Introduction
According to the classification system in the
Diagnostic and Statistical Manual of Mental Disorders: DSM-V (5th ed., 2013), which is published by the American Psychiatric Association, dissociative disorders can be divided into three major types that share the underlying process of dissociation. When some people are faced with unusual stress from a traumatic event, they cannot cope with the situation and experience overwhelming levels of anxiety. To escape the anxiety, they may experience dissociation as a defensive reaction. Dissociation involves the splitting of the event from the conscious mind so that the stressor or trauma is not remembered. Consequently, these people may experience a loss of memory about the trauma, which enables them to escape the emotional distress. Dissociation has often been associated with such traumatic events as combat, rape, incest, natural disasters, and accidents. Without the memory of the trauma in the conscious mind, a person can avoid the emotional turmoil and anxiety that normally would be present.
Dissociative disorders emerge when the dissociation becomes extreme and begins to negatively affect everyday functioning. The split in consciousness can affect a person’s integration of thoughts and feelings while influencing how the individual acts toward others. Some people with dissociative disorders develop conflicting images of themselves or form actual coexisting personalities.
The DSM-V presents the diagnostic criteria for three major types of dissociative disorders: dissociative amnesia, dissociative identity disorder, and depersonalization/derealization disorder. Dissociative fugue, a fourth subtype listed in previous editions of the DSM, has now been combined with dissociative amnesia.
Amnesia
The most common dissociative symptom is
amnesia, which can be found in most of the dissociative disorders. The DSM-V identifies dissociative amnesia as one of the dissociative disorders. This diagnosis is made when the dissociation is limited to amnesia and does not involve other symptoms. The person with dissociative amnesia is unable to remember information, and this memory loss cannot be explained as mere forgetfulness. The memory loss usually involves a traumatic event. A specific trauma, such as an accident, is the precipitating event for the amnesia and is associated with painful emotions and psychological turmoil. Most often the amnesia has an abrupt onset and the memory loss is apparent to the person with amnesia. However, the person with amnesia usually shows a lack of concern about or appears indifferent to this loss of memory. The lack of concern or indifference stems from the fact that the amnesia prevents the person from experiencing emotional upset or anxiety as a result of undergoing a stressful event. The dissociation serves as a protective device to retain emotional stability. The DSM-V describes several forms of dissociative amnesia, including localized amnesia with loss of memory of a specific situation, generalized amnesia with loss of memory of an entire lifetime of experiences, and selective amnesia with only partial loss of memory. An interesting aspect of dissociative amnesia is the person’s attempt to adapt to the memory loss. Some individuals begin to create false information or false memories to hide the loss in memory caused by the amnesia. This process is termed confabulation.
Dissociative fugue is a variant of dissociative amnesia in which those with memory loss travel away from their homes, leave their jobs, and take on new activities. The onset of the fugue occurs very suddenly. This type of amnesia is considered to be fairly rare and takes place in response to unusual stressors such as war or natural disasters. When a dissociative fugue begins, the person usually wanders far from home. The wandering and amnesia can last for several days or even months but most often last only for a brief period of time. Amnesia is present during the dissociative fugue, but the person is unaware of the memory loss. It is only when the dissociative fugue disappears that the person is again aware of events preceding the onset of the disorder.
Identity Disorder
Dissociative identity disorder is commonly referred to as multiple personality disorder. The person with dissociative identity disorder has at least two distinct personalities that repeatedly take over the individual’s actions. The number of personalities varies for people with the disorder, but the number usually ranges from five to ten distinct personalities that can emerge at any given time. Usually one personality is dominant and is termed the host, and the other secondary personalities are called alters. The movement from one personality to another is usually sudden and can be dramatic. It is common for each personality to be unaware of or to have amnesia about the existence of the other personalities. Memories of events that took place when one personality is present usually remain with only that personality. However, in many cases, one personality has knowledge of all of the alter personalities, or there is superficial awareness among all the personalities. The personalities that emerge in dissociative identity disorder can be either male or female, can differ in ethnicity, and can have dissimilar ages. The different personalities typically show different traits or characteristics, such as one alter being extroverted and another shy and introverted. In casual conversation, the different personalities do not usually seem unusual or strange in their behavior or manner. It is often only through lengthy interactions or clinical interviews with mental health professionals that the different personalities become apparent. The exact cause of dissociative identity disorder is not clear, but people with the disorder usually have experienced a traumatic event in childhood. The most common childhood traumas are physical or sexual abuse, including incest.
