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Module 6: Dissociative Disorders

2nd edition as of August 2020

 

Module Overview

In Module 6, we will discuss matters related to dissociative disorders to include their clinical presentation, epidemiology, comorbidity, etiology, and treatment options. Our discussion will consist of dissociative identity disorder, dissociative amnesia, and depersonalization/derealization.  Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of models to explain psychopathology (Module 2), and descriptions of the various therapies (Module 3).

 

Module Outline

  • 6.1. Clinical Presentation
  • 6.2. Epidemiology
  • 6.3. Comorbidity
  • 6.4. Etiology
  • 6.5. Treatment

 

Module Learning Outcomes

  • Describe how dissociative disorders present.
  • Describe the epidemiology of dissociative disorders.
  • Describe comorbidity in relation to dissociative disorders.
  • Describe the etiology of dissociative disorders.
  • Describe treatment options for dissociative disorders.

 


6.1. Clinical Presentation

 

Section Learning Objectives

  • Describe dissociative disorders.
  • Describe how Dissociative Identity Disorder presents.
  • Describe how dissociative amnesia presents.
  • Describe how depersonalization/derealization presents.

 

Dissociative disorders are a group of disorders characterized by symptoms of disruption in consciousness, memory, identity, emotion, perception, motor control, or behavior (APA, 2013). These symptoms are likely to appear following a significant stressor or years of ongoing stress (i.e., abuse; Maldonadao & Spiegel, 2014).  Occasionally, one may experience temporary dissociative symptoms due to lack of sleep or ingestion of a substance; however, these would not qualify as a dissociative disorder due to the lack of impairment in functioning. Furthermore, individuals who suffer from acute stress disorder and PTSD often experience dissociative symptoms, such as amnesia, flashbacks, depersonalization and derealization; however, because of the identifiable stressor (and lack of additional symptoms listed below), they meet diagnostic criteria for a stress disorder as opposed to a dissociative disorder.

There are three main types of dissociative disorders: Dissociative Identity Disorder, Dissociative Amnesia, and Depersonalization/Derealization Disorder.

 

6.1.1. Dissociative Identity Disorder (DID)

Dissociative Identity Disorder (DID) is what people commonly refer to as multiple personality disorder. The key diagnostic criteria for DID is the presence of two or more distinct personality states or expressions. The identities are distinct in that they often have a unique tone of voice, engage in different physical gestures (including gait), and have different personalities—ranging anywhere from cooperative and sweet to defiant and aggressive. Additionally, the identities can be of varying ages and gender, have different memories, and sensory-motor functioning.

The second main diagnostic criteria for DID is that there must be a gap in the recall of events, information, or trauma due to the switching of personalities. These gaps are more excessive than typical forgetting one may experience due to lack of attention. These personalities must not be a secondary effect of a substance or medical condition (i.e., gap of information due to seizure).

While personalities can present at any time, there is generally a dominant or primary personality that is present the majority of the time. From there, an individual may have several subpersonalities. Although it is hard to identify how many subpersonalities an individual may have at one time, it is believed that there are on average 15 subpersonalities for women and 8 for men (APA, 2000).

The presentation of switching between personalities varies among individuals and can range from merely appearing to fall asleep, to very dramatic, involving excessive bodily movements. While often sudden and unexpected, switching is generally precipitated by a significant stressor, as the subpersonality best equipped to handle the current stressor will present. The relationship between subpersonalities varies between individuals, with some individuals reporting knowledge of other subpersonalities while others have a one-way amnesic relationship with subpersonalities, meaning they are not aware of other personalities (Barlow & Chu, 2014). These individuals will experience episodes of “amnesia” when the primary personality is not present.

 

6.1.2. Dissociative Amnesia Disorder

Dissociative amnesia disorder is identified by the inability to recall important autobiographical information. This type of amnesia is different from what one would consider permanent amnesia in that the information was successfully stored in memory; however, the individual cannot retrieve it. Additionally, individuals experiencing permanent amnesia often have a neurobiological cause, whereas dissociative amnesia does not (APA, 2013).

There are a few types of amnesia within dissociative amnesia. Localized amnesia, the most common type, is the inability to recall events during a specific period. The length of time within a localized amnesia episode can vary—it can be as short as the time immediately surrounding a traumatic event, to months or years, should the traumatic event occur that long (as commonly seen in abuse and combat situations). Selective amnesia is, in a sense, a component of localized amnesia in that the individual can recall some, but not all, of the details during a specific period. For example, a soldier may experience dissociative amnesia during the time they were deployed, yet still have some memories of positive experiences such as celebrating Thanksgiving dinner or Christmas dinner with their unit.

