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The relationship between dissociation and trauma

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Title: The relationship between dissociation and trauma


1
The relationship between dissociation and trauma
  • Etzel Cardeña, Ph. D.
  • Thorsen Professor
  • Lunds Universitet

2
(No Transcript)
3
Plan for the lecture
  • What is dissociation?
  • The domain of dissociation
  • Epidemiology, comorbidity, etc
  • The relationship between dissociation and trauma
  • Dissociative disorders
  • Assessment

4
Spalding Gray
  • All that is left of me is this horrid, lingering
    awareness that knows there is no longer any solid
    configuration of me It is a true horror. Its
    the making of a haunted ghost.(1999)

5
Narratives from 1989 SFBay Area earthquake
  • 1 For the next few seconds I felt totally
    estranged from all things and people... I felt
    dazed and detached from what was going on all
    around me.
  • 2 I drove on automatic pilot... didnt really
    realize what had happened or what was happening
  • 3 I felt numb...too numb to panic

6
Three common uses of the term
  • D. as non-integrated mental/behavioral modules
    or systems that should ordinarily be integrated
    into conscious awareness (compartmentalization)
  • D. as a consciousness alteration wherein
    disconnection/disengagement from the
    self/environment is experienced (detachment)
  • D. as a defense mechanism to ward off pain,
    anxiety, experience of trauma (repression vs.
    dissociation?)
  • (Cardeña, 1994 implications for psychotherapy
    (Holmes et al., 2005)

7
The domain of dissociation





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8
Dissociative phenomena
  • Alterations in the sense of self or surrounding
    environment (e.g., derealization)
  • Alterations in physical sensation and sense of
    agency (e.g., conversion)
  • Alterations in emotion (e.g., depersonalization)
  • Alterations in memory (e.g., amnesia)
  • Alterations in identity (e.g., DID)
  • (Butler et al., 1996 Cardeña, 1997)

9
Epidemiology
  • 38 of inpatient psychiatric patients (Robles
    García et al., 2006)
  • 29 of outpatient psychiatric patients (Foote et
    al. 2006)
  • 11 in a non-clinical sample (Ross, 1991)
  • Lifetime prevalence among psychiatric patients of
    27-44.5 (Ross et al., 2002)
  • 10 in Turkish sample (Tutkun et al., 1998)
  • 8 in Dutch sample (Friedl Draijer, 2000)

10
Misdiagnoses
  • On average four previous diagnoses and years
    before DD diagnosis (typically affective
    disorders, personality disorders, schizophrenias
    Coons et al., 1988 Putnam et al., 1986)
  • Lack of systematic research on misdiagnoses of
    children, but anecdotal evidence of false
    diagnoses of ADHD, learning and conduct disorders

11
Comorbidity
  • Affective disorders (and SIB)
  • Anxiety
  • Somatoform disorders
  • Personality disorders (avoidant pd, borderline
    pd)
  • Substance abuse and eating disorders
  • First rank symptoms
  • (Cardeña Spiegel, 1996)
  • Conduct, learning disorders (e.g., hypersexual
    behavior) in children?

12
Disorders with a dissociative component
  • Dissociative amnesia
  • Dissociative fugue
  • Dissociative identity disorder (DID)
  • Depersonalization
  • DDNOS (including proposal for dissociative trance
    disorder)
  • Acute stress disorder
  • Posttraumatic stress disorder
  • Somatization disorder
  • Conversion disorder
  • Panic disorder

13
Dissociation and trauma 1
  • Association of various dissociative phenomena
    with exposure to trauma (Spiegel Cardeña, 1991)
  • Dose relationship between exposure and
    dissociation severity (Koopman, Classen,
    Spiegel, 1996)

14
Dissociation and trauma 2
  • Comorbidity of posttraumatic and dissociative
    symptomatology (Van der Kolk et al., 1996)
  • High hypnotizability of ASD and PTSD patients
    (Spiegel et al., 1988 Bryant, 2004)

15
Dissociation and trauma 3
  • Hx of severe trauma among DD patients (Coons,
    1994), often corroborated (e.g., Chu, 1998)
  • High correlation between dissociation and PTSD
    subscales (Gold Cardeña, 1998)

16
Dissociation and trauma 4
  • Longitudinal, prospective study of medical
    traumatic treatment and later dissociation
    (Diseth, 2006)
  • Peritraumatic dissociation as the strongest
    non-demographic predictor of chronic pathology
    among adults (Ozer et al., 2003) and children
    (Saxe, 2002) also in response to cancer
    diagnoses and treatment

17
Morton Prince
  • Disintegrated personality is no bizarre
    phenomenon, but in its mild forms an almost
    every-day clinical affair. (1906-1907, 187).

