Dissociative Disorders
Unknown authors
Abstract
Dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Dissociative symptoms can potentially disrupt every area of psychological functioning. This chapter includes dissociative identity disorder , dissociative amnesia , depersonalization/derealization disorder , other specified dissociative disorder , and unspecified dissociative disorder . Dissociative disorders are frequently found in the aftermath of a wide variety of psychologically traumatic experiences in children, adolescents, and adults. Throughout this chapter, “traumatic experiences” refers to experiences that result in psychological sequelae, as opposed to the physical impact that can cause traumatic brain injury. Therefore, in DSM-5, the dissociative disorders are placed next to, but are not part of, the trauma- and stressor-related disorders, reflecting the close relationship between these diagnostic classes. Both acute stress disorder and posttraumatic stress disorder include dissociative symptoms, such as amnesia, flashbacks, numbing, and depersonalization/derealization. Dissociative symptoms are experienced as unbidden intrusions into awareness and behavior, with accompanying losses of continuity in subjective experience (i.e., ‘‘positive’’ dissociative symptoms such as division of identity, depersonalization, and derealization) and/or inability to access information or to control mental functions that normally are readily amenable to access or control (i.e., “negative” dissociative symptoms such as amnesia). Across cultural contexts, risk factors for dissociative pathology include earlier onset of trauma; neglect and sexual, physical, and emotional abuse by parents; cumulative early life trauma and adversities; and repeated sustained trauma or torture associated with captivity (e.g., experienced by prisoners of war, victims of trafficking) Choi et al. 2017; Loewenstein 2018; Stein et al. 2013 . Depersonalization/derealization disorder is characterized by clinically significant persistent or recurrent depersonalization (i.e., experiences of unreality or detachment from one’s mind, self, or body) and/or derealization (i.e., experiences of unreality or detachment from one’s surroundings). These alterations of experience are accompanied by intact reality testing. There is no evidence of any distinction between predominantly depersonalization and predominantly derealization symptoms. Individuals with this disorder can have depersonalization, derealization, or both. Dissociative amnesia is characterized by an inability to recall autobiographical information that is inconsistent with normal forgetting. The amnesia may be localized (i.e., an event or period of time), selective (i.e., a specific aspect of an event), or generalized (i.e., identity and life history). In dissociative amnesia, memory deficits are primarily retrograde and often associated with traumatic experiences (e.g., lack of recall of third grade when the individual was kidnapped and held hostage). Although some individuals with amnesia promptly notice that they have gaps or a sense of fragmentation in their remote memory, most individuals with dissociative disorders are initially unaware of their amnesia or minimize or rationalize the deficits. For them, awareness of amnesia occurs when they realize that they do not recall their personal identity or when circumstances make these individuals aware that important autobiographical information is missing (e.g., when they discover evidence or are told of past events that they cannot recall). Generalized dissociative amnesia with loss of a major part or all of the individual’s life history and/or identity is rare. Dissociative identity disorder is characterized by a) the presence of two or more distinct personality states or an experience of possession and b) recurrent episodes of dissociative amnesia. The fragmentation/division of identity may vary across cultural contexts (e.g., possession-form presentations) and with circumstance. Thus, individuals may experience discontinuities in identity and memory that may not be immediately evident to others or are obscured by attempts to hide dysfunction. Individuals with dissociative identity disorder experience recurrent, inexplicable intrusions into their conscious functioning and sense of self (e.g., voices; dissociated actions and speech; intrusive thoughts, emotions, and impulses); alterations of sense of self (e.g., attitudes, preferences, and feeling like their body or actions are not their own); odd changes of perception (e.g., depersonalization or derealization, such as feeling detached, as if watching themself from outside their body); and intermittent functional neurological symptoms. Stress often produces transient exacerbation of dissociative symptoms that makes them more evident. The residual category of other specified dissociative disorder includes presentations in which symptoms characteristic of a dissociative disorder that cause clinically significant distress or impairment predominate but do not meet the criteria for any of the specific dissociative disorders. Examples include identity disturbances associated with less-than-marked discontinuities in sense of self and agency, alterations of identity, or episodes of possession in the absence of a history of episodes of dissociative amnesia; identity disturbance due to prolonged and intensive coercive persuasion as may occur in sects/cults or terrorist organizations; acute dissociative reactions to stressful events that last less than 1 month; and dissociative trance, which is characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness or insensitivity to environmental stimuli.