Tag Archives: DID

Dissociative Disorders | Dissociative Amnesia | Dissociative Fugue | Dissociative Identity Disorder (DID) | Depersonalization Disorder | Dissociative Disorder NOS


Dissociative Disorders as a category generally encompass dissociative amnesia, dissociative fugue, dissociative identity disorder (DID), depersonalization disorder, and dissociative disorder not otherwise specified (DDNOS).  DDNOS is a residual category intended to capture clinical presentations of DID that fail to meet the full criteria, including derealization unaccompanied by depersonalization, dissociative states in individuals who have been subjected to sever coercive persuasion (makes no sense), dissociative trance disorder, medically unexplained loss of consciousness, stupor, or coma (conversion disorder?); and Ganser syndrome (nonsense, balderdash, approximate answers; syndrome).   The irony is that DDNOS represents the majority of clinical presentations, suggesting that some reorganization of the category is needed since the residual diagnostic label gets more airplay than the flagship disorders.

Structural dissociation of the personality translates into “a lack of integration among two or more psychobiological subsystems of the personality as a whole system, each endowed with at least a rudimentary sense of self.”  One person, multiple personalities; where personalities are defined as “the dynamic organization within the individual of those psychophysical systems that determine his characteristic behavior and thought.”  (Blaney & Millon, 2009, p. 453)

Add to FacebookAdd to DiggAdd to Del.icio.usAdd to StumbleuponAdd to RedditAdd to BlinklistAdd to TwitterAdd to TechnoratiAdd to Yahoo BuzzAdd to Newsvine

“Dissociative Amnesia is the sudden inability to recall personal information that is too extensive to be explained by ordinary forgetfulness.”  (Blaney & Millon, 2009, p. 457)  Of note, is that the diagnosis requires that no other dissociative disorders be present or diagnosed… as a result, this is often a precursor to or a marker for more pervasive dissociative disorders.  Like dissociative fugue, it can be a symptom or a syndrome.  Blaney and Millon embrace an etiological background that includes environmental factors (lack of support, exposure to trauma) with biological predispositions (personal and social factors, low integrative capacity).

Dissociative fugue is similar to tic disorder in the respect that it can be either a symptom or a disorder in and of itself.  Fugue’s onset is relatively sudden in most cases, resulting when an individual travels away from one’s customary home or work.  The result is an inability to recall the past, similar to amnesia, but fugue is predicated by travel.  The amnesia aspect indicates that there may be a strong division between dissociative parts of the personality, and the normally inactive emotional personality (EP) totally dominates the apparently normal personality (ANP).  (Blaney & Millon, 2009, p. 458)

The spectrum of Dissociative Disorders culminates with Dissociative Identity Disorder (DID).  Two or more distinct identities or personality states must be present, and they must recurrently take control of the person’s behavior.  There are some inherent problems with the DID diagnosis, particularly because there is no clarity on the range of what is considered “complete control.”  The list of comorbid disorders with DID read like a laundry list (it is the longest one I have seen to date).  PTSD, self-mutilation, aggressive and suicidal behaviors, impulsivity, repetitive abusive relationships, conversion symptoms, mood, substance-related, sexual and eating disorders, as well as personality disorders are among them.  (Blaney & Millon, 2009, p. 458)  I have never seen comorbity suggestions include entire categories!

Depersonalization Disorder represents persistent or recurring episodes of “feelings of detachment or estrangement from one’s self, while reality testing remains intact.”  (Blaney & Millon, 2009, p. 459)  This reminded me of schizophrenia.  “Out of body experiences” coupled with feeling like your living in a dream or a movie sound like schizophrenia to me.  Maybe I am off here though.

DDNOS is a grab bag of disorders, including the most prevalent disorder in the dissociative family.  Specifically, I am referring to presentations of DID symptoms but are much less “extreme.”  “The identities or dissociative parts exhibit less elaboration and autohomy and are commonly not active or not as active in daily life as some dissociative parts of the personality in patients with DID.”  (Blaney & Millon, 2009, p. 459)  It’s basicly “DID Lite.”  They experience partial intrusion instead of complete switches in executive control.

Dissociative States in individuals who have experienced extreme coercive persuasion doesn’t make any sense, it sounds like it is describing the category, not a separate entity?  I’d bet it gets scratched from the DSM-V.

Dissociative Disorder that “are indigenous to particular locations and cultures” is a fascinating concept.  I am again reminded of the cultural nature of somatization disorders, and I have to wonder if this is just a difference in cultural interpretation, or if indeed cultural traditions have an impact on it’s presentation.

Dissociative stupor should be under somatoform disorders, or conversion disorder should be classified as a dissociative disorder.  They broke up a suited pair.

Of all the theories of dissociation disorders, the one I identified with the most was the “theory of structural dissociation of the personality.”  The basic premise “involves the role of evolutionary prepared actions systems as the underlying psychobiosocial systems that become dissociative in an individual.  The categorization of the systems into 1) systems that promote adaptive functioning and 2) mammalian action systems for defense against bodily threat make sense to me.  The distinction between the ANP and the EP makes sense to me.  It makes me wonder, can you provoke the EP into “coming out” by threatening someone with DID?

