Dissociative Spectrum Disorders in the Primary Care Setting.
Netranee Anju Ramdinny Purryag
Consultant Psychiatrist St. Jeen Pharmacy, Mauritius
Keywords: Dissociative Spectrum disorder
It was 1st time introduced by France philosopher and psychiatrist Pierre Janet (1859-1947). Dissociation is a protective mechanism governed by nervous system both internally and externally. Several studies conducted on a series of inpatients and outpatients in general psychiatric settings in diverse countries yielded results depending on the hinterland of the particular institution. Two studies in North America demonstrated that 13.0 to 20.7% of psychiatric inpatients had a dissociative disorder.3 Studies on dissociative disorders in Istanbul and Turkey yielded prevalence slightly above 10% among psychiatric inpatients and outpatients.4 A finish study reported higher rates for psychiatric outpatients (14%) and inpatients (21%).5 Another two recent studies on outpatient and inpatient psychiatric units in North America reported higher rates than those of previous studies.6 Japanese are very similar to those reported in North America.7
In an Indian study, it was observed that most patients with dissociation presented with a brief dissociative stupor that coexisted with anxiety and panic symptoms. No fugue, amnesia, possession or identity disorders were observed.8
Dissociative disorders usually develop as a way to cope with trauma. The disorders most often form in children subjected to chronic physical, sexual or emotional abuse or, less frequently, a home environment that is otherwise frightening or highly unpredictable. Personal identity is still forming during childhood; a child is more able than an adult to step outside of him or herself and observe trauma. A child, who learns to dissociate in order to endure an extended period of his or her youth, may use this coping mechanism in response to stressful situations throughout life. Adults may develop dissociative disorders in response to severe trauma.
People who experience chronic physical, sexual or emotional abuse during childhood are at greatest risk of developing dissociative disorders. Children and adults who experience other traumatic events, including war, natural disasters, kidnapping, torture and invasive medical procedures, may also develop dissociative disorders.
From a psychological perspective, dissociation is a protective activation of altered states of consciousness in reaction to overwhelming psychological trauma. After the patient returns to baseline, access to the dissociative information is diminished. Psychiatrists have theorized that the memories are encoded in the mind but they have been repressed.
In normal memory function, memory traces are laid down in 2 forms, explicit and implicit.9 Explicit memories are available for immediate and conscious recall and include recollection of facts and experiences of which one is conscious, whereas implicit memories are independent of conscious memory. Further, explicit memory is not well developed in children, raising the possibility that memories become more implicit at this age. Alterations at this level of brain function in response to trauma may mediate changes
in memory encoding for those events and time periods.10 Dissociation is also a neurological phenomenon that can occur from various drugs and chemicals that may cause acute, sub chronic and dissociative episodes.
The DSM IV TR dissociative disorders are described in table 1.
Table 1: General description of DSM-1V TR Dissociative Disorders
Area of Disruption
Inability to recall important personal information, usually of a traumatic or stressful nature, too extensive to be explained by ordinary forgetfulness.
Sudden unexpected travel away from home or one’s customary place of work, accompanied by inability to recall one’s past and confusion about personal identity or the assumption of a new identity.
Dissociative Identity Disorder
Presence of 2 or more distinct identities or personality states that recurrently take control of the individual’s behaviour accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
Persistent or recurrent feeling of being detached from one’s mental processes or body that is accompanied by intact reality testing.
DSM-1V TR notes that dissociative disorder NOS includes disruption of consciousness, memory, identity or perception of the environment but does not meet the criteria for any specific dissociative disorder. The person does not have 2 or more distinct personality states or significant amnesia.
ICD-10 classifies conversion disorder as a dissociative disorder while DSM-1V TR classifies it as a somatoform disorder.
Dissociative disorders occur in acute stress disorder, PTSD and somatisation disorder as well as in alcohol and substance abuse. These dissociative symptoms are usually not manifest within distinct and developed personalities. They may take the form of ego disruptive behavioural states.11 Dissociative disturbances are by definition not due to a substance or a medical condition such as complex partial seizures. They are said to occur in the face of perceived danger and may begin as early as 6 months of age.12
In dissociative amnesia, amnesia may be localised (surrounding an event), selective (partial), generalized (involving one’s entire life), continuous (having a fixed beginning with continuation to the present) or systematized (involving only certain categories of information). The latter 3 types are less common.