Conversely, some individuals experience generalized amnesia where they have a complete loss of memory of their entire life history, including their own identity. Individuals who experience this amnesia experience deficits in both semantic and procedural knowledge. This means that individuals have no common knowledge of (i.e. cannot identify letters, colors, numbers) nor do they have the ability to engage in learned skills (i.e. typing shoes, driving car).

While generalized amnesia is extremely rare, it is also extremely frightening. The onset is acute, and the individual is often found wandering in a state of disorientation. Many times, these individuals are brought into emergency rooms by law enforcement following a dangerous situation such as an individual wandering on a busy road.

Dissociative fugue is considered to be the most extreme type of dissociative amnesia. Not only does an individual forget personal information, but they also flee to a different location (APA, 2013). The degree of the fugue varies among individuals—with some experiencing symptoms for a short time (only hours) to others lasting years, affording individuals to take on new identities, careers, and even relationships. Similar to their sudden onset, dissociative fugues also end abruptly. Post dissociative fugue, the individual generally regains most of their memory and rarely relapses. Emotional adjustment after the fugue is dependent on the time the individual spent in the fugue, with those having been in a fugue state longer experiencing more emotional distress than those who experienced a shorter fugue (Kopelman, 2002).

 

6.1.3. Depersonalization/Derealization Disorder

Depersonalization/Derealization disorder is categorized by recurrent episodes of depersonalization and/or derealization. Depersonalization can be defined as a feeling of unreality or detachment from oneself. Individuals describe this feeling as an out-of-body experience where you are an observer of your thoughts, feelings, and physical being. Furthermore, some patients report feeling as though they lack speech or motor control, thus feeling at times like a robot. Distortions of one’s physical body have also been reported, with various body parts appearing enlarged or shrunken. Emotionally, one may feel detached from their feelings, lacking the ability to feel emotions despite knowing they have them.

Symptoms of derealization include feelings of unreality or detachment from the world—whether it be individuals, objects, or their surroundings. For example, an individual may feel as though they are unfamiliar with their surroundings, even though they are in a place they have been to many times before. Feeling emotionally disconnected from close friends or family members whom they have strong feelings for is another common symptom experienced during derealization episodes. Sensory changes have also been reported, such as feeling as though your environment is distorted, blurry, or even artificial. Distortions of time, distance, and size/shape of objects may also occur.

These episodes can last anywhere from a few hours to days, weeks, or even months (APA, 2013). The onset is generally sudden, and like the other dissociative disorders, is often triggered by intense stress or trauma. As one can imagine, depersonalization/derealization disorder can cause significant emotional distress, as well as impairment in one’s daily functioning (APA, 2013).

 

Key Takeaways

You should have learned the following in this section:

  • Dissociative disorders are characterized by disruption in consciousness, memory, identity, emotion, perception, motor control, or behavior. They include Dissociative Identity Disorder (DID), dissociative amnesia, and depersonalization/derealization disorder.
  • First, DID is present when a person has two or more distinct personality states or expressions with one becoming the dominant or primary personality.
  • Dissociative amnesia is characterized by the inability to recall important autobiographical information, whether during a specific period (localized) or one’s entire life (generalized) or forgetting personal information and fleeing to a different location (fugue).
  • Depersonalization/derealization disorder includes a feeling of unreality or detachment from oneself (depersonalization) and feelings of unreality or detachment from the world (derealization).

 

Section 6.1 Review Questions

  1. Identify the diagnostic criteria for each of the three dissociative disorders. How are they similar? How are they different?
  2. What is the difference between depersonalization and derealization?

 


 

6.2. Epidemiology

 

Section Learning Objectives

  • Describe the epidemiology of dissociative disorders.

 

Dissociative disorders were once believed to be extremely rare; however, more recent research suggests that they may be more present in the general population than once thought. Estimates for the prevalence rate of DID is 1.5%, with an equal distribution between men and women (APA, 2013). Similarly, a large community sample suggested dissociative amnesia occurs in approximately 1.8% of the population. Unlike DID, females are twice as more likely to be diagnosed with dissociative amnesia than males (APA, 2013). Similar to trauma-related disorders, it is believed that more women experience dissociative amnesia due to their increased chances of encountering significant stress/trauma compared to that of men.

