Transcript Dissociative Disorders

Dissociative Disorders
Common Dissociative Experiences
in Everyday Life
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Daydreaming
Missing parts of conversations
Vivid fantasizing
Forgetting part of drive home
Calling one number when intending to call another
Driving to one place when intending to drive elsewhere
Reading an entire page & not knowing what you read
Not sure whether you’ve done something or only thought
about doing it
Seeing oneself as if looking at another person
Remembering the past so vividly you seem to be reliving
it
Not sure if an event happened or was just a dream
Definition
According to Richard
P. Kluft, Dissociative
Identity Disorder “is a
complex, chronic,
posttraumatic
dissociative
psychopathology
characterized by
disturbances of
memory and identity.”
Qualifications
Years in Practice: 30+ Years
School: Harvard Medical
School
Year Graduated: 1968
License No. and State: MD011120-E Pennsylvania
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Dissociative Disorders
This is an extremely rare
disorder.
It occurs to 1% of the
general population, but
recent 2012 statistics
estimate an average of
7% that have not been
diagnosed properly with
the disorder.
History
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 The first published description of
Dissociative Identity Disorder was made
by Petetain in 1787.
 In the 20th century, DID was put under
the rubric of schizophrenia.
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Because of this the use of the diagnosis of DID dropped
significantly, and people almost stopped studying it
altogether.
History
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 In the 1980’s, feminism really helped
to bring back interest in DID.
 Most of what we know about DID
come from studies made in 1980-1985.
1984 marked the beginning of annual
international conferences on DID.
DID Critics
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Between 1930 to 1960 the diagnosis was
only 2 percent
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Since it made it to DSM in 1980’s the
reported cases has jumped to 20,000
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Number of personalities mushroomed from
3 to 12 per patient
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This disorder is unknown in Japan and India
DID Critics
Critics’ Arguments
1. Role-playing by people open to a
therapist’s suggestion.
2. Learned response that reinforces
reductions in anxiety.
When is Dissociation a problem?
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Loss of overall, integrative control
Unable to access information
Loss of a coherent sense of self
Causes
Traumatic
experiences.
Mainly experienced
during childhood.
Possible Causes of
Dissociation
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Fatigue
Sleep deprivation
Stress
Binge drinking
Drug use
Confronting a new environment
Feeling preoccupied or conflicted
Engaging in certain religious or cultural
rituals or events
Symptoms
One of the most
common known
symptoms are the
different identities,
also known as the
“alters”.
What are the diagnostic criteria for Dissociative Amnesia?
• Cannot recall important personal information—usually of
a traumatic or stressful nature—and too extensive to be
explained by ORDINARY FORGETFULLNESS
• Not due to
– Dissociative Identity Disorder
– Dissociative Fugue
– Somatization Disorder
– Posttraumatic Stress Disorder
– Acute Stress Disorder
– Substance use
– Neurological or General Medical Condition
• Causes significant impairment in social or occupational
functioning
Other Specified Dissociative
Disorder
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Establishes itself securely during early
childhood, and is thought to be caused by
child abuse, that resulted in a lack of a
secure attachment with a primary caregiver.
An absence of secure attachment in
childhood, among repeated abuse,
eventually resulted in an accumulation of
unresolved trauma, causing structural
dissociation
Dissociative Disorders
Types of Dissociative Disorders
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Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Depersonalization Disorder
Dissociative Amnesia
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Partial or total forgetting of past
experience without a biological cause
Almost always anterograde – blocking
out a period of time after psychogenic
cause (e.g. stress / trauma)
Memory loss is often selective
Relative indifference to loss of memory
Remain well oriented to time and place
Dissociative Amnesia
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Impairment is reversible and usually
reported retrospectively (in past tense).
Types of disturbance:
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Localized – affects a few hours around a
traumatic event.
Selective – affects some but not all events
during a period of time, or some categories.
Generalized – affects entire past.
