Anxiety Disorders >> Dissociative Disorders

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Dissociative Disorders
M. S. Ahluwalia

Psychopathology

Copyright © 2021, by M S Ahluwalia
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Psychopathology >> Dissociative Disorders >> Contents
Contents
1. Introduction to Dissociative Disorders
2. Types & Prevalence (Epidemiology)
3. Symptoms & Case Studies
4. Aetiology (Causes)
5. Treatment
10

Psychopathology >> Dissociative Disorders >> Introduction to Dissociative Disorders
11
Dissociative
Disorders
A group of disorders where the activities of a person are separated from conscious
awareness. One may forget one’s own identity or feel detached from oneself.
• There is a stressful situation which is not responded to by overt expression of anxiety. The overt
anxieties are replaced by distorting the relation between self and reality by selective modification
of memory and identity.
• There is an attempt on the part of the person to escape the unpleasant stressful situation by using a
particular intrapsychic mechanism.
• There is a dramatic expression of the symptoms. But one must not presuppose that these people are
necessarily faking or ‘malingering’. The dramatization occurs at a level below the consciousness, and
the person, at her conscious level actually feels only whatever she reports. This process makes it a
challenge for the mental health professional to differentiate Dissociative Disorders from Malingering
and intentional falsification.
• While in children the symptoms are often transient, in adults these disorders may take a chronic
and disabling form.
Malingering
It refers to the deliberate imitation of the symptoms of a physical or psychological
disease by an individual with the purpose of gaining some practical advantage.
Dissociation The separation of the activities of a person from conscious awareness.

Contents
5. Treatment
12

Psychopathology >> Dissociative Disorders >> Types & Prevalence
2. Types & Prevalence
13
Major Types of Dissociative Disorders and their Epidemiology (Prevalence)
1
Dissociative Amnesia and
Fugue
• Amnesia probably
occurs in about 5% - 7%
of the population.
• Fugue is much less
common, about 0.2%.
2
Depersonalisation
Disorder
• It occurs in about 2% -
3% of the population.
3
Dissociative Identity
Disorder
• It was once considered
to be very rare.
• Then its diagnosis
became influenced by
the scientific culture of
the time.
• Some doctors diagnose
it more, some merge it
with schizophrenia.
• It may be prevalent in
1% - 2% of the
population.
The prevalence of Dissociative Disorders in population is not well researched.

Contents
5. Treatment
14

Psychopathology >> Dissociative Disorders >> Symptoms & Case Studies
3.1. Dissociative Amnesia - Symptoms
15
Amnesia
Refers to inability to remember all or certain parts of personal history and identity. It
may occur in organic brain disorders like Dementia, or in psychiatric conditions like
Dissociation.
Dissociative
Amnesia
Defined by DSM IV – TR as a disturbance in one or more episodes of life or inability to
recall significant events
Difference between Amnesia due to Organic and Psychological Causes
• Amnesia may appear as a psychological escape from stress, but it may be a symptom in many organic
diseases and brain damage also. How would you differentiate between the two?
• Neurological investigation can help, but functional differences can help as well.
Amnesia due to
Organic Causes
• The person is:
• unable to remember
all or most of the
recent or remote past,
or
• unable to retain newly
acquired information.
Amnesia due to Psychological Causes
• The person is unable to retrieve selective portions of personal history
and that forgetting is not explained by biological causes.
• This usually happens following some stressful condition.
• The information is not permanently lost. It can be retrieved by
hypnosis, narcotic analysis and sometimes spontaneously.
• It can be localised to a specific period of life or may be generalised
over a major part of the person’s life.
• It can be selective, that is specific events may be lost. It can be
continuous also, that is nothing is remembered beyond a certain point.
• Localised and selective amnesia are more common.

3.1. Dissociative Fugue - Symptoms
16
Fugue
The word fugue means flight. In Dissociative fugue the person suddenly wanders away
from work or home. This state is accompanied with amnesia.
• The person with fugue may be confused about personal identity.
• She may also assume a new identity.
• The fugue usually occurs after a stressful event which probably was difficult to
handle staying in the same place.
Difference between Fugue due to Organic and Psychological Causes
• Even in Alzheimer’s, which is an organic disease, people tend to wander away.
• The motive to flight along with absence of other symptoms of Dementia
distinguishes Dissociative fugue from wandering in the Alzheimer’s disease.