While many individuals experience brief episodes of depersonalization/derealization throughout their life, the estimated number of individuals who experience clinically significant symptoms is estimated to be 2%, with an equal ratio of men and women experiencing these symptoms (APA, 2013).

The onset of dissociative disorders is generally late adolescence to early adulthood, with the exception of DID. Due to the high comorbidity between childhood abuse and DID, it is believed that symptoms begin in early childhood following the repeated exposure to abuse; however, the full onset of the disorder is not observed (or noticed by others) until adolescence (Sar et al., 2014).

 

Key Takeaways

You should have learned the following in this section:

  • In general, somewhere between 1.5 and 2% of individuals experience a dissociative disorder with an equal number of males and females experiencing DID and depersonalization/derealization disorder and more females experiencing dissociative amnesia.

 

Section 6.2 Review Questions

  1. What are the prevalence rates for dissociative disorders? What are some identified barriers in determining prevalence rates of these disorders?

 


 

6.3. Comorbidity

 

Section Learning Objectives

  • Describe the comorbidity of dissociative disorders.

 

Given that a traumatic experience often precipitates dissociative disorders, it should not be surprising that there is a high comorbidity between dissociative disorders and PTSD. Similarly, depressive disorders are also commonly found in combination with dissociative disorders, likely due to the impact the disorders have on social and emotional functioning. In individuals with dissociative amnesia, a wide range of emotions related to their inability to recall memories during the episode often present once the amnesia episode is in remission (APA, 2013). These emotions frequently contribute to the development of a depressive episode.

Due to the rarity of these disorders with respect to other mental health disorders, it is often difficult to truly determine comorbid diagnoses. There has been some evidence of comorbid somatic symptom disorder and conversion disorder, particularly for those who experience dissociative amnesia. Furthermore, dependent, avoidant, and borderline personality disorders have been suspected as co-occurring disorders among the dissociative disorder family.

 

Key Takeaways

You should have learned the following in this section:

  • Many dissociative disorders have been found to have a high comorbidity with PTSD and depressive disorders.
  • Somatic symptom and conversion disorders, as well as some personality disorders, have also been found to be comorbid.

 

Section 6.3 Review Questions

  1. What are the common comorbid diagnoses for individuals with dissociative disorders?

 


 

6.4. Etiology

 

Section Learning Objectives

  • Describe the biological causes of dissociative disorders.
  • Describe the cognitive causes of dissociative disorders.
  • Describe the sociocultural causes of dissociative disorders.
  • Describe the psychodynamic causes of dissociative disorders.

 

6.4.1. Biological

While studies on the involvement of genetic underpinnings need additional research, there is some suggestion that heritability rates for dissociation rage from 50-60% (Pieper, Out, Bakermans-Kranenburg, Van Ijzendoorn, 2011). However, it is suggested that the combination of genetic and environmental factors may play a larger role in the development of dissociative disorders than genetics alone (Pieper, Out, Bakermans-Kranenburg, Van Ijzendoorn, 2011).

 

6.4.2. Cognitive

One proposed cognitive theory of dissociative disorders, particularly dissociative amnesia, is a memory retrieval deficit. More specifically, Kopelman (2000) theorizes that the combination of psychological stress and various other biopsychosocial predispositions affects the frontal lobes executive system’s ability to retrieve autobiographical memories (Picard et al., 2013). Neuroimaging studies have supported this theory by showing deficits to several prefrontal regions, which is one area responsible for memory retrieval (Picard et al., 2013).   Despite these findings, there is still some debate over which specific brain regions within the executive system are responsible for the retrieval difficulties, as research studies have reported mixed findings.

Specific to DID, neuroimaging studies have shown differences in hippocampus activation between subpersonalities (Tsai, Condie, Wu & Chang, 1999). As you may recall, the hippocampus is responsible for storing information from short-term to long-term memory. It is hypothesized that this brain region is responsible for the generation of dissociative states and amnesia (Staniloiu & Markowitsch, 2010).