Continuous – a specific time up to the present
Dissociative Fugue
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Amnesia + sudden, unexpected trip
away from home
Often involves the creation of a new
identity
Fugue state usually ends abruptly –
then amnesic for events during the
fugue
Dissociative Identity Disorder
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Sense of self, or personality breaks up
into two or more distinct identities
which take turns “controlling” behavior
At least one “personality” is amnesic
for the experiences of the others
“Alter” often coconscious with the host
Dissociative Identity Disorder
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Identities are often polarized
Often each identity specializes in
different areas of functioning,
encapsulates different memories
Very high proportion report significant
trauma in childhood – possible
strategy that children use to distance
themselves from trauma
Controversy re. cause of DID
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Faking - malingering
Induced by therapy - iatrogenic
Social Role
Hypnotizability
“False Memory Syndrome”
Depersonalization Disorder
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Disruption in identity without amnesia
Sense of strangeness or unreality in
oneself
Derealization
Reduced emotional responsiveness
How can you keep these patients straight?
No
Memory loss?
Yes
Altered sense
of self or reality?
Travel to
another place?
Yes
Depersonalization
Disorder
No
Yes
Evidence of
more than
one identity?
Dissociative
Fugue
No
Yes
Dissociative
Amnesia
Dissociative
Identity Disorder
Dissociative Disorders 2
Common Dissociative Experiences
in Everyday Life
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Daydreaming
Missing parts of conversations
Vivid fantasizing
Forgetting part of drive home
Calling one number when intending to call
another
Driving to one place when intending to
drive elsewhere
Historical Roots
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Hysteria: “wandering uterus”
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physical symptoms without a known cause
term dates back to Hippocrates and
Egyptians
Neurosis: emotional distress due to
underlying unconscious conflicts, anxiety,
and implementation of defense
mechanisms
The Evolution of the Concept
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Three Theorist
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Pierre Janet
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Neodissociation (Hilgard)
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One or more automatisms could split off from the
rest, thus functioning outside of awareness,
independent of voluntary control or both.
Links within the brain would be disrupted or isolated
from phenomenal awareness and the experience of
intentionality.
Woody and Bowers
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The phenomena of dissociation reflect the failure of
these modules (i.e., conscious & unconscious) to be
integrated at higher levels of the system.
Dissociation is a natural state, to some degree.
When is Dissociation a problem?
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Loss of overall, integrative control
Unable to access information
Loss of a coherent sense of self
Dissociative Amnesia
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Person is unable to
recall important
personal information
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Usually related to a
traumatic or stressful
event
Variations
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Generalized
Localized
Selective
Dissociative Fugue
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Person suddenly
leaves home and
work and assumes a
new identity
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Usually triggered by
stress or trauma
Depersonalization Disorder
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Person’s perception or
experience of the self is
disconcertingly and
disruptively altered
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Frequent episodes
Reality does remain
intact during episodes
No amnesia or new
identities
Defenses..
Frequently used in all dissociative disorders
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Repression:
Disturbing impulses are blocked from
consciousness
Denial: external reality is ignored
Dissociation:
Separation & independent functioning of 1 group of
mental processes from others-(mental contents
exist in parallel consciousness)
The psychodynamic view
• Psychodynamic theorists believe that dissociative
disorders are caused by repression, the most basic
ego defense mechanism
• People fight off anxiety by unconsciously
preventing painful memories, thoughts, or
impulses from reaching awareness
• In this view, dissociative amnesia and fugue are
single episodes of massive repression
• DID is thought to result from a lifetime of excessive
repression, motivated by very traumatic childhood
events
The psychodynamic view
• Most of the support for this model is
drawn from case histories, which report
brutal childhood experiences, yet:
• Some individuals with DID do not seem
to have these experiences of abuse
• Further, why might only a small fraction
of abused children develop this
disorder?
