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| Dissociative Disorders What are Dissociative Disorders? Dissociative Disorders are a group of uncommonly recognized conditions not explicitly discussed in Psychiatric Mental Health Nursing. Some students and instructors may want more information on these conditions because they are fascinating, highly controversial, and frequently discussed in the popular media. They also form the subject matter for a number of books and films, some of the latter of which are reviewed in the text (p. 761). Certainly, students who see the films Sybil or Three Faces of Eve will want to know more about the dissociative disorder they depict. DSM-IV includes four specific diagnoses under the category Dissociative Disorders. These include Dissociative Amnesia, Dissociative Fugue, Depersonalization Disorder, and Dissociative Identity Disorder. There is also a fifth category for Dissociative disorder that does not meet criteria for any of these other four. Amnesia is the loss of memory, sometimes concerning events that are particularly traumatic or frightening. Fugue is sudden unexplained travel away from home or normal environment; fugue is usually associated with confusion about past identity or more rarely with the assumption of a completely new personal identity. Depersonalization refers to either persistent or recurrent feelings of being separated from one's normal mental functions, or feeling as if one is outside one's body. Each of these symptoms - amnesia, fugue, and depersonalization - can be part of other psychological conditions, most commonly anxiety or somatoform disorders. Historically, these conditions have often been considered to be part of the spectrum of "hysteria", but this diagnosis - so important in the development of psychoanalysis - is no longer part of the DSM-IV diagnostic vocabulary. Symptoms which were once considered "hysterical" are now commonly ascribed to a range of disorders, including Dissociative Disorders. Amnesia, fugue, and depersonalization all refer to quite specific and circumscribed symptoms for which there are no alternative physical or psychological explanations. Amnesia. While amnesia, or memory loss, is a psychological symptom, it is also exceedingly common after head injury. When amnesia follows a blow to the head, it is considered a neurological rather than a psychological condition. Such amnesia due to physical trauma is almost invariably "retrograde": memory is lost for a period of time before and up to (usually including) the physical injury. Dissociative amnesia associated with psychological trauma is almost always "anterograde": memory is lost for a period after the traumatic event. A careful assessment will occasionally determine that both physical trauma and dissociative amnesia (triggered by the psychological trauma of an accident or assault) have occurred together. Amnesia is a form of memory loss, and memory deficits are also seen in persons with a variety of neurological and psychiatric conditions. For example, persons with dementia often have memory loss, but this is generally quite global and not restricted to a specific period of time. Alcoholics and other substance abusers will frequently have periods of amnesia related to heavy substance use. These amnesic episodes are not regarded as dissociative. Fugue. Fugue is far more often a uniquely dissociative phenomenon, but occasionally occurs in other conditions. For example, elements of fugue - undirected wandering - may be seen in neurological disorders, particularly complex partial seizures (temporal lobe epilepsy). Psychiatrists and neurologists can usually separate neurologically mediated fugue states from the more prolonged wanderings of a person in dissociative fugue. However, persons in a fugue state may function remarkably normally until questioning reveals confusion about their identity. Other than identity confusion, their orientation and global mental functioning may be entirely intact. In contrast, individuals with Alzheimer's or other forms of dementia often wander, but because of their generalized intellectual deficits, this wandering is classified as part of their dementia, not as fugue. Depersonalization. Persons experiencing depersonalization feel as if they are living in a dream or even a film. They may feel as if they are watching themselves from a vantage point outside their own bodies. Depersonalization does, of course, occur with use of many psychoactive substances and may be a component of "flashback" experiences which occur months or years after prior substance use. Many individuals who describe panic attacks describe depersonalization as part of these. Dissociative phenomena can be seen as part of trance-like states that occur normally in some individuals and are commonly seen in a variety of religious and cultural observances. Dissociation is only abnormal if it is prolonged, leads to distress or social dysfunction, and has not occurred as part of culturally normative ceremonies or practices. Dissociative Identity Disorder Dissociative Identity Disorder (DID) is by far the most complex and controversial of the Dissociative Disorders. Formerly termed Multiple Personality Disorder, DID refers to individuals who possess two or more distinct identities, at least two of which periodically take control of the individual's behavior - typically not at the same time. Periods of amnesia are found in DID and may be quite extensive. The expression of multiple identities (personalities) may be exceedingly dramatic and even colorful. Each identity may have a separate name, gender, voice, or set of psychological symptoms. While not part of the diagnostic criteria for DID, there is often a reported history of severe psychological, physical, or sexual trauma or abuse in early childhood. These memories may be