 

6.4.3. Sociocultural

The sociocultural model of dissociative disorders has been primarily influenced by Lilienfeld and colleagues (1999) who argue that the influence of mass media and its publications of dissociative disorders, provide a model for individuals to not only learn about dissociative disorders but also engage in similar dissociative behaviors. This theory has been supported by the significant increase in DID cases after the publication of Sybil, a documentation of a woman’s 16 subpersonalities (Goff & Simms, 1993).

These mass media productions are not just suggestive to patients. It has been suggested that mass media also influences the way clinicians gather information regarding dissociative symptoms of patients. For example, therapists may unconsciously use questions or techniques in session that evoke dissociative types of problems in their patients following exposure to a media source discussing dissociative disorders.

 

6.4.4. Psychodynamic

The psychodynamic theory of dissociative disorders assumes that dissociative disorders are caused by an individual’s repressed thoughts and feelings related to an unpleasant or traumatic event (Richardson, 1998). In blocking these thoughts and feelings, the individual is subconsciously protecting himself from painful memories.

While a single incidence of repression may explain dissociative amnesia, psychodynamic theorists believe that DID results from repeated exposure to traumatic experiences, such as childhood abuse, neglect, or abandonment (Dalenberg et al., 2012). According to the psychodynamic perspective, children who experience repeated traumatic events such as physical abuse or parental neglect lack the support and resources to cope with these experiences. In an effort to escape from their current situation, children develop different personalities to essentially flee the dangerous situation they are in. While there is limited scientific evidence to support this theory, the nature of severe childhood psychological trauma is consistent with this theory, as individuals with DID have the highest rate of childhood psychological trauma compared to all other psychiatric disorders (Sar, 2011).

 

Key Takeaways

You should have learned the following in this section:

  • Though there is some evidence for a genetic component to dissociative disorders, a combination of genes and environment are thought to play a larger role.
  • A cognitive explanation assumes a memory retrieval deficit, particularly related to dissociative amnesia, and differential hippocampus activation between subpersonalities in DID.
  • Mass media is also purported to have caused a rise in dissociative disorders due to the attention it gives these disorders in its publications and movies such as Sybil.
  • Finally, repressed thoughts and feelings are thought to be the cause of dissociative disorders in the psychodynamic theory.

 

Section 6.4 Review Questions

  1. How do the biological, cognitive, sociocultural, and psychodynamic perspectives differ in their explanation of the development of dissociative disorders?

 


6.5. Treatment

 

Section Learning Objectives

  • Clarify why treatment for dissociative disorders is limited.
  • Describe treatment options for dissociative identity disorder.
  • Describe treatment options for dissociative amnesia.
  • Describe treatment options for depersonalization/derealization.

 

Treatment for dissociative disorders is limited for a few reasons. First, with respect to dissociative amnesia, many individuals recover on their own without any intervention. Occasionally treatment is sought out after recovery due to the traumatic nature of memory loss. Second, the rarity of these disorders has offered limited opportunities for research on both the development and effectiveness of treatment methods. Due to the differences between dissociative disorders, treatment options will be discussed specific to each disorder.

 

6.5.1. Dissociative Identity Disorder

The ultimate treatment goal for DID is the integration of subpersonalities to the point of final fusion (Chu et al., 2011). Integration refers to the ongoing process of merging subpersonalities into one personality. Psychoeducation is paramount for integration, as the individual must have an understanding of their disorder, as well as acknowledge their subpersonalities. As mentioned above, many individuals have a one-way amnesic relationship with the subpersonalities, meaning they are not aware of one another. Therefore, the clinician must first make the individual aware of the various subpersonalities that present across different situations.

Achieving integration requires several steps. First, the clinician needs to build a relationship and strong rapport with the primary personality. From there, the clinician can begin to encourage communication and coordination between the subpersonalities gradually. Making the subpersonalities aware of one another, as well as addressing their conflicts, is an essential component of the integration of subpersonalities, and the core of DID treatment (Chu et al., 2011).

Once the individual is aware of their personalities, treatment can continue with the goal of fusion. Fusion occurs when two or more alternate identities join together (Chu et al., 2011). When this happens, there is a complete loss of separateness. Depending on the number of subpersonalities, this process can take quite a while. Once all subpersonalities are fused and the individual identifies themselves as one unified self, it is believed the patient has reached final fusion.

