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