18
Dissociative amnesia
  • 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 (DSM-IV).
  • Does nor occur exclusively in conjunction with
    other DD disorders, ASD, PTSD, or somatization,
    and is not due to the direct effect of a
    substance or a neurological condition

19
Dissociative amnesia
  • Topical organization Emotional/episodic
  • Type of amnesia Selective/systematized
  • Temporal organization Retrograde to the whole
    event (i.e., few problems in new learning), or
    recurrent to specific areas
  • Etiology Traumatic event /severe stress
  • Acute/severe and/or chronic/recurrent
  • Associated symptoms Depression, anxiety,
    conversion, other dissociative symptoms

20
Dissociative amnesia-2
  • Sometimes indifference to memory loss
  • Early life (lt40s) condition
  • Secondary gain Typical
  • Prognosis Good in isolated events, variable in
    chronic conditions
  • Responsive to hypnosis and other suggestive
    techniques.
  • Evidence for the validity of both recovered
    accurate memories, and created false memories
    (especially of plausible events)

21
Amnestic disorders due to a general medical
condition
  • Topical organization Event or time centered
  • Extent of amnesia Localized or generalized
  • Memory loss Not exclusively episodic (e.g.,
    procedural)
  • Temporal organization Anterograde or retrograde
    (e. g., head trauma or intoxication) to the
    event.
  • Etiology vascular (e.g., TGA), physical (e.g.,
    concussion), chemical (e.g., alcohol blackout),
    etc.

22
Amnestic disorders due to a general medical
condition-2
  • Comorbidity Other neurological or medical
    symptoms
  • Late life (gt40) condition in the case of vascular
    or some cognitive disorders (e.g., dementias).
  • Secondary gain Variable.
  • Prognosis Variable.
  • Not responsive to hypnosis and other suggestive
    techniques.

23
Dissociative fugue
  • Sudden, unexpected travel away from home or ones
    customary place of work, with inability to recall
    ones past.
  • Confusion about personal identity or assumption
    of a new identity.
  • Narrowing of consciousness, dazed look, trance
  • A special case of amnesia? (DSM-V?)

24
Dissociative fugue
  • Distribution No information about a sex
    preponderance.
  • Etiology Traumatic event/severe stress.
  • Comorbidity Depression, anxiety, other
    dissociative symptoms.
  • Duration Typically hours or longer.

25
Dissociative fugue-2
  • Generally, indifference to memory loss but
    confusion about identity.
  • Early life (lt40) condition.
  • Secondary gain Typical
  • Prognosis Positive for isolated incidents.
  • Responsive to hypnosis and other suggestive
    techniques.

26
Medically caused fugue (epileptic poriomania)
  • Distribution More prevalent among males.
  • Etiology Postictal episodes of aimless wandering
    .
  • Comorbidity Irritability, emotionality,
    religiosity in some TLE patients. Episodes of
    amnesia, depersonalization.
  • Duration Typically some minutes, but it can last
    hours or, more rarely, days.

27
Medically caused fugue (epileptic poriomania)-2
  • No indifference to memory loss or long-term
    confusion about identity.
  • Variable age of onset.
  • Secondary gain Variable.
  • Prognosis Variable.
  • Responsive to antiseizure medication.

28
Depersonalization disorder-1
  • Persistent or recurrent experiences of feeling
    detached from, and as if one is an outside
    observer of, ones mental processes or body.
  • Sense of unreality about the self and/or the
    environment (derealization)
  • During depersonalization reality testing remains
    intact (vs. psychoses).

29
Depersonalization 2
  • Common features (altered sense of self,
    precipitating event, sense of unreality, sensory
    alterations)
  • Attentional and memory problems
  • Cortical abnormalities in sensory integration and
    body schema areas
  • HPA dysregulation.

30
Depersonalization disorder-3
  • Depersonalization symptom may be the 3rd most
    prevalent psychiatric symptom (e.g., they are
    very common in panic attacks).
  • Depersonalization disorder is characterized by
  • Ongoing and recurrent interactive dialogue.
  • Comorbidity Other dissociative symptoms,
    depression and anxiety

31
Depersonalization disorder-4
  • Frequency Persistent or recurrent.
  • Duration. Chronic and habitual.
  • Triggers Not present only in association with
    unusual precipitating factors (e.g., hypnosis,
    drugs, severe stress), but related to an
    emotional precipitant.

32
Depersonalization in seizure disorders
  • Not associated with interactive dialogue.
  • Comorbidity Other seizure symptoms (EEG
    abnormalities, episodes of amnesia).
  • Frequency and duration Variable
  • Postictal confusion.

33
Dissociative identity disorder 1
  • The presence of two or more distinct identities
    or personality states, which recurrently take
    control of the persons behavior, and psychogenic
    amnesia.
  • Sometimes alternating with DDNOS.
  • Frequent comorbidity with depression, anxiety,
    substance abuse, borderline and other personality
    disorders, self-injurious behavior, etc.
    Differential diagnosis with psychosis and seizure
    disorder

34
DID 2
  • Very scant support for iatrogenic hypothesis
    (e.g., previous symptoms, no use of hypnosis for
    diagnosis, etc.)
  • Evidence for diagnostic validity of the disorder
    according to Blashfield et al. criteria
    (literature, diagnostic criteria, interviews,
    reliability, differentiation Gleaves, May,
    Cardeña, 2000)
  • Evidence for validity from cognitive (Eich et
    al., 1997) and brain imaging (e.g., Sar et al.,
    2001)

35
Differential diagnosis
  • Affective disorders
  • Borderline personality disorder
  • Personality disorders
  • Schizophrenias
  • Seizure disorder

36
DDNOS
  • Dissociative disorders that do not meet criteria
    for any specific DD
  • In some studies, the most common DD (e.g.,
    Mezzich et al., 1989)
  • Examples include partial fulfillment of DID
    criteria, derealization without
    depersonalization, dissociative trance disorder
    (e.g., amok, ataque de nervios), dissociative
    states in those subjected to chronic coercion and
    brainwashing, loss of consciousness or stupor,
    Ganser syndrome.
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