3.1. Dissociative Amnesia and Fugue – Case Study
17
Background
• Raju, 30, was a middle manager in the sales department of a private company.
Stressors
• For the last few months he was consistently unable to reach the target and was receiving
unpleasant feedback from both boss and subordinates.
• At home also he was having marital problems.
Problem
• One day he did not come back home from work. His wife waited for him till midnight and then informed
the police.
• About seven days later he was found wandering in a small town far off from the city.
• He was having an altercation with the local people near a tea shop where he had stopped for a cup of
tea. He identified himself as Amit, and affirmed that he was looking for a job. However, he could not
produce any identification or could not say anything about his past.
• The local people were suspicious, held him back, and informed the police. When the police found Raju
alias Amit, he could not remember his identity or how he had reached this place.
• He was wearing the same dress he had on seven days back.
• His orientation to the time and date was intact.

3.2. Depersonalisation Disorder - Symptoms
18
Depersonali-
sation
Refers to feeling as if one is not oneself. The person seems detached from one’s body
and mind.
• Sometimes, under duress, an individual may feel somewhat detached from reality. As if
what is happening is not true, or as if you are observing the sequence of events as an
outsider. This is a mode of tolerating immense pain, used automatically by the human
mind.
• This may happen to anybody under extreme conditions, but if a person persistently and
recurrently suffers from these kind of experiences, a diagnosis of Depersonalisation
disorder may be considered.
• During this disorder:
• The person feels detached from her body and own mental processes.
• The person feels strangely detached from the internal and external events.
• Some may imagine oneself floating above one’s body.
• There is usually a dreamlike character in the flow of existence, and one might be
puzzled at the isolated and unfamiliar nature of the environment.
• However, reality testing remains intact. There are no hallucination and delusions.
Derealisation It is a dissociated state of mind where one feels what is happening around is not real.

3.2. Depersonalisation Disorder – Case Study
19
Background: Bano, 18, works as a maid servant in an affluent house. She’s been there for about 3 years.
Problem
• The mistress of the house recently noted that sometimes, when instructed to do a job, Bano stands for
a while in a strange manner and looks vaguely around.
• Sometimes she stumbles over things and goes away to any random direction.
• Since Bano had been a lovable girl and worked well, the mistress was compassion towards her.
• She suspected some epileptic problem and took Bano to a neurologist.
Assessment
• There Bano reported that for the last few months she had been occasionally feeling ‘out of the body’,
and as if ‘having no control on her mind’.
• In these moments, her thinking gets clouded. She can ‘come back only by shaking herself violently’.
• No neurological problem was found in the investigations.
• Case history revealed that some time back she had fallen in love with a married man and knew that it
was impossible to be united with him. Neither her own family, nor the family where she worked, would
approve of this union.
• Symptoms appeared after she strictly forbade the man to see her.

3.3. Dissociative Identity Disorder – Symptoms
20
• Dissociative Identity disorder is the modern name of Multiple Personalities.
• The movies ‘Three faces of Eve’ and ‘Sybil’ are based on real documented cases of Dissociative
Identity disorder. Eve had three alters, whereas Sybil had sixteen!
• To diagnose a person as suffering from Dissociative Identity disorder, DSM IV – TR requires that
she has at least two separate alters and they would be in complete control of her thinking,
feeling and acting for different periods of times.
• Sometimes these alters are in touch with each other; often at least one alter is unaware of the
existence of another. Therefore, gaps in memory are common signs.
• The existence of the different alters is persistent and recurrent and not introduced by any
chemical substance. These alters may have different or even opposite nature; they may dress,
eat, interact differently.
• Often the subordinate alter works at a covert level while the host or original personality is operating
at the surface. Such subordinate alter is said to be co-conscious. Gradually, this alter makes its
presence felt, and at one point takes over the control from the host.
• After prolonged treatment some of the alters may be integrated with the host.
Alter
In Dissociative Identity Disorder, two or more ego states may appear and be in
complete control of one’s thinking, feeling and acting for different periods of times.
These ego states are known as alters.

