Dissociative disorders, definition
The word dissociation is often used in literature and in the clinic to indicate different concepts that include symptoms, psychic mechanisms and mental disorders.
In the DSM-5, dissociative disorders are described as characterized by the disconnection and/or the discontinuity of the normal integration of the functions of:
- consciousness
- memory
- identity
- emotion
- perception
- body representation
- motor control
These symptoms can be tested as intrusions or loss of continuity in subjective experience or with the impossibility of accessing information or controlling mental functions that are usually accessible and recoverable.
A continuum from normal to pathological
There is a continuum of these disconnection experienceswhich ranges from normal absorption in thoughts and concerns that we all experience daily to symptoms that are strongly misunderstood and have serious repercussions on the functioning of the person in the extreme of the continuum that defines the pathology.
The diagnostic categories included in dissociative disorders are:
- Dissociative amnesia
- Depersonalization/derehealization
- Dissociative identity disorder
- Dissociative disorder with other specification.
Dissociative identity disorder, description
One of the most discussed and complex to diagnose and understand in its phenomenology is the dissociative disorder of identity (DID). Historically known as Multiple personality disorder It has always been the subject of disputes and debates.
The DSM-5 describes it as: “Disintegration of identity characterized by two or more states of distinct personalitieswhich in some cultures can be described as an experience of possession. The disintegration of identity includes a marked discontinuity of the sense of self and awareness of one’s actions, accompanied by related changes in affectivity, behavior, consciousness, memory, perception, cognitiveness and/or sensomotor functioning.
These signs and symptoms can be observed by others or reported by the individual.
The voids are also recurring in the re -enactment of daily events, important personal information and/or traumatic events not attributable to a normal forgetfulness. Hallucinatory symptoms may also be present.
How the DID is manifested
What happens in the DID is the structuring of real autonomous identities, called alter in psychopathology. These, alternating, take on the control of behavior, thoughts and memory.
Everything is fine alter somehow has its own point of view e one’s own separated sense of selfin addition to having specific memories of the events lived, often not accessible to the other parts.
The alter They can manifest themselves explicitly with a change in the voice or postural attitude for example, but also more veiled, with partial changes.
There may be moments of absence ascribable to phenomena of depersonalization/deralization or amnesia relating to periods of life or newspapers
Diagnostic difficulties and connection with trauma
It is evident that despite the diagnostic criteria it is often difficult to identify the presence of such a complex disorder. In part because those who suffer from dissociative disorder of identity do not present a symptomatology attributable in a linear way to this diagnosis, in part because the very nature of the disorder prevents the patient’s complete awareness.
However, one of the elements that can direct the clinical investigation towards the exploration of symptoms relating to DID is the presence of trauma in the development period.
Literature shares and confirms the presence of trauma of development In complex paintings with the presence of dissociative symptoms, including the DID.
Already Janet in his pioneering studies on trauma conceptualized how the vehement emotions related to trauma prevented the normal synthesis functions and integration of operating consistently and contributing to a unitary sense of experience.
What seems to happen in those who experience a traumatic development story, with unpredictable, threatening, neglecting or abusive attachment figures is the compartmentalization of consciousness, memory and identity that prevents a sense of continuity of self -experience.
This compartmentalization can hesitate in the most serious cases in the structure of dissociated identities typical of Dissociative identity disorder.
Further clinical specifications
As already mentioned, those suffering from Did arrives at clinical attention often for other types of symptoms. To a specific investigation, he can report to experience involuntary experiences, such as thoughts, memories or emotions experienced as not his own. Or unidentified voices, sometimes childish, that the patient lives as intrusive but not understandable (differently from the psychotic paintings in which the voices can more easily have a link with delusional ideations).
The sensations of non -control of emotions or “non -mine” behaviors is painful and hardly explained if not with the fear of being going crazy, in addition to being perhaps accused by those around senselessness or dissimulation.
