Dissociation
Dissociation is a term that is used both as a psychiatric
'symptom' and a 'diagnostic category' for a group of psychiatric disorders
(illnesses).
As a SYMPTOM, dissociation includes the following:
- A subjective sense of numbing, detachment
or absence of normal emotional responsiveness.
- a reduced sense of personal awareness of one's surroundings
(i.e. being a daze).
- Depersonalization feelings: Feeling that
somehow one's body has changed or does not feel real or that it is
not “attached”. Some may feel that they have briefly left
their body (“out of body experience”) and may experience
themselves as if looking at their body from a distance.
- Derealization feelings: Feeling that some
how the outside world has changed and seems unreal, foggy, two dimensional
or dream-like in quality.
- Amnesia: (a loss of memory for a discrete
period of time, often caused by stress or psychological trauma (as
opposed to a head injury or effects of alcohol or drugs).
- Somatoform dissociation: is a term sometimes
used by therapists and refers to bodily sensations that can be present
(i.e. body memory pains, psychosomatic symptoms) or absent (i.e. loss
or decreased body sensation). Such symptoms are based on psychological
factors in the absence of physical causes.
As a DISORDER, dissociation has been
divided into five diagnoses (DSM-IV, 1994):
1. Dissociative Amnesia
This disorder used to be called “psychogenic amnesia” and
refers to experiences of 'blackouts' or 'time losses' which are more
prominent than just everyday forgetting. Individuals with dissociative
amnesia may “come to awareness” realizing that a lot of
time has passed (i.e. minutes, hours, or rarely days) without having
any memory of that lost period of time. Others may point these time
losses out to the individual. These time gaps become distressing as
the person becomes aware that have no memory of these periods. The time
losses cannot be explained by substance use (i.e. excessive alcohol,
medications) or a physical problem (i.e., a seizure disorder or head
trauma). For this disorder, amnesia is the primary problem. If other
dissociative experiences are also present, other dissociative disorders
may need to be considered.
2. Dissociative Fugue
This disorder was previously referred to as “psychogenic fugue.”
In this condition, amnesia is present, but in addition the person may
travel extensive distances and end up in a different place, city or
even a different country without any memory of how they got there. The
amnesia for this travel period may be hours, days, or even months. If
the person is seen during this period, they may have assumed a different
identity, having forgotten their real identity and where they live.
Sometimes this “fugue” (a word meaning rapid travel) may
be triggered by a personal trauma. The fugue may end abruptly with the
person suddenly finding themselves in a totally unknown place and not
knowing how they got there nor how long they were there. Some may try
to sort the puzzle out themselves and get back to their normal environment
without telling others. Others may be so distressed they may seek help
from the police or a medical institution. When seen by health care professionals,
they usually cannot recall the events which occurred while they were
in this fugue state.
3. Dissociative Identity Disorder
(DID)
In the recent past, this disorder was referred to as multiple personality
disorder (MPD). In addition to amnesia and fugue behavior, individuals
with DID may experience (or be told) they have different personality
states which take control of their behavior. The person may have no
memory when this other “state” or “states” take
control of their life (often only learning about this when later being
told by other people). Sometimes the person may be aware when a personality
state is its control, yet be helpless to stop it. In this case, one
is aware (co-conscious) but essentially helpless to stop the action
and words of this controlling state. For some, it may feel like they
are “possessed” by another being. However it is important
to emphasize that DID is not possession, nor are the personality states
separate “people”. In reality, normal personality is a smooth
coordination of various emotional and functioning styles of behavior.
If the normal blending of personality styles is interfered with (usually
as a result of repeated physical or psychological trauma in the early
childhood developmental years) then normal diverse behavior patterns
do not evolve into a unitary personality. The interference may lead
to development progressing in a disjointed and disconnected manner and
over the years and may lead to a sense of being “separate”
from other parts of self. Each state (sometimes called “ego states”
or “personality states”) may believe itself to be a separate
“person” rather than the reality of being only one “part/aspect”
of that “person”. (Normal personality is a blended group
of personality “styles” or “states”). It is
often initially difficult to help these ego states realize they are
not separate people. They sometimes believe the therapist really wants
to eliminate them - which is really neither possible nor sensible.
Dissociative Identity Disorder is a treatable condition though psychotherapy
may take considerable time (i.e. weekly sessions for a year or more).
In brief, the intent of therapy is to help correct this major misconception
of separate existence and to help all of these states to blend (unite)
into the full personality they were intended to be, each adding their
own skills to this new combination of “ego states”.
In addition to dissociative symptoms, other psychiatric conditions (such
as depression, panic attacks, substance abuse, eating disorders and
posttraumatic stress disorder) frequently occur with DID. Although at
present there does not seem to be any medications that directly target
dissociation, the other psychiatric conditions may be treated with medications.
4. Depersonalization Disorder
This disorder is characterized by a persistent and recurrent feeling
as if one’s body does not seem real or fully attached, to the
extent that this interferes with functioning. It may include “out
of body” experiences or feeling as if parts of the body are unattached,
changed, or numb.. Depersonalization disorder can sometimes be associated
with a feeling of derealization in which the outside world feels unreal,
fog-like or two dimensional. Depersonalization experiences can occur
in other dissociative disorders and in other medical conditions such
as temporal lobe seizure. This diagnosis should not be made if it is
part of such other conditions.
5. Dissociative Disorder Not Otherwise Specified (DDNOS)
This is a category for other conditions which do not fit into the above
four dissociative disorders. For instance if there is derealization
without depersonalization DDNOS would be the proper diagnosis. Cases
that are like DID but do not show the exact characteristics would fit
into this category as would conditions in which there appears to be
some outside force controlling ones actions i.e. , a feeling of “possession”.
These feelings of outside influences may have special cultural interpretations
which are then called dissociative trance disorders.
Treatment of Dissociative Disorders
Dissociative disorders are treatable but may require special strategies
including ego-state therapy, guided imagery and hypnosis, as well as
medications when other conditions like depression and anxiety disorders
exist. Not all therapists are familiar with these strategies and not
all therapists agree that dissociative disorders exist (in spite of
being official diagnoses with the American Psychiatric Association and
the World Health Organization).
Related Sites:
The International Society for the Study of Dissociation
www.issd.org
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