• Clinical science

Dissociative disorders

Summary

Dissociative disorders are psychiatric conditions characterized by disruption and/or discontinuity of normal consciousness, memory, identity, and perception. Abnormalities may also be seen in behavior, control of motor functions, and body representation. The disorders are typically seen in individuals with a history of very stressful or traumatic events and often manifest already in childhood. DSM-5 recognizes the following types: dissociative identity disorder, dissociative amnesia (with or without dissociative fugue), depersonalization disorder, as well as other specified dissociative disorder and unspecified dissociative disorder. Patients usually experience positive dissociative symptoms such as derealization, fragmentation of identity, and depersonalization (i.e., intrusive and involuntary changes in awareness and behavior) and/or negative dissociative symptoms, such as amnesia or difficulties controlling mental functions. Dissociative disorders are often associated with other psychiatric symptoms and conditions, including anxiety, depression, somatic symptom disorders, and eating disorders.

Definition

  • (Nonpathological) dissociation: a psychological defense mechanism (natural protective response) to a traumatic or very stressful experience.
    • Disruption of normal integration of memories, identity, perception, experiences, and emotions to cope with stress or stimulation overload
    • Detachment from self (physical and emotional experiences) and/or surroundings
    • Can be a fleeting phenomenon (e.g. daydreaming) or more severe with impaired consciousness
  • Pathological dissociation: an excessive reaction to a traumatic or very stressful experience that is characterized by:
    • Positive symptoms: derealization; (the mind detaches from one's environment), fragmentation of identity; , and depersonalization (the mind detaches from one's self)
    • Negative symptoms: amnesia, altered consciousness (e.g., narrowed awareness, trance), altered behavior [1]

Dissociative amnesia

  • Epidemiology
    • Most common dissociative disorder (lifetime prevalence is ∼ 7%) [2]
    • More common in women than in men [3]
  • Diagnostic criteria
    1. Inability to recall autobiographical information after a traumatic or stressful event, , that is distinct from ordinary forgetting
      • Can be described as:
        • Localized (i.e. amnesia of a single event or time period)
        • Selective (i.e. amnesia of a specific aspect of an occurrence)
        • Generalized (i.e. amnesia of personal history and identity)
    2. Symptoms cause significant social or occupational impairment.
    3. Symptoms are not due to substance use or another medical condition.
    4. Symptoms cannot be explained by another psychiatric disorder (e.g., dissociative identity disorder, acute stress disorder, posttraumatic stress disorder).
    5. May present with dissociative fugue: wandering or purposeful travel (associated with amnesia of identity or autobiographical information)
  • Treatment
    • Primarily psychotherapy
    • No effective pharmacotherapy is available
  • Prognosis

Patients may experience the return of memories as nightmares or flashbacks. The complete resolution of amnesia and full return of memory may be overwhelming and coincide with an increased risk for suicide.

Depersonalization/derealization disorder

Patients with a depersonalization/derealization disorder may report out-of-body experiences or a feeling of being in a dream.

Dissociative identity disorder

  • Epidemiology
    • Prevalence: < 1% [5]
    • More prevalent in women [6]
    • May manifest at any age
  • Associated conditions
  • Diagnostic criteria
    1. Alternation of at least two separate personality states that cause identity disruption and dominate at different times
    2. Frequent gaps in recall of normal daily events or personal information that are significantly different from ordinary forgetfulness
    3. Symptoms cause the patient significant social or occupational impairment.
    4. Symptoms are not related to substance use or another medical condition.
    5. Symptoms can not be explained by broadly accepted religious or cultural practice. In children, symptoms can not be attributed to imaginary friends or other fantasy play.
  • Treatment [7]
  • Prognosis

Patients are often unaware of the other personalities and describe a feeling of being possessed or experiencing frequent gaps in recall.

Other

Other specified dissociative disorder [8]

Other specified dissociative disorder are characterized by symptom constellations that are typical for dissociative disorders and cause significant social or occupational impairment, but do not fully match the definitions of the disorders listed above. The diagnosis is based on the leading feature of the patient's disorder (e.g., dissociative trance). Examples include the following:

  • Chronic and recurrent syndromes of mixed dissociative symptoms: slight disturbance in identity and sense of agency or identity alterations or episodes of possession in patients without dissociative amnesia
  • Identity disturbance due to prolonged and intense coercive persuasion: prolonged alterations or conscious questioning of identity after being subjected to intense coercive persuasion (e.g., torture, brain washing, thought reform, recruitment by terror organizations, political imprisonment)
  • Acute dissociative reactions to stressful events
  • Dissociative trance
    • Decreased or complete loss of awareness of immediate surroundings that presents as profound unresponsiveness or insensitivity to external stimuli
    • Further symptoms include transient paralysis, loss of consciousness, or uncontrollable, stereotypical behaviors (e.g., rocking, repetitive finger movements) of which patients are unaware
  • Ganser syndrome: giving of approximate answers and occurrence of dissociative symptoms in people where a psychogenic etiology is likely

Unspecified dissociative disorder

Unspecified dissociative disorder are characterized by occurrence of some of the typical symptoms of one of the dissociative disorders described above, without meeting the full criteria of that disorder.

  • 1. American Psychiatric Association. Dissociative Disorders. http://dsm.psychiatryonline.org/doi/abs/10.1176/appi.books.9780890425596.dsm08. Accessed May 15, 2017.
  • 2. Hunter EC, Sierra M, David AS. The epidemiology of depersonalisation and derealisation. A systematic review. Social psychiatry and psychiatric epidemiology. 2004; 39(1): pp. 9–18. doi: 10.1007/s00127-004-0701-4.
  • 3. Reddy LS, Patil NM, Nayak RB, Chate SS, Ansari S. Psychological Dissection of Patients Having Dissociative Disorder: A Cross-sectional Study. Indian journal of psychological medicine. ; 40(1): pp. 41–46. doi: 10.4103/IJPSYM.IJPSYM_237_17.
  • 4. Simeon D. Depersonalisation disorder: a contemporary overview. CNS Drugs. 2004; 18(6): pp. 343–54. doi: 10.2165/00023210-200418060-00002.
  • 5. Rehan MA, Kuppa A, Ahuja A, et al. A Strange Case of Dissociative Identity Disorder: Are There Any Triggers?. Cureus. 2018; 10(7): p. e2957. doi: 10.7759/cureus.2957.
  • 6. Myrick AC, Brand BL, McNary SW, et al. An exploration of young adults' progress in treatment for dissociative disorder. J Trauma Dissociation. 2012; 13(5): pp. 582–95. doi: 10.1080/15299732.2012.694841.
  • 7. Gentile JP, Dillon KS, Gillig PM. Psychotherapy and pharmacotherapy for patients with dissociative identity disorder. Innov Clin Neurosci. 2013; 10(2): pp. 22–9. pmid: 23556139.
  • 8. Trauma Dissociation. Other Specified Dissociative Disorder and DDNOS. http://traumadissociation.com/osdd.html. Accessed May 15, 2017.
last updated 10/19/2020
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