In dissociative fugue, travel may range from brief trips over relatively short periods of time (i.e hours or days) to usually complex, usually unobtrusive wandering over long time periods (eg weeks or months), with some individuals crossing numerous national borders and traveling thousands of miles. The person may assume a new name, take up a new residence and engage in complex social activities that are well integrated and that do not suggest the presence of a mental disorder.
In dissociative identity disorder, each personality state may be experienced as if it has a distinct personal history, self-image and identity, including a separate name. The alternate identities frequently have different names and characteristics that contrast with the primary identity. Alternate identities are experienced as taking control in sequence, one at the expense of the other and may deny knowledge of one another, or appear to be in open conflict. Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. Differential diagnosis in adults include comorbid disorders such as somatisation disorder, post traumatic stress disorder, seizures and amnesia. Pseudoseizures and conversion phenomena are both reported to share similar psychological processes with dissociative disorders.13 An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (eg a voice giving instructions).
In depersonalization disorder, the individual may feel like an automaton or as if he or she is living in a dream or a movie. There may be a sensation of being an outside observer of one’s mental processes, one’s body or part of one’s body. Various types of sensory anesthesia, lack of affective response and a sensation of lacking control of one’s actions, including speech are often present. The person with depersonalization disorder maintains an intact reality testing.
Ellason et al14, Giese et al15 and Ganaway16 all report on the high levels of co morbidity of dissociative disorder NOS and dissociative identity disorder with borderline and other personality disorders. Atlas and Wolfson17 found that adolescents with borderline personality disorder evidenced significant dissociation and depression. These reports suggest that the clinician should be wary of diagnosing discrete dissociative syndromes in the presence of other psychiatric diagnoses.
Dissociative auditory hallucinations, unlike schizophrenic hallucinations, are most often described as voices in one’s head (rather than outside the individual) talking, arguing, directing or commenting on one’s action (and do not have the ‘disintegrated quality’ and disorganization of schizophrenic hallucinations).18 In one study19, about half of the patients with dissociative identity disorder had been diagnosed and treated for schizophrenia.
Investigations and Diagnosis
Dissociative disorders are diagnosed based on a review of the symptoms and the history. Investigations are carried out to rule out intracranial brain lesions, sleep deprivation and intoxication; conditions that cause symptoms such as memory loss and a sense of unreality.
Hypnosis is often used to help diagnose dissociative identity disorders. Hypnosis helps to identify alternate personalities or may help describe repressed memories that played a role in the development of dissociative patterns. Hypnosis creates a state of deep relaxation and the patient can concentrate intensely on a specific thought, memory, feeling or sensation while blocking out distractions.
Several techniques and treatment approaches are utilized by mental health professionals in managing dissociative disorders.20 Psychotherapy, the primary treatment in this condition, and other treatment options however focus into a similar main objective, and that is, to facilitate healthy coping mechanisms to trauma and life’s other stresses.
Some of the therapeutic methods that are integrated in the care of patients with dissociative disorders include:
1. Creative Art Therapy: Individuals who experience difficulties in expressing deep seated thoughts and feelings can utilize the opportunities of self-expression in creative arts. Through creative art therapy, patients can enhance their awareness of self and coping abilities. Creative art therapy may be executed in form of dancing, drawing, music and poetry.
2. Cognitive therapy: Cognitive therapy is a subcategory of psychotherapy which involves the transformation of negative perceptions into positive and healthy ones. Based on the theory that one’s thoughts dictate one’s behaviour, patients are trained on how to positively behave when faced in adverse situations.
Well defined psychodynamic, cognitive and hypnotic therapy models for treatment of dissociative identity disorders have been developed and described in literatures. These approaches comprise integrative techniques, generally involving lengthy dynamic and insight- oriented therapies.21
Treatment approaches in Dissociative Amnesia
Treatment approaches for dissociative amnesia usually depends on the duration of the memory loss. For short term dissociative amnesia, the provision of a supportive environment will usually be sufficient especially when patients do not manifest signs of confusion and disorientation. Dissociative amnesia occurring for longer duration commonly needs the careful implementation of more rigorous interventions to therapeutically restore the patient’s sense of identity and self perception.