Depersonalization and Derealization
Depersonalization/derealization disorder is characterized by the symptom of people experiencing recurrent alterations in their perceptions. People’s perception of the physical environment may change so that it seems unreal or strange. This change in perception is known as derealization. When derealization takes place, people report that everything seems different, as if they have entered a dream state. Depersonalization is the sensation or perception that the person’s body or personal self has become strange or different. Both internal feelings and external perceptions become changed, so that the person feels estranged or alienated. A person may have the sensation that part of the body have changed in size or shape. Some specific symptoms of depersonalization include hemidepersonalization, in which the person feels that one half of the body has changed or is unreal; doubling, in which a person feels himself or herself to be outside the body; and double orientation, which is having the sensation of being in two places at the same time. A person with depersonalization/derealization disorder may experience symptoms of either depersonalization or derealization, or may experience both.
The symptoms of depersonalization usually occur quickly and afflict mostly young adults. Although the causes of this disorder are not exactly known, it has been found that it develops after periods of extreme stress, or after an experience of extreme anxiety.
Other Dissociative Conditions
Beyond the three major types of dissociative disorders, the DSM-V includes two diagnoses for dissociative conditions which do not fall under any of those categories, other specified dissociative disorder and unspecified dissociative disorder. Other specified dissociative disorders include chronic symptoms of more than one dissociative disorder, identity issues as a result of brainwashing or torture, and short-term dissociative reactions to stressful events. Unspecified dissociative disorder (like its predecessor in the DSM-IV, Dissociative Disorder—Not Otherwise Specified) is a diagnosis used when a patient experiences dissociative symptoms but does not fully meet the criteria for any existing dissociative disorder, or when the clinician has insufficient information to determine which specific diagnosis would best fit the patient.
Patient Demographics
Dissociative amnesia is fairly common and appears to occur more often in women than in men. The incidence of dissociative amnesia varies depending on the prevalence of traumatic events such as natural disasters and combat situations. The majority of cases are initially identified in emergency departments of hospitals.
Dissociative identity disorder has been found to be most common in adolescence and young adulthood, with most diagnoses made around the age of thirty. Women have most often been diagnosed with the disorder, which is considered to be a fairly rare disorder. The professional community has engaged in extensive debate about the prevalence of the disorder in the general population. Some professionals dispute the validity of the diagnosis.
Depersonalization/derealization disorder is most often seen in women and is usually diagnosed during young adulthood or adolescence. According to the DSM-V, 95% of those who experience symptoms of this disorder do so prior to the age of 25. There are insufficient scientific studies to establish the prevalence of the disorder in the general population.
Treatment Options
Treatments for dissociative disorders usually focus on the underlying trauma or source of anxiety that triggered the dissociative symptoms. In dissociative amnesia, the treatment tries to reveal the lost memories through extensive psychiatric interviewing, drug-assisted interviews to overcome the memory blocks, and hypnosis. The most common drugs used to assist in the recovery of lost memories are the barbiturates and the benzodiazepines. After forgotten memories are retrieved, the person receives psychotherapy to help cope with the associated anxiety of the memory.
The treatment process for dissociative identity disorder is directed toward discovering the childhood traumatic event that began the development of alternative personalities. The psychotherapy for this disorder is usually a long-term process as the various personalities need to be assessed and eventually integrated into the host personality. The therapist needs to eventually work with the personality that recalls the trauma that triggered the dissociation to overcome the anxiety associated with the event. The person must come to terms with the early childhood trauma and begin to give up the various alters that have helped to manage the anxiety and other negative emotions that were created from the childhood experience. The childhood traumas associated with dissociative identity disorder involve serious violations of basic trust and security. For example, the child who is sexually abused or is the target of incest experiences the extreme betrayal of the nurturing and security that a parent should provide. The different characteristics of the various personalities develop over time to cope with that basic betrayal.
The treatment for the depersonalization disorder has a different focus. There is little scientific evidence regarding the best approach for treatment. Many of the persons with this disorder eventually receive psychotherapy and some psychoactive medication. Most often antianxiety medications such as the benzodiazepines are used to help control the patient’s apprehensions and worries.
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