiazepines reduce anxiety but can also exacerbate dissociation. Although not routinely used for dissociative disorders, neuroleptics are sometimes employed in patients who are grossly disorganized.^11,^20,²¹

Depersonalization Disorder

According to the DSM-IV, depersonalization disorder is characterized by “persistent or recurrent episodes…. of detachment or estrangement from one’s self.” Often, patients with symptoms of depersonalization will “feel like an automaton or like he or she is living in a movie.” (Table 35-4 lists the DSM-IV criteria of the condition and exclusions to it.)

However, reality testing remains intact in those who suffer from depersonalization disorder, representing an important distinction from what would otherwise be seen as primarily a psychotic process.

Studies have suggested that as many as 50% of people will at some point endorse transient symptoms of depersonalization, and in most cases these symptoms cause little disruption and are not considered pathological. However, frequent depersonalization can be quite disruptive, interfering with daily function and preventing the integration of new experiences. Also, while transient depersonalization is roughly equal among men and women, depersonalization disorder is about twice as common in women as it is in men. Depersonalization disorder usually begins by late adolescence or early adulthood, with most episodes lasting from hours to weeks at a time. Symptoms of depersonalization have also been described in those with severe depression or psychosis, among patients taking illicit substances, and as result of specific brain damage, migraines, or seizures.

Treatment is difficult, and patients are often refractory to interventions. Treatment of accompanying psychiatric conditions (such as depression or anxiety) may help. As with other dissociative disorders, exploration of prior traumatic events may prove useful.^11,^22,²³

Dissociative Disorder Not Otherwise Specified

This category is reserved for presentations in which the predominant feature is dissociation without meeting criteria for any specific dissociative disorder. (Table 35-5 lists the DSM-IV criteria of this condition and exclusions to it.) Examples of dissociative disorder NOS vary widely. These include patients who experience derealization (the quality of perceiving previously familiar objects in the external world as strange and unfamiliar) but not depersonalization, or patients with ill-defined alternate personalities. In addition, symptoms that result from torture or brainwashing may be classified in this category. Ganser’s syndrome (sometimes called “prison psychosis”) is classified as a dissociative disorder NOS. It is characterized by the provision of approximate answers, that is, offering half-correct answers to simple inquiries, such as answering “Five” to the question, “What is two plus two?” The correct set of the response is given, but the answer is inaccurate. Ganser’s syndrome is often reported in incarcerated populations.²⁴^–²⁶

Finally, certain culture-bound syndromes (such as amok in Indonesia or latah in Malaysia) are often characterized by dissociation and sometimes by violence. These syndromes have been included in the DSM-IV as dissociative disorder NOS.