It should be noted that final fusion is difficult to obtain. As you can imagine, some patients do not find final fusion a desirable outcome, particularly those with harrowing histories; chronic, severe stressors; advanced age; and comorbid medical and psychiatric disorders, to name a few. For individuals where final fusion is not the treatment goal, the clinician may work toward resolution or sufficient integration and coordination of subpersonalities that allows the individual to function independently (Chu et al., 2011). Unfortunately, individuals that do not achieve final fusion are at greater risk for relapse of symptoms, particularly those with whose DID appears to stem from traumatic experiences.

Once an individual reaches final fusion, ongoing treatment is essential to maintain this status. In general, treatment focuses on social and positive coping skills. These skills are particularly helpful for individuals with a history of traumatic events, as it can help them process these events, as well as help prevent future relapses.

 

6.5.2. Dissociative Amnesia

As previously mentioned, many individuals regain memory without the need for treatment; however, there is a small population that does require additional treatment. While there is no evidenced-based treatment for dissociative amnesia, both hypnosis and phasic therapy have been shown to produce some positive effects in patients with dissociative amnesia.

     6.5.2.1. Hypnosis. One theory of dissociative amnesia is that it is a form of self-hypnosis and that individuals hypnotize themselves to forget information or events that are unpleasant (Dell, 2010). Because of this theory, one type of treatment that has routinely been implemented for individuals with dissociative amnesia is hypnosis. Through hypnosis, the clinician can help the individual contain, modulate, and reduce the intensity of the amnesia symptoms, thus allowing them to process the traumatic or unpleasant events underlying the amnesia episode (Maldonadao & Spiegel, 2014). To do this, the clinician will encourage the patient to think of memories just before the amnesic episode as though it was the present time. The clinician will then slowly walk them through the events during the amnesic period in an effort to reorient the individual to experience these events. This technique is essentially a way to encourage a controlled recall of dissociated memories, something that is particularly helpful when the memories include traumatic experiences (Maldonadao & Spiegel, 2014).

Another form of “hypnosis” is the use of barbiturates, also known as “truth serums,” to help relax the individual and free their inhibitions. Although not always effective, the theory is that these drugs reduce the anxiety surrounding the unpleasant events enough to allow the individual to recall and process these memories in a safe environment (Ahern et al., 2000).

 

6.5.3. Depersonalization/Derealization Disorder

Depersonalization/derealization disorder symptoms generally occur for an extensive period before the individual seeks out treatment. Because of this, there is some evidence to support that the diagnosis alone is effective in reducing symptom intensity, as it also relieves the individual’s anxiety surrounding the baffling nature of the symptoms (Medford, Sierra, Baker, & David, 2005).

Due to the high comorbidity of depersonalization/derealization disorder with anxiety and depression, the goal of treatment is often alleviating these secondary mental health symptoms related to the depersonalization/derealization symptoms. While there has been some evidence to suggest treatment with an SSRI is effective in improving mood, the evidence for a combined treatment method of psychopharmacological and psychological treatment is even more compelling (Medford, Sierra, Baker, & David, 2005). The psychological treatment of preference is cognitive-behavioral therapy as it addresses the negative attributions and appraisals contributing to the depersonalization/derealization symptoms (Medford, Sierra, Baker, & David, 2005). By challenging these catastrophic attributions in response to stressful situations, the individual is able to reduce overall anxiety levels, which consequently reduces depersonalization/derealization symptoms.

 

Key Takeaways

You should have learned the following in this section:

  • Treatment for DID involves the integration of subpersonalities to the point of final fusion and takes several steps to achieve.
  • For some patients, this is not possible as they do not find final fusion to be a desirable outcome.
  • Instead, the clinician will work to achieve resolution or sufficient integration and coordination of the subpersonalities to allow the person to function independently.
  • For dissociative amnesia, hypnosis and phasic therapy are used, as well as barbiturates known as “truth serums.”
  • Finally, diagnosis alone is sometimes enough to reduce the intensity of symptoms related to depersonalization/derealization disorder and due to the high comorbidity with anxiety and depression, alleviation of these secondary symptoms is often the goal of treatment.

 

Section 6.5 Review Questions

  1. What is the treatment goal for dissociative identity disorder? How is it achieved?
  2. What are the treatment options for dissociative amnesia and depersonalization/depersonalization disorder?

 


 

Module Recap

In this module, we discussed the dissociative disorders of Dissociative Identity Disorder, Dissociative Amnesia, and Depersonalization/Derealization Disorder in terms of their clinical presentation, epidemiology, comorbidity, etiology, and treatment approaches.

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