Symptoms of Dissociative Disorders

Dissociative Disorders

Quick Guide to the Dissociative Disorders Dissociative symptoms are principally covered in this chapter, but there are some conditions (especially involving loss or lapse of memory) that are classified elsewhere. Yep, the link indicates where a more detailed discussion begins. Primary Dissociative Disorders Dissociative amnesia. The patient cannot remember important information that is usually of a personal nature. This amnesia is usually stress-related. Dissociative identity disorder. One or more additional identities intermittently seize control of the patient’s behavior. Depersonalization/derealization disorder. There are episodes of detachment as if the patient is observing the patient’s own behavior from outside. In this condition, there is no actual memory loss. Other specified, or unspecified, dissociative disorders. Patients who have symptoms suggestive of any of the disorders above, but who do not meet the criteria for any one of them, may be placed in one of these two categories. Other Causes of Marked Memory Loss When dissociative symptoms are encountered in the course of other mental diagnoses, a separate diagnosis of a dissociative disorder is not ordinarily given. Panic attack. Some patients who panic may experience depersonalization or derealization as part of an acute panic attack. Posttraumatic stress disorder. A month or more following severe trauma, the patient may not remember important aspects of personal history. Acute stress disorder. Immediately following severe trauma, patients may not remember important aspects of personal history. Somatic symptom disorder. Patients who have a history of somatic symptoms that cannot be explained on the basis of known disease mechanisms can also forget important aspects of personal history. Non-rapid eye movement sleep arousal disorder, sleepwalking type. Sleepwalking resembles dissociative disorders, in that there is amnesia for purposeful behavior. But it is classified elsewhere in order to keep all the sleep disorders together. Borderline personality disorder. When severely stressed, these people will sometimes experience episodes of dissociation, such as depersonalization. Malingering. Some patients consciously feign symptoms of memory loss. Their object is material gain, such as avoiding punishment or obtaining money or drugs. INTRODUCTION

Dissociation occurs when one group of normal mental processes becomes separated from the rest. In essence, some of an individual’s thoughts, feelings, or behaviors are removed from conscious awareness and control. For example, an otherwise healthy college student cannot recall any of the events of the previous 2 weeks. As with so many other mental symptoms, you can have dissociation without disorder; if it’s mild, it can be entirely normal. (Perhaps, for example, while enduring a boring lecture, you once daydreamed about your weekend plans, unaware that you’ve been called on for a response?) There’s also a close connection between the phenomena of dissociation and hypnosis. Indeed, over half the people interviewed in some surveys have had some experience of a dissociative nature. 200 Episodes of dissociation severe enough to constitute a disorder have several features in common:



•  They usually begin and end suddenly. •  They are perceived as a disruption of information that is needed by the individual. They can be positive, in the sense of something added (for example, flashbacks) or negative (a period of time for which the person has no memory). •  Although clinicians often disagree as to their etiology, many episodes are apparently precipitated by psychological conflict. •  Although they are generally regarded as rare, their numbers may be increasing. •  In most (except depersonalization/derealization disorder), there is a profound disturbance of memory. •  Impaired functioning or a subjective feeling of distress is required only for dissociative amnesia and depersonalization/derealization disorder. Conversion symptoms (typical of the somatic symptom disorders) and dissociation tend to involve the same psychic mechanisms. Whenever you encounter a patient who dissociates, consider whether such a diagnosis is also warranted. F48.1 [300.6] Depersonalization/Derealization Disorder

Depersonalization can be defined as a sense of being cut off or detached from oneself. This feeling may be experienced as viewing one’s own mental processes or behavior; some patients feel as though they are in a dream. When a patient is repeatedly distressed by episodes of depersonalization, and there is no other disorder that better accounts for the symptoms, you can diagnose depersonalization/derealization disorder (DDD). DSM-5 offers another route to that diagnosis: through the experience of derealization, a feeling that the exterior world is unreal or odd. Patients may notice that the size or shape of objects has changed, or that other people seem robotic or even dead. Always, however, the person retains insight that it is only a change in perception—that the world itself has remained the same. Because about half of all adults have had at least one such episode, we need to place some limits on who receives this diagnosis. It should not be made unless the symptoms are persistent or recurrent, and unless they impair functioning or cause pretty significant distress (this means something well beyond the bemused reflection, “Well, that was weird!”). In fact, depersonalization and derealization are much more commonly encountered as symptoms than as a diagnosis. For example, derealization or depersonalization is one of the qualifying symptoms for panic attack. Episodes of DDD are often precipitated by stress; they may begin and end suddenly. The disorder usually has its onset in the teens or early 20s; usually it is chronic. Although still not well studied, prevalence rates in the general population appear to be around 1–2%, with males and females nearly equal. 201 Essential Features of Depersonalization/Derealization Disorder