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Dissociative Disorder

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Title: 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 individuals 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
    orunconsciously 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.
  • Ellenbergers 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?vP9RcFyAoQTsmodere
    latedsearch
  • Session 13
  • http//www.youtube.com/watch?vm2uMhHDe4Qsmodere
    latedsearch

18
DID within Laboratory Studies
  • DID may involve a dissociation between explicit
    and implicit memory
  • Explicit memory refers to the persons 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 persons
    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?
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