In addition to supportive treatment, patients with dissociative amnesia may need to undergo hypnosis in order to facilitate the recollection of events. Once the amnesia is relieved, the focus of treatment shifts to the resolution of problems that have led to the amnestic event.
Treatment approaches in Dissociative Identity Disorder
Cohesion of identities and alter egos is the primary goal of treatment for dissociatve identity disorder.22 Regular psychotherapeutic sessions may be integrated with medication administration to allay anxiety, depression and impulsivity. Through psychotherapy, psychiatrists and other mental health professionals focus on addressing the patient’s painful and traumatic memories.
Hypnosis is also helpful in gaining access to alter egos and initiating a means of communication with them. Once a hypnotic state is achieved, psychotherapists interpret the meaning and existence of multiple distinct identities.
Treatment approaches in Dissociative Fugue
The nature of interventions implemented to address dissociative fugue differs during fugue states and after fugue states. When patients are still in a fugue, it is necessary to determine the person’s identity with the help of law enforcing agencies and social services personnel. The patient shall then be supported for restoration of memory and identity.
Psychotherapy is only initiated once a fugue episode is over. The main purpose of psychotherapy for patients experiencing dissociative fugue is the assessment of precipitating factors and the evaluation of means of coping implemented by these patients when conflicts and distressing events arise. Hypnosis will then be achieved through administration of medications in order to develop the patients’ skills in handling stressful situations appropriately.
Treatment approaches in Depersonalization Disorder
Treatment for depersonalization disorder usually focuses on the management of factors that led to the disease progression. This may include minimizing the psychological effects of childhood abuse and maltreatment through desensitization.
Various psychotherapeutic interventions have proven helpful in the management of dissociative disorder. These may include the implementation of cognitive therapy to stop recurring thoughts about the unreal state of being, and behavioral techniques to involve the patient in activities that divert the individual from depersonalization.
Pharmacotherapy is adjunctive in the treatment of dissociative disorders. Dissociative symptoms may occur in normal individuals in stressful circumstances; these spontaneously improve, but patients may benefit from short-term treatment with an anxiolytic medication. In patients with psychiatric disorders, medication approaches should address the primary disorder. Concurrent diagnoses such as anxiety disorder, depressive disorder, bipolar affective disorder, schizophrenia or schizoaffective disorder should be managed with anxiolytics, antidepressants, and mood stabilizers respectively or as indicated. In one particular case example, a patient was essentially psychotic and self-destructive when interviewed, but benefited remarkably from adequate doses of neuroleptic medication. Brief psychotherapies for crisis intervention in addition to supportive treatment and medications greatly decrease the anxiety that drives the dissociative symptoms.2
Education of patient and family
When dissociative features are noted, the patient and family are educated about the symptoms. The origin of the symptoms as a method of coping with past trauma (sexual, physical or neglect), overwhelming affect, or present boredom, loneliness, interpersonal conflict or anxiety in a patient’s life is explained to the individual and his or her family. It should be pointed out to them that the trance state or other symptoms may be innate or learned and that the patient can over time develop more control over these experiences.
Learning of new skills
Patients are educated that they are not ‘crazy’ and can learn to identify the precipitants of trance state or other dissociative phenomena and develop more adaptive coping skills. This involves teaching patients to make a conscious effort to remain in touch with reality and develop new coping skills such as assertion (countering a learned submissive response and expressing his or her own wishes instead) and relaxation (a positive use of the auto hypnotic trance and rationalization to deal with stressful situations).
Basic relaxation responses to anxiety include deep inhalation to a count of 4 for 4 breaths. Other self-relaxation approaches including repeating an important word while breathing slowly in and out as well as visualizing a peaceful scene while breathing deeply and quietly.
Dissociative disorders present with an increased risk of complications which include:
1. Self mutilation
2. Suicide attempts
3. Sexual dysfunction, including sexual addiction or avoidance
4. Alcoholism and substance abuse
5. Sleep disorders (nightmares, insomnia and sleep walking)
6. Anxiety disorders
7. Severe headaches
Dissociative disorders are also associated with significant difficulties in relationships and at work. People with these conditions often are not able to cope well with emotional or personal stress and their dissociative reactions (from turning out to disappearing) may worry loved ones and cause colleagues to view them as unreliable.
