Dissociative Disorders DSM: 4 types: dissociative amnesia; dissociative fugue, depersonalization disorder; dissociative identity disorder I.

Dissociative Amnesia A. Definition 1. Significantly impaired memory for important experiences B. DSM IV Criteria A. The predominant disturbance is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. B. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder, Dissociative Fugue, Posttraumatic Stress Disorder, Acute Stress Disorder, or Somatization Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a neurological or other general medical condition (e.g., Amnestic Disorder Due to Head Trauma). C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. Forms of Dissociative amnesia 1. generalized 2. selective amnesia 3. localized amnesia D. Epidemiology, Etc. 1. Prevalence - Unknown 2. Comorbidity - Anxiety, depression and substance abuse; Something is nagging them, but they dont know what 3. Onset - Any age 4. course - One or multiple episodes 5. gender - None E. Etiology 1. Neurological a. Brain trauma b. Cortisol release in response to stress 2. Psychological a. dissociation theory (arousal disruption theory) - 1907, Janet b. Neodissociation theory - Hilgard, 1994 3. Social a. traumatic events are often social II. Dissociative Fugue A. Definition - Sudden, unplanned travel and difficulty remembering the past Sometimes individual takes a new identity B. DSM IV Criteria A. The predominant disturbance is sudden, unexpected travel away from home or one's customary place of work, with inability to recall one's past. B. Confusion about personal identity or assumption of a new identity (partial or complete). C. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy). D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. Syndrome 1. Individual episodes can last from hours to weeks or months 2. Individual functions normally 3. Once fugue has terminated, individual has no memory of it. D. Epidemiology etc. 1. Prevalence 2. Comorbidity 3. Onset a. following a traumatic or overwhelming event - 1880s France epidemic 4. Course a. Usually a single event b. recovery process unknown 5. Gender a. no difference 6. Cultural Influences a. not observed worldwide pibloktoq (Arctic), grisi siknis (Nicaragua, Honduras) - involve running or fleeing; amnesia for the event once its over 25.03 E. Etiology 1. Neurological a. Frontal Lobes activation is decreased in DF patients (as measured by EEG) when recalling personal information; especially right frontal lobe (might be due to cortisol) 2. Psychological a. high hypnotizability in patients - Thus perhaps greater ability to dissociate. b. High susceptibility to hypnosis might be implicated in the disorder 1). Increases vulnerability to dissociative fugue after stress 2). Having experienced a fugue state, people become more hypnotizable, and more able to dissociate 3). A third, unknown factor results in both hi hypnotizability and ability to dissociate

III. Depersonalization Disorder A. Definition 1. A persistent feeling of being detached from ones body B. DSM IV Criteria A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body (e.g., feeling like one is in a dream). B. During the depersonalization experience, reality testing remains intact. C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The depersonalization experience does not occur exclusively during the course of another mental disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder, and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy). C. Syndrome 1. feeling as if one were a robot

2. Non-reactivity to emotional events feel detached like when youre told somebody just died or you won the lottery and you just say oh, thats too bad or thats nice, and after a while, it hits. D. Epidemiology Etc. 1. Prevalence - rare 2. Comorbidity - anxiety 3. Onset - Average age is 16 episodes can be triggered by panic attacks, substance induced 4. Gender differences 2x higher in females E. Etiology 1. Neurological a. unusually high activation of temporal lobe areas involved in visual and auditory recognition b. unusually high activation of parietal lobe involved in localization of body parts (might explain the dissociation; like your parietal lobe is overly activated trying to find where your body is) c. disruption of emotional processing negative face expressions (anger, disgust) dont cause increase in limbic area d. Norepinephrine levels are decreased; important in attention and alertness 2. Psychological a. cognitive deficits spatial orientation 3. Social a. Childhood emotional abuse - acts a trigger when later stressful events occur. IV. Dissociative Identity Disorder A. Definition - the existence of two or more distinct alters each with its own characteristics and history that take turns controlling the persons behavior B. DSM Criteria A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self). B. At least two of these identities or personality states recurrently take control of the person's behavior. C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play. 2. Criticisms of the DSM IV Criteria a. can be easily faked b. can be difficult to distinguish from bipolar rapid cycling c. can be confused with borderline personality disorder d. little reliability among psychiatrists e. by not defining personality states or identities normal emotional mood swings can be considered pathological C. Syndrome 1. Some alters have no knowledge about the existence of other alters ; theres one who knows them all (the one whos usually in control); the # of alters varies (they die, are killed by the others, re-emerge) 2. Alters can have different medical histories a. one needs glasses, the other doesnt b. one has high blood pressure, the other doesnt c. one has allergies, the other doesnt d. one can run a temperature, the other doesnt

3. Stressful events precipitate the emergence of a different alter 4. most people with DID have 2-10 alters, some reports of up to 100 D. Epidemiology Etc. 1. Prevalence - difficult to determine accurately; 1% perhaps 2. comorbidity a. PTSD, mood disorders b. sometimes misdiagnosed as schizophrenia 3. Onset - no accurate estimate; might start in early childhood (due to the correlation w/ child abuse) 4. Course - chronic 5. Gender differences - females 39x more likely to develop it 6. Cultural Differences - DID is observed only in some Western Cultures E. Etiology 1. Neurological a. mixed findings regarding different EEGs among alters b. some of the findings can also be found in people under hypnosis (e.g. changing BP on command) 2. Psychological a. primary finding highly susceptible to hypnosis b. at least one alter recalls severe physical abuse, but it never happened to that alter (the recall at as happening to a different alter). c. adults who were abused as children frequently report that while the abuse was taking place they went to another place, thus dissociated Debate does it exist at all? Is it media driven (Sybil)? Is it a product of patient/doctor relationship? Does the treatment produce the disorder? The treatment usually involves hypnosis, to bring the alters together; the problem is, because they are so hypnotizable, its too easy to suggest that they have another personality or have been abused. Iatrogenic physician-induced

The Three Faces of Eve Joan Crawford