3.4. Dissociative Identity Disorder – Case Study
21
Background:
• Krish was a teenage boy - an obedient, if not a very good student at school.
• He belonged to a middle class family and lived with his parents in a city.
• He was shy by nature and introvert, though good at games.
The Problem
• Some time back, his parents started observing that Krish was becoming fidgety and suppressive,
unable to explain some of his time away from home.
• There were reports about his absence from the school, but Krish could not remember anything.
• His parents feared that he might have started drugs or alcohol, and brought him to a psychiatrist.
• While being asked by the doctor about his activities, he suddenly spoke in a different tone and
identified himself as Vish, a rough and tough fellow with an aggressive personality and lack of concern
for social rules. Vish said that he knows all about Krish, the boy who feigns innocence, and had
appeared to save Krish from his plight. He bunked school and went to ‘bad boys’ to learn their ways to
fight the outer world.
• Later, Krish revealed that as a small child he had witnessed gross physical and sexual torture of his
mother by his father and grandparents. He was so afraid that he never told his parents what he saw.
• The parents admitted the truth of the family violence, which was dowry related and particularly
poignant while Krish’s grandparents were alive.
• His parents patched up the relation after the older generation passed away.
• Vish seemed to compensate for the suppressed aggression Krish had against his father’s family.

Contents
5. Treatment
22

Psychopathology >> Dissociative Disorders >> Aetiology
4. Dissociative Disorders – Aetiology
23
Causes of
Dissociative
Disorders
1
Biological Factors .
2
Psychological Factors
2.1
Psychoanalytical
Approach
2.2
Behavioural Approach
2.3
Cognitive Approach
2.4
Vulnerable Personality
and Life Events
3
Cultural and Social
Factors
• Biological factors, are of less significance than psychological
factors in the aetiology of Dissociative disorders.
• At best a vulnerable personality with greater suggestibility
may have been genetically inherited.
3. Cultural and Social Factors
• Some cultures tolerate or even
encourage dissociative
phenomena like possession
and trance.
• Disturbances of identity have
support within the culture and
are, therefore, reinforced.
• Dissociated identity in the form
of possession by spirit is more
common in non-western
cultures.

Psychopathology >> Dissociative Disorders >> Aetiology
4.2. Psychological Factors
24
1. Psychoanalytic Approach
• It highlights the operation of the defences of
repression and denial in amnesia and fugue.
• When certain unconscious conflicts are
extremely painful, and no acceptable escape
route is left open, the ego may take resort to
repression, making the content of the conflict
unavailable, at least temporarily.
• Another important defence mechanism
operative in all Dissociative disorders, is
isolation of emotion and event. This is most
prominent in Depersonalisation disorder.
2. Behavioral Approach
• It attributes dissociation to the attempt of
the person to avoid extreme stress.
• This dissociation is reinforced as it relieves
the person from the stress.
• Sometimes they may self – hypnotize to go
into the dissociated states.
3. Cognitive Approach
• It suggests that selective memory deficit takes place.
• Usually the episodic or autobiographical memory is
affected, while semantic memory is relatively intact.
• Some case reports imply that implicit memory is intact
while explicit memory is disturbed.
• Example: a man with dissociative amnesia may not
remember his wife’s name. But if he is asked to guess the
wife’s name from a list of possible names he might strike
on the right name.
4. Vulnerable Personality and Stressful Life Events
• Evidence indicates that those with dissociative disorder
have often underwent severe trauma in childhood.
• Some experienced physical abuse; others had been
sexually abused or forced into incestual relations.
• Dissociative disorders are common in PTSD also, after
natural or man made disasters.
• Persons who are more hypnotizable are more prone to
develop Dissociative Identity disorder after a trauma.

Contents
5. Treatment
25

Psychopathology >> Dissociative Disorders >> Treatment
5. Dissociative Disorders Treatment
26
• There is no systematic
and controlled study
about treating
Depersonalisation
Disorders.
• Antidepressants have
been used, but their
effectiveness is not
known.
• Hypnotherapy and self
hypnosis may be of some
use.
Depersonalisation Disorder
• Some therapists have
claimed success by using
Hypnotherapy and
insight therapy to
integrate the personalities
and convince each of
them that there is no need
to stay separate.
• The person needs to
understand that coping
can be done without
splitting.
• The therapist needs to be
empathic towards each of
the identities and deal
with each on a fair level.
Dissociative Identity
Disorder
• Dissociation is an escape from stress.
Therefore, the first thing to do is to make sure
to keep her in a safe environment.
• Try to elicit the precipitating stressful event and
assure her that she is safe from that danger.
Sometimes, staying away from perceived
danger leads to spontaneous recovery.
• Psychoanalytically oriented therapies and
hypnotherapy may help to bring out the lost
memory.
• Sometimes anxiolytic medicines are also used
as adjunct to psychotherapy.
• Not all memories that are retrieved from the
person with amnesia are reliable. You need to
cross validate them from independent sources.
• After reviving the memory, the therapist
needs to work through the retrieved material so
that the memories are properly
contextualised.
Dissociation

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