Dissociative Disorder
Chapter #10
John F. Kihlstrom
Presentation By:
Jennifer Keller
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).
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.
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
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.
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).
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.
3 -States of dissociation that 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 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.
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
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).
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.
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.
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.
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.
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
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.
Videos of Howie
Session #1
http://www.youtube.com/watch?v=P9RcFy
AoQTs&mode=related&search=
Session #13
http://www.youtube.com/watch?v=m2uMhH
De4Qs&mode=related&search=
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.
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.
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?
Kenny (1986) after an ethnographic
analysis of DID, argues that DID is a
response to changing conditions in
American culture.
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.
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
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.
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.
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.
Etiology of Dissociative
Disorder cont.
At this point, the traumatic etiology for
dissociative identity disorder and other
dissoicative disorders must be
considered a hypothesis.
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.
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
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
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?