highly repressed, "known" only to some of the individual's identities, and highly difficult to corroborate through independent witnesses. Such memories may emerge only after long periods of intense psychotherapy. In recent years there has been immense controversy about such repressed memories. Experts differ in their opinions as to whether the abuse actually happened, or whether such "memories" are actually created during the process of psychotherapy. There are few areas of mental health practice in which expert opinion has been so strongly divided and forcefully expressed. Whether or not repressed memory can and does occur is of great legal and ethical importance. Those who believe in the ability of psychotherapy to identify true repressed memories defend their viewpoint on the high frequency of known child abuse and sexual molestation. For every case that is detected there must surely be some that are unreported and unprosecuted. There is no doubt that perpetrators of childhood abuse go to great lengths to deny their involvement, and abuse frequently is revealed (and admitted by the perpetrator) only many years after it has occurred. The supporters of repressed memories believe that many victims find their experiences too terrible to remember. They bury these memories deep in the unconscious - only to have them emerge later as elements of dissociative behavior. The opponents of repressed memories feel that most memories of prior abuse are subtly suggested to highly suggestible individuals by generally well-meaning therapists. Sometimes these memories are recognized during therapy involving hypnosis, when suggestibility is perhaps at its highest. Additionally, persons who can be readily hypnotized may often be more suggestible than the average. Close corroborative investigation makes it seems likely that some persons - especially those with DID - have not really experienced the abuse which they describe vividly to their psychological interviewers. Unfortunately, since many repressed memories recall criminal acts (physical or, especially, sexual assault), courts frequently need to judge the truth of allegations based solely on memories recalled during the course of psychotherapy for dissociative symptoms. Many believe that in at least some cases, innocent persons have been punished for crimes which were incorrectly "recalled" from amnestic memory during psychotherapy for dissociative disorders. Does Dissociative Identity Disorder Really Exist? There is little doubt that the phenomenon of Dissociative Identity or multiple personality does exist. There is an immensely long history - in nearly all cultures - of reports of "possession" and exorcism; these are surely forms of dissociative phenomena. There is, however, also reason to believe that at least one of the most prominent cases of DID, the multiple personalities of a woman given the name of "Sybil" and made the subject of a best-selling book and widely-viewed movie, were at least in part an artifact of her psychotherapy. In a recent interview, the psychiatrist Herbert Spiegel recalls his own work with the real Sybil and raises significant questions about the accuracy of the written descriptions of Sybil's illness and course of psychotherapy for Multiple Personality Disorder - now DID. While Dr. Spiegel's recollections by no means discredit the diagnosis of DID, others have been more assertive in their challenge and have argued that DID and the concept of repressed sexual abuse are both unscientific myths. There have been both sensational legal settlements and thoughtful essays detailing unquestioned errors in the recovery of repressed memory. There is, in fact, considerable evidence for what some have termed False Memory Syndrome in which memories, particularly of repressed physical or sexual abuse, come to play a major role in a person's self-image and daily life, but appear not to be objectively true. In few areas of psychiatry are opinions so strongly divided between those who question the existence, perhaps not primarily of DID, but of its origins in childhood abuse and those who feel that such abuse is extraordinarily common and devastating in its effects. Despite skepticism and controversy over repressed memories and DID, many persons and their therapists believe that their symptoms have, in fact, been caused by profound repressed psychological trauma during childhood. Readers who like to peruse the Internet will find intriguing sites created by persons who view themselves as having multiple personalities. How Does DID or Multiple Personality Disorder Differ from Schizophrenia? On page 211 of the text we emphasize the difference between DID ("disorders of multiple personalities") and Schizophrenia. Schizophrenia does not mean split personality as in Dr. Jekyll and Mr. Hyde (Robert Lewis Stevenson's classic short novel describing a fictional character with DID). Instead, Schizophrenia is a term chosen to emphasize the serious effects of this disorder on language and thought. Persons with DID retain full control of their thought processes, though they may be amnestic for major periods of their lives. DSM-IV adopted the term Dissociative Identity Disorder at least in part because in psychological terms an individual has only one personality but may have a number of independent identities. The older term (multiple personality disorder) was apparently felt to misrepresent the unity of personality. How is DID treated? There is no good evidence that supports the use of medication in treating DID. Psychotherapy has been the major
form of treatment used, and remains the treatment of choice for most therapists. The role
of hypnosis remains controversial partly because of concerns that hypnosis may increase
the risk of creating false memories. Lawrence E. Frisch
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