Dissociative Disorders
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Dissociative disorders occur after significant adverse experiences/traumas, and individuals respond to stress with a severe interruption of consciousness. |
Dissociation is an unconscious defense mechanismOpens in new window that protects the individual against overwhelming anxiety through an emotional separation; however, this separation results in disturbances in memory, consciousness, self-identity, and perception.
Patients with dissociatie disorders have intact reality testing; that is, although the person may have flashbacks or images, these are triggered by current events, relate to the past trauma, and are not delusions or hallucinations.
Mild, fleeting dissociative experiences are relatively common to all of us; for example, we say we are on “automatic pilot” when we drive home from work and cannot recall the last 15 minutes before reaching the house. These common experiences are distinctly different from the processes of pathological dissociation.
DissociationOpens in new window is involuntary and results in failure of the normal control over a person’s mental processes and normal integration of conscious awareness (Spiegel et al., 2011). Dimensions of a memory that should be linked are not and are fragmented. For example, a person may be aware of a sound or smell, but these sensations would not be linked to the actual event itself, leaving the person fearful and/or confused. In addition, the person may re-enact, as well as re-experience, trauma without consciously knowing why.
Symptoms of dissociation may be either positive or negative.
- Positive symptoms refer to unwanted additions to mental activity such as flashbacks.
- Negative symptoms refer to deficits such as memory problems or the ability to sense or control different parts of the body.
It is thought that dissociation decreases the immediate subjective distress of the trauma (a self-protective mechanism) and also continues to protect the individual from full awareness of the disturbing event. Continued dissociative symptoms, however, can interfere with activities of daily living and relationships.
In the case of abused or neglected children dissociation can be interpreted as somewhat protective, allowing the child to continue to be attached to abusive or neglectful caretakers. This instinctive mechanism highlights the importance of attachments and relationships in allowing the child to grow socially, intellectually, and cognitively.
If abuse or neglect has occurred, memories of it become compartmentalized and often do not intrude into awareness until later in life during a stressful situation or in tryihng to develop another significant relationship.
All of the dissociative disorders affect both the patient and the patient’s family. For example, people with depersonalization disorderOpens in new window are often fearful that others may perceive their appearance as distorted and may avoid being seen in public. If they exhibit consistently high levels of anxiety, the family is likely to find it difficult to keep relationships stable.
By comparison, people who experience fugue statesOpens in new window often function adequately in their new identities by choosing simple, undemanding occupations, and having few intimate social interactions.
Patients with amnesiaOpens in new window, in contrast to those with fugueOpens in new window, may be more dysfunctional. Their perplexity often renders them unable to work, and their memory loss impairs normal relationships. Families often direct considerable attention toward the patient but may exhibit concern over having to assume roles that were once assigned to the patient.
Finally, patients with dissociative identity disorder (DID)Opens in new window often have both family and work problems. Families find it difficult to accept the seemingly erratic behaviors of the patient. Employers dislike the lost time that may occur when alternate identities are in control.
Comorbidity
Comorbidity is common with dissociative disorders. DepressionOpens in new window, panic attacksOpens in new window, eating disordersOpens in new window, PTSDOpens in new window, somatoform symptomsOpens in new window, eating disordersOpens in new window, obsessive-compulsive disorder (OCD)Opens in new window, reactive attachment disorder (RAD)Opens in new window, attention deficit disorderOpens in new window with or without hyperactivity, personality disorders such as borderline personality disorderOpens in new window, and substance-use disordersOpens in new window, as well as sexualOpens in new window and sleep disordersOpens in new window, commonly co-occur with all of the dissociative disorders (ISSTD, 2012).
In addition, dissociative amnesiaOpens in new window may be comorbid with conversion disorder or a personality disorder. Dissociative fugueOpens in new window, a type of dissociative amnesia, may co-occur with PTSDOpens in new window. Depersonalization and derealizationOpens in new window also occur in hypochondriasis, mood and anxiety disorders, obsessive compulsive disorder (OCD), and schizophrenia (Spiegel et al., 2011).
Etiology
Childhood physical, sexual, or emotional abuse and other traumatic life events are associated with adults experiencing dissociative symptoms. Dissociative symptoms, or “mind-flight,” actually reduce disturbing feelings and protect the person from full awareness of the trauma.
Biological Factors
- Genetic
Although genetic variabilityOpens in new window is thought to play a role in stress reactivity, dissociation is thought to be largely due to extreme stress or environmental factors.
- Neurobiological
Research suggests that the limbic system is involved in the development of dissociative disorders.
Animal studies show that early, prolonged detachment from the caretaker negatively affects the development of the limbic system. Traumatic memories are processed in the limbic systemOpens in new window, and the hippocampusOpens in new window stores this information. Individuals with dissociative disorders have increased activation of the orbital frontal cortex Opens in new window that inhibits activation of the amygdale and insular cortex as well as the hippocampal areas (Spiegel et al., 2011).
Psychological Factors
One of the most primitive ego defense mechanisms is dissociation. The theory of structural dissociationOpens in new window of the personality proposes that patients with complex trauma have different parts of their personality, the apparently normal part and the emotional, that are not fully integrated with each other (Steele et al., 2005).
Each part has its own responses, feelings, thoughts, perceptions, physical sensations, and behaviors. These different parts may not be aware of each other, with only one dominant personality operating depending on the situation and circumstance of the moment.
Environmental Factors
Dissociative disorders are responses to acute overwhelming trauma and as such are due to environmental factors. These may include any experience that is overwhelming to the person such as a motor vehicle accident, combat, emotional/verbal abuse, incest, neglectful or abusive caregivers, imprisonment, and many other types of traumatic events.
Cultural Considerations
Certain culture-bound disorders exist in which there is a high level of activity, a trancelike state, and running or fleeing, followed by exhaustion, sleep, and amnesia regarding the episode.
These syndromes include pibloko, seen in native people of the Arctic, frenzy witchcraft among the Navajo, and amok among Western Pacific natives. These syndromes, if observed in individuals native to the corresponding geographical areas, should be differentiated from dissociative disorders.
See also:
- Bernstein, E.M., & Putnam, F.W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174(12), 727 – 735.
- Boon, S., Steele, K., & van der Hart, O. (2011). Coping with trauma-related dissociation: Skills training for patients and therapists. New York, NY: Norton.
- Friedrich, W., Gerber, P., Koplin, B., Davis, M., Giese, J., Mykelebust, C., & Franckowiak, D. (2001). Multimodal assessment of dissociation in adolescents: Inpatients and juvenile sex offenders. Sexual Abuse: Journal of Research and Treatment, 13, 167 – 177.
- International Society for the Study of Trauma and Dissociation. (2012). Guidelines for treating dissociative identity disorder in adults, 3rd rev. Journal of Trauma and Dissociation, 12 (2), 115 – 187.
- Koch, S.C., & Harvey, (2012). Dance/movement therapy with traumatized dissociative patiens. In S.C. Koch, T. Fuchs, M. Summa & C. Muller (Eds.), Body memory, methaphor and movement (pp. 369 – 386). Philadelphia, PA: John Benjamins.
- Ross, C.A., Heber, S., Norton, G.R., Anderson, D., Anderson, G., & Barchet, P. (1989). The Dissociative Disorders Interview Schedule: A structured interview. Dissociation, 2, 169 – 189.
- Spiegel, D., Loewenstein, R., Lewis-Fernandez, R., Sar, V., Simeon, D., Vermetten, E., et al. (2011). Dissociative disorders in DSM-5. Depression and Anxiety, 28, 824 – 852.