Add to FacebookAdd to DiggAdd to Del.icio.usAdd to StumbleuponAdd to RedditAdd to BlinklistAdd to TwitterAdd to TechnoratiAdd to Yahoo BuzzAdd to Newsvine

Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Examining the Relationships between PTSD, Somatization, and Disassociation


There are clinically significant relationships that can be drawn between PTSD and Somatization Disorder, first and foremost because dissociative symptoms are included in the criteria for both.  The disassociation spectrum of disorders culminates in Dissociative Identity Disorder, where an individual has two or more distinct personalities that serve different functions in a person’s life.  Although pure cases of Dissociative Identity Disorder are extremely rare, the occurrence of dissociative-like symptoms is relatively common (especially in patients that are diagnosed with Somatization Disorder and PTSD).  We can visualize these symptoms as a form of psychological defense mechanism which results in an inability to recall events; a selective memory of sorts.  Reports of “disturbances in time” are not uncommon, for example when someone is unable to remember how they arrived at a certain location.  Disassociation sometimes manifests in depersonalization, or the sensation of “not being in one’s own body.”  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 519)

Add to FacebookAdd to DiggAdd to Del.icio.usAdd to StumbleuponAdd to RedditAdd to BlinklistAdd to TwitterAdd to TechnoratiAdd to Yahoo BuzzAdd to Newsvine

Although the DSM-IV-TR has conveniently compartmentalized diagnoses into categorical systems, we should “apply skilled clinical judgment to establish functional relationships among various symptom clusters in any given patient.”  (Van Der Kolk, Pelcovitz, Roth, & Mandel, 1996, expression DISCUSSION)  There is no better forum to explore functional relationships between and among specific diagnosis than the exploration of the interrelationship between PTSD, Somatization Disorder, and Dissociative Disorders.  After all, the disassociations associated with these disorders will frequently present at the same time to the extent that it may be difficult to distinguish where one begins and the other ends.

The DSM-IV-TR diagnostic criteria for 309.81 Posttraumatic Stress Disorder (PTSD) include being exposed to a traumatic event that involved a threat to the physical integrity of self or others.  Secondly, the event must be persistently experienced through recurrent recollections, dreams, flashbacks, illusions, or hallucinations.  Third, the client should demonstrate active and persistent avoidance of stimuli associated with the trauma, and/or a general numbing of general responsiveness.  This frequently manifests in dissociative symptoms, serving as a conscious or unconscious effort to avoid thoughts, feelings, conversations, activities, places, or people.  The resulting disassociation results in feelings of detachment or estrangement, restricted range of affect, or a sense of a foreshortened future.  Finally, the client may present with symptoms of increased arousal including difficulty sleeping, irritability, outbursts of anger, difficulty concentrating, hypervigilance, and/or exaggerated startle response.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 467-468)

In contrast, the DSM-IV-TR diagnostic criterions for 300.81 Somatization Disorder are characterized by a pattern of recurring clinically significant somatic complaints.  The somatic complaints cannot be fully explained by any known general medical condition or the direct effects of a substance.  If they occur in the presence of a general medical condition, the resulting impairment is in excess of what would be expected based on the norm for the general medical condition.  Finally, there are criterions regarding the quantitative and qualitative aspects of the somatic complaints, requiring that individuals present with a relatively wide variance of physical effects.  We could describe this disorder as a form of “somatic dissociation” whereby the client has lost their ability to perceive somatic sensory information, ultimately resulting in a distorted sense of self.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 486)

In a controlled study of Vietnam-era combat veterans, researchers found that combat veterans with PTSD reported and were rated as having a greater number of health problems than combat veterans without PTSD.  They had a greater number of total illnesses across a wider number of medical categories, contributing to the belief that as part of their PTSD, “PTSD patients have difficulty determining the salience of information and that this deficit in information processing may contribute to a patient’s focus on and misinterpretation of somatic sensations.”  (Beckham, Moore, Feldman, & Hertzberg, 1998, expression DISCUSSION)

In another study, researchers attempted to investigate the relationships between exposure to extreme stress, the emergence of PTSD, and the symptoms traditionally associated with “hysteria.”  They found that exposure to extreme stress may result in a variety of combinations of symptoms over time, including symptoms characteristic of somatization disorder and PTSD.  (Van Der Kolk, Pelcovitz, Roth, & Mandel, 1996, expression MODERN TRENDS)

In yet another study that focused primarily on pediatric cancer survivors, researchers found empirical support for the “trauma spectrum model” within which “somatic symptoms may play an instrumental role in the presentation and subsequent detection” of PTSD.  Although we cannot eliminate the possibility that somatic complaints represent true physical symptoms, children with chronic illness typical report higher levels of somatic complaints than healthy peers.  Researchers concluded that “long-term pediatric cancer survivors appear to exhibit somatic symptoms,” as well as PTSD-like symptoms, years after treatment completion.  (Erickson & Steiner, 2000)

Without, all three of these studies strengthen the argument for an interrelationship between stress, the presentation of unexplained physical symptoms, and dissociation.  Despite our best effort to compartmentalize disorders in the DSM-IV-TR, it is critical for us as clinicians to recognize and interrelationships between and among these disorders.  Despite an abundance of applicable research, more study is needed to establish the definitive relationship between and among PTSD, somatization disorder, and the spectrum of disassociation disorders.

Add to FacebookAdd to DiggAdd to Del.icio.usAdd to StumbleuponAdd to RedditAdd to BlinklistAdd to TwitterAdd to TechnoratiAdd to Yahoo BuzzAdd to Newsvine

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Beckham, J. C., Moore, S. D., Feldman, M. E., & Hertzberg, M. A. (1998, Nov). Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder.  The American Journal of Psychiatry, 155(11), 1565-1570. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=36011996&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Erickson, S. J., & Steiner, H. (2000, Jul/Aug). Trauma spectrum adaptation: Somatic symptoms in long-term pediatric cancer survivors. Psychosomatics, 41(4), 339-347. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=56303410&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Van Der Kolk, B. A., Pelcovitz, D., Roth, S., & Mandel, F. S. (1996, Jul). Dissociation, somatization, and affect dysregulation. The American Journal of Psychiatry, 153(7), 83-94. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=9840989&sid=3&Fmt=2&clientId=4683&RQT=309&VName=PQD