The behavioral view
• Behaviorists believe that dissociation grows from normal
memory processes and is a response learned through
operant conditioning:
• Momentary forgetting of trauma leads to a drop in
anxiety, which increases the likelihood of future forgetting
• Like psychodynamic theorists, behaviorists see
dissociation as escape behavior
• Also like psychodynamic theorists, behaviorists rely largely
on case histories to support their view of dissociative
disorders
• Moreover, these explanations fail to explain all aspects of
these disorders
State-dependent learning
• If people learn something when they are in a
particular state of mind, they are likely to
remember it best when they are in the same
condition
• This link between state and recall is called
state-dependent learning
• This model has been demonstrated with
substances and mood and may be linked
to arousal levels
State-dependent learning
• People who are prone to develop
dissociative disorders may have state-tomemory links that are unusually rigid and
narrow; each thought, memory, and skill
is tied exclusively to a particular state of
arousal, so that they recall a given event
only when they experience an arousal
state almost identical to the state in which
the memory was first acquired
Self-hypnosis
• Although hypnosis can help people remember
events that occurred and were forgotten years ago,
it can also help people forget facts, events, and their
personal identity
• Called “hypnotic amnesia,” this phenomenon has
been demonstrated in research studies with word
lists
• The parallels between hypnotic amnesia and
dissociative disorders are striking and have led
researchers to conclude that dissociative disorders
may be a form of self-hypnosis
How Do Therapists Help
Individuals With DID?
Recognizing the disorder
• Once a diagnosis of DID has been made, therapists
try to bond with the primary personality and with each
of the subpersonalities
• As bonds are forged, therapists try to educate the
patients and help them recognize the nature of the
disorder
• Some use hypnosis or video as a means of
presenting other subpersonalities
• Many therapists recommend group or family therapy
How Do Therapists Help
Individuals With DID?
Recovering memories
• To help patients recover missing
memories, therapists use many of the
approaches applied in other dissociative
disorders, including psychodynamic
therapy, hypnotherapy, and drug treatment
• These techniques tend to work slowly in
cases of DID
How Do Therapists Help
Individuals With DID?
Integrating the subpersonalities
• The final goal of therapy is to merge the different
subpersonalities into a single, integrated identity
• Integration is a continuous process; fusion is the final
merging
• Many patients distrust this final treatment goal and
their subpersonalities see integration as a form of
death
• Once the subpersonalities are integrated, further
therapy is typically needed to maintain the complete
personality and to teach social and coping skills to
prevent later dissociations
Quiz
True/False
1) Dissociative Identity Disorder is
directly related to Schizophrenia.
Quiz
True/False
1) Dissociative Identity Disorder is
directly related to Schizophrenia.
False: Schizophrenia is mainly
characterized by hearing or seeing things
that aren't real (hallucinations) and
thinking or believing things with no basis
in reality (delusions).
Quiz
True/False
2) One of the symptoms of DID is known
as an “alter”.
Quiz
True/False
2) One of the symptoms of DID is known
as an “alter”.
True
Quiz
True/False
3) Every one of us has experienced
some mild form of dissociation.
Quiz
True/False
3) Every one of us has experienced some
mild form of dissociation.
True
Quiz
Multiple Choice
1) Which of the following are NOT
symptoms of DID?
a)
mood swings
b)
suicidal tendencies
c)
eating disorders
d)
hallucinations
Quiz
Multiple Choice
1) Which of the following are NOT
symptoms of DID?
a)
mood swings
b)
suicidal tendencies
c)
eating disorders
d)
hallucinations
Quiz
Multiple Choice
2) Which of the following is a known
treatment for DID?
a)
psychotherapy
b)
medication
c)
hypnotherapy
d)
all of the above
Quiz
Multiple Choice
2) Which of the following is a known
treatment for DID?
a)
psychotherapy
b)
medication
c)
hypnotherapy
d)
all of the above
Quiz
Multiple Choice
3) Which of the following symptoms
does NOT distinguish DID from other
mental disorders?
a)
delusions
b)
memory disruption
c)
separate identities
d)
amnesia
Quiz
Multiple Choice
3) Which of the following symptoms
does NOT distinguish DID from other
mental disorders?
a)
delusions
b)
memory disruption
c)
separate identities
d)
amnesia
Questions?