Another often discriminating element is the presence of fragmentation of memorythat these patients experience not only in relation to remote information of their personal history or entire periods of life they cannot remember. But also to significant empty of memory in everyday life, such as the memory of what happened in a given period of time or typically present skills (concerning one’s work, driving the machine etc.).
They can also trace tests of events that have no memory, such as purchases, writings or even injuries that generate a sense of general loss difficult to manage.
Differential diagnosis
The alternation of alter’s intrusions can have complex effects, including suicidal thoughts, selfish acts, symptoms relating to the area of anxiety or instability of the mood tone not easy to differentiate with respect to the presentation that characterizes the borderline personality disorder (DBP).
Differential diagnosis is not easy since dissociative symptoms And traumatic attachment are also present in the DBP.
The clinician can deepen the search for mnestic gaps and altered states of consciousness by proposing for Did’s diagnosis when the symptomalogical presentation is more frequently and intensely characterized by these elements.
The same dilemma presents itself in front of the items or the hallucinatory presentations caused by the intrusion of the alter that can suggest disorders relating to the psychosis area.
Voices or other sensory intrusions are, differently from psychotic disorders, not linked to a delusional conception, often not identifiable and have a more typical presentation of the post traumatic disorder of stress and its manifestations.
Treatment
The DID is therefore a complex disorder, which requires targeted and attentive treatment, as well as experience and competence.
There are no specific guidelines but it is possible to face this condition thanks to a psychotherapeutic interventionwith the main purpose of bringing the patient back to a more integrated operation and an increasing and more unitary awareness of his own experience.
The procedures are those typical of trauma treatment: work stages aimed at symptomatological stabilization and psychoeducation on one’s experience, elaboration of traumatic memories and integration and reinforcement of a stable and coherent sense of self.
In addition to cognitive-behavioral and cognitive-evolutionist psychotherapy, patients may benefit from specific interventions for the management of emotion such as DBT dialectical-behavioral therapy (Linehan, 1987), the EMDR for work on traumatic memories (EMDR; Shapiro, 2001), and sensomotor psychotherapy for processing and buttom-up management of trauma outcomes (Ogden et al., 2006).
Bibliography
- American Psychiatric Association, Author. Diagnostic and Statistical Manual of Mental Dysorders, Fifth Edition. American Psychiatric Association; Arlington: 2013.
- International Society for the Study of Trauma and Dissociation (2011). Chu, Ja, Dell, PF, Van der Hart, O., Cardeña, E., Barach, PM, Somer, E., Loewenstein, RJ, Brand, B., et al Guidelines for Treating Dissociative Identity Disorder in Adults, 3rd Revision. Journal of Trauma & Dissociation, 12, 115–118.
- Kluft RP (1999). An ovserview of the psychotherapy of dissociative identity disorder. American Journal of Psychotherapy, 53(3), 289–319.
- Linehan MM (1987). Dialectrical Behavior Therapy for Borderline Personality Disorder. Theory and Method. Bulletin of the Menninger Clinic, 51(3), 261–276.
- Ogden P, Minton K, Pain C (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. Norton, New York.
- Reinders, A., & Veltman, DJ (2021). Dissociative Identity Disorder: Out of the Shadows at Last?. The British Journal of Psychiatry: The Journal of Mental Science, 219(2), 413–414.
- Shapiro, F. (2001). Eye Movement Dessensitization and Reprocessing: Basic Principles, Protocols, and Procedures (2nd ed.). Guilford Press.
- Spiegel D., Lewis-Fernandez R., Lanius R., Vermeten E., Simeon D., & Friedman M. (2013). Dissociative disorders in DSM-5. Annual Review of Clinical Psychology9, 299–326.
- Van Minnen, A., & Tibben, M. (2021). In Brief Cognitive-BEHAVIORAL TREATMENT RANDA FOR PTSD AND DISSOCATIVE IDENTITY DISAM, A CASE REPORT. Journal of Behavior Therapy and Experimental Psychiatry, 72101655.
