Chapter 5: Somatoform and Dissociative Disorders (focus on dissociative disorders)

Dissociative Disorders are disorders in which individuals feel detached from themselves or their surroundings, and reality, experience and identity may disintegrate.

Derealisation is a situation in which the individual loses his or her sense of the reality of the external world (things may change in shape or size and people may seem dear or mechanical).

Types of Dissociative Disorders

1) Depersonalisation Disorder

Definition: dissociative disorder in which feelings of depersonalization are so severe they dominate the client’s life and prevent normal functioning.

Defining features:
- Severe depersonalisation and derealisation.
- Easily distracted and have problems perceiving 3-dimensonal objects.
- Frequent experience of “tunnel vision” (perceptual distortions) and “mind emptiness” (difficulty in absorbing new information).

Statistics:
- Mean age of onset: 16.1 years old.
- Chronic course, averaging 15.7 years.
- More than 50% suffered from additional mood and anxiety disorders.

2) Dissociative Amnesia

Definition: Dissociative disorder featuring te inability to recall personal information, usually of a stressful or traumatic nature.

Defining features:

- Generalised amnesia: condition in which the person loses memory of all personal information, including his or her own identity.
- Localised amnesia: memory loss limited to specific times and events, particularly traumatic events. Also known as selective amnesia.
- Memory loss need not be isolated to simply the events, but the intense emotional reactions to the events as well.

Statistics:
- Could be life long or episodic (6 months or a year).
- Localised amnesia is more common.

3) Dissociative Fugue

Definition: Dissociative disorder featuring sudden, unexpected travel from home, along with an inability to recall one’s past, sometimes with assumption of a new identity.

Defining features:
- Leaving behind an intolerable situation.
- Becomes confused about old identity.
- Running syndromes: individual enters a trancelike state and suddenly imbued with a mysterious source of energy , runs or flees for a long time.
- Amok (a type of running syndrome): individuals enters a trancelike state and often brutally assault and sometimes kill people of animals. If the person is not killed himself, he will probably not remember the episode.

Statistics:
- Usually occur in adulthood.
- Chronic course.
- Fugues states usually end rather abruptly.

4) Dissociative Trance Disorder (DTD)

Definition: Altered state of consciousness in which the person believes firmly that he or she is possessed by spirits; considered to be a disorder only where there is distress and dysfunction.

Defining features:
- Common part of some traditional religious and cultural practices and are not considered abnormal in that context.
- Possession trance: a single or episodic alteration in the state of consciousness characterised by the replacement of customary sense of personal identity b a new identity, often a spirit, power, deity or other person.
- Only when the state is undesirable and considered pathological by members of the culture is it defined as DTD.

Statistics:
- Most common in women.
- Often associated with stress or trauma (current).

5) Dissociative Identity Disorder (DID)

Definition: Dissociative disorder in which as many as 100 personalities or fragments of personalities coexist within one body and mind. Formerly known as multiple personality disorder.

Clinical description:
- DSM-IV criteria include amnesia, as in dissociative amnesia and dissociative fugue.
- Certain aspects of the person’s identity are dissociated.
- Alters: shorthand term for alter egos, the different personalities or identities in DID (could be cross gendered).
- Host identity: Person who becomes the patient and asks for treatment is usually the, which is the identity that keeps the other identities together but end up being overwhelmed.
- Switch: Transition from one personality to another (there could be physical transformations).

Statistics:
- Average number of identities is close to 15.
- Ratio is 9:1 females.
- Onset is always in early childhood, as early as 4 years of age.
- Chronic course without treatment.
- Different personalities can emerge in response to new life situations.
- Comorbid with substance abuse, depression, somatization disorder, borderline personality disorder, panic attacks and eating disorders.
- Often misdiagnosed as psychotic disorder since DID patients usually experience hallucinations (voices in their head motivating them to do something against their will) and are aware of it.

Etiology:
- Child abuse, usually sexual and physical abuse.
- Traumatic experience.
- Hence, DID as an escape mechanism.
- Diathesis-stress model: DID similar to posttraumatic stress disorder (PTSD) in that only people who are biologically and psychologically vulnerable to anxiety are at risk for developing PTSD in response to moderate levels of trauma or stress.
- Suggestability: susceptibility or responsiveness to suggestion.
- Autohypnotic model: people who are suggestible may be able to use dissociation as a defense against extreme trauma.

Treatment:
- Long term psychotherapy to reintegrate identities.
- Prognosis remains guarded nevertheless.
- Catharsis: identify cues or triggers that provoke memories of trauma and/or dissociation and to neutralise them.
- Hence, hypnosis.
- However, reemergence of memories of trauma may trigger further dissociation, which emphasizes the importance of trust in a therapeutic relationship.
- Antidepressant drugs.

Malingerers of DID:
- No changes in physiological responses.
- Recent up-to-date MRI procedures showed changes in hippocampal and medial temporal activity after switch.
- Eager to demonstrate symptoms and do so in a fluid fashion, as opposed to real DID patients who usually attempt to hide symptoms.

Real Memories and False Memories:
- Controversial issue: extent to which memories of early trauma, particularly sexual abuse, are accurate.
- Memories could be a result of strong suggestions by careless therapists.
- If sexual abuse occurred by is forgotten due to amnesia/repression, catharsis is crucial to relief suffering (under direction of a skilled therapist) and perpetrators must be punished.
- However, false memories may result in false accusations.