Because one is more open than usual to suggestions while under hypnosis, there is some controversy that therapists may unintentionally ‘implant’ false memories by suggestion. However, when conducted under the care of a trained therapist, hypnosis is generally safe as a complementary treatment method.
1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association, Washington, DC, USA, 4th Edition, 1994.
2. James L, Elmore MD. Dissociative Spectrum Disorders in the primary care setting. J Clin Psychiatry 2000; 2: 37-41.
3. Ross CA, Anderson G, Fleischer WP, Norton GR. The frequency of multiple personality personality disorder among psychiatric inpatients. AJP 1991; 148(12): 1717-1720.
4. Sar V, Kundakci E, Kizitan. The Axis 1 dissociative disorder comorbidity of borderline personality disorder among psychiatric outpatients. Journal of Trauma and Dissociation 2003; 4(1): 119-136.
5. Lipsanen T, Korkella J, Peltola P et al. Dissociative Disorders among psychiatric patients: comparison with a non clinical sample. European Psychiatry 2004; 19(1): 53-54.
6. Ross CA. Prevalence, reliability and validity of dissociative disorders in an outpatient setting. Journal of Trauma and Dissociation 2002; 3(1): 7-17.
7. Umesue M, Matsuo T, Iwata N, Tashiro N. Dissociative Disorders in Japan: a pilot study with the dissociative experiences Scale and a semistructural interview. Dissociation: Progress in the dissociative disorders 1996; 9: 182-189.
8. Alexander PJ, Joseph S, Das A. Limited utility of ICD-10 and DSM-1V classification of dissociative and conversion disorders in India. Acta Psychiatr Scand 1997; 95(3): 177-182.
9. Reinhold N, Markowitsch HJ. Retrograde episodic memory and emotion: a perspective from patients with dissociative amnesia. Neuropsychologica 2009; 47(11): 2197-2206.
10. Bremner JD, Krystal JH, Charney DS, Southwick SM. Neural Mechanisms in dissociative amnesia for childhood abuse: relevance to the current controversy surrounding the false memory syndrome. Am J Psychiatry 1996; 153(7): 71-82.
11. Armstrong JG. Reflections on multiple personality disorder as a developmentally complex adaptation. In: Solnit AJ, Neubauer PB, Abrams S et al. The Psychoanalytic study of the child. New Haven, Conn: Yale University Press 1994: 349-364.
12. Putnam FW. Dissociation: a response to extreme trauma. In: Kluft RP. Childhood of Multiple Personality. Washington, DC: American Psychiatric Press 1985: 66-69.
13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Association; 1994: 349-364.
14. Ellason JW, Ross CA, Fuchs DL. Lifetime axis 1 and 11 comorbidity and childhood trauma history in dissociative identity disorder. Psychiatry 1996; 59: 255-266.
15. Giese AA, Thomas MR, Dubovsky SL. Dissociative symptoms in psychotic mood disorders: an example of symptom non-specificity. Psychiatry 1997; 60: 60-66.
16. Ganaway JK. Historical versus narrative truth: clarifying the role of exogenous trauma in the etiology of Multiple Dissociative Disorder and its variants. Dissociation 1989; 2: 205-222.
17. Atlas JA, Wolfson MA. Depression and dissociation as features of borderline personality disorders in hospitalised adolescents. Psychol Rep 1996; 78: 624-626.
18. Boon S, Draijer N. Multiple personality disorder in the Netherlands: a clinical investigation of 71 patients. Am J Psychiatry 1993; 150: 489-494.
19. Ellason J, Ross C. Positive and negative symptoms in dissociative identity disorder and schizophrenia: a comparative analysis. J Nerv Dis 1995; 183: 236-241.
20. Frankel FH. Dissociation: the clinical realities. Am J Psychiatry 1996;153(7): 64-70.
21. Kluff RP. Multiple personality disorders. American Psychiatric Press 1991; 10: 161-188.
22. Kluft RP. Treating the traumatic memories of patients with dissociative identity disorder. Am J Psychiatry 1996; 153: 103-110.
Copyright @ INDIAN PSYCHOSOCIAL FOUNDATION