1. Dissociative Disorders

3. Common Dissociative Experiences in Everyday Life Daydreaming Missing parts of conversations Vivid fantasizing Forgetting part of drive home Calling one number when intending to call another Driving to one place when intending to drive elsewhere Reading an entire page & not knowing what you read Not sure whether you’ve done something or only thought about doing it Seeing oneself as if looking at another person Remembering the past so vividly you seem to be reliving it Not sure if an event happened or was just a dream

4. Definition According to Richard P. Kluft, Dissociative Identity Disorder “is a complex, chronic, posttraumatic dissociative psychopathology characterized by disturbances of memory and identity.” Qualifications Years in Practice: 30+ Years School: Harvard Medical School Year Graduated: 1968 License No. and State: MD- 011120-E Pennsylvania

5. Dissociative Disorders This is an extremely rare disorder. It occurs to 1% of the general population, but recent 2012 statistics estimate an average of 7% that have not been diagnosed properly with the disorder.

7. History  The first published description of Dissociative Identity Disorder was made by Petetain in 1787.  In the 20 th century, DID was put under the rubric of schizophrenia.  Because of this the use of the diagnosis of DID dropped significantly, and people almost stopped studying it altogether.

8. History  In the 1980’s, feminism really helped to bring back interest in DID.  Most of what we know about DID come from studies made in 1980-1985. 1984 marked the beginning of annual international conferences on DID.

9. Between 1930 to 1960 the diagnosis was only 2 percent Since it made it to DSM in 1980’s the reported cases has jumped to 20,000 Number of personalities mushroomed from 3 to 12 per patient This disorder is unknown in Japan and India DID Critics

10. Critics’ Arguments 1.Role-playing by people open to a therapist’s suggestion. 2.Learned response that reinforces reductions in anxiety.

12. When is Dissociation a problem? Loss of overall, integrative control Unable to access information Loss of a coherent sense of self

13. Causes Traumatic experiences. Mainly experienced during childhood.

14. Possible Causes of Dissociation Fatigue Sleep deprivation Stress Binge drinking Drug use Confronting a new environment Feeling preoccupied or conflicted Engaging in certain religious or cultural rituals or events

15. Symptoms One of the most common known symptoms are the different identities, also known as the “alters”.

16. What are the diagnostic criteria for Dissociative Amnesia? Cannot recall important personal information—usually of a traumatic or stressful nature—and too extensive to be explained by ORDINARY FORGETFULLNESS Not due to –Dissociative Identity Disorder –Dissociative Fugue –Somatization Disorder –Posttraumatic Stress Disorder –Acute Stress Disorder –Substance use –Neurological or General Medical Condition Causes significant impairment in social or occupational functioning

17. Other Specified Dissociative Disorder Establishes itself securely during early childhood, and is thought to be caused by child abuse, that resulted in a lack of a secure attachment with a primary caregiver. An absence of secure attachment in childhood, among repeated abuse, eventually resulted in an accumulation of unresolved trauma, causing structural dissociation

18. Dissociative Disorders

19. Types of Dissociative Disorders Dissociative Amnesia Dissociative Fugue Dissociative Identity Disorder Depersonalization Disorder

20. Dissociative Amnesia Partial or total forgetting of past experience without a biological cause Almost always anterograde – blocking out a period of time after psychogenic cause (e.g. stress / trauma) Memory loss is often selective Relative indifference to loss of memory Remain well oriented to time and place

21. Dissociative Amnesia Impairment is reversible and usually reported retrospectively (in past tense). Types of disturbance:  Localized – affects a few hours around a traumatic event.  Selective – affects some but not all events during a period of time, or some categories.  Generalized – affects entire past.  Continuous – a specific time up to the present

22. Dissociative Fugue Amnesia + sudden, unexpected trip away from home Often involves the creation of a new identity Fugue state usually ends abruptly – then amnesic for events during the fugue

23. Dissociative Identity Disorder Sense of self, or personality breaks up into two or more distinct identities which take turns “controlling” behavior At least one “personality” is amnesic for the experiences of the others “Alter” often coconscious with the host

24. Dissociative Identity Disorder Identities are often polarized Often each identity specializes in different areas of functioning, encapsulates different memories Very high proportion report significant trauma in childhood – possible strategy that children use to distance themselves from trauma

25. Controversy re. cause of DID Faking - malingering Induced by therapy - iatrogenic Social Role Hypnotizability “False Memory Syndrome”

26. Depersonalization Disorder Disruption in identity without amnesia Sense of strangeness or unreality in oneself Derealization Reduced emotional responsiveness

27. How can you keep these patients straight? Memory loss? Yes No Travel to another place? Altered sense of self or reality? DepersonalizationDisorder YesNo DissociativeFugue Evidence of more than one identity? Yes No Dissociative Identity Disorder DissociativeAmnesia Yes

28. Dissociative Disorders 2

29. Common Dissociative Experiences in Everyday Life Daydreaming Missing parts of conversations Vivid fantasizing Forgetting part of drive home Calling one number when intending to call another Driving to one place when intending to drive elsewhere

30. Historical Roots Hysteria: “wandering uterus”  physical symptoms without a known cause  term dates back to Hippocrates and Egyptians Neurosis: emotional distress due to underlying unconscious conflicts, anxiety, and implementation of defense mechanisms

31. The Evolution of the Concept Three Theorist  Pierre Janet  One or more automatisms could split off from the rest, thus functioning outside of awareness, independent of voluntary control or both.  Neodissociation (Hilgard)  Links within the brain would be disrupted or isolated from phenomenal awareness and the experience of intentionality.  Woody and Bowers  The phenomena of dissociation reflect the failure of these modules (i.e., conscious & unconscious) to be integrated at higher levels of the system.  Dissociation is a natural state, to some degree.

32. When is Dissociation a problem? Loss of overall, integrative control Unable to access information Loss of a coherent sense of self

35. Dissociative Amnesia Person is unable to recall important personal information  Usually related to a traumatic or stressful event Variations  Generalized  Localized  Selective 24

36. Dissociative Fugue Person suddenly leaves home and work and assumes a new identity  Usually triggered by stress or trauma

37. Depersonalization Disorder Person’s perception or experience of the self is disconcertingly and disruptively altered  Frequent episodes  Reality does remain intact during episodes  No amnesia or new identities

42. Defenses.. Frequently used in all dissociative disorders Repression: Disturbing impulses are blocked from consciousness Denial: external reality is ignored Dissociation: Separation & independent functioning of 1 group of mental processes from others-(mental contents exist in parallel consciousness)

43. The psychodynamic view Psychodynamic theorists believe that dissociative disorders are caused by repression, the most basic ego defense mechanism People fight off anxiety by unconsciously preventing painful memories, thoughts, or impulses from reaching awareness In this view, dissociative amnesia and fugue are single episodes of massive repression DID is thought to result from a lifetime of excessive repression, motivated by very traumatic childhood events

44. The psychodynamic view Most of the support for this model is drawn from case histories, which report brutal childhood experiences, yet: Some individuals with DID do not seem to have these experiences of abuse Further, why might only a small fraction of abused children develop this disorder?

45. The behavioral view Behaviorists believe that dissociation grows from normal memory processes and is a response learned through operant conditioning: Momentary forgetting of trauma leads to a drop in anxiety, which increases the likelihood of future forgetting Like psychodynamic theorists, behaviorists see dissociation as escape behavior Also like psychodynamic theorists, behaviorists rely largely on case histories to support their view of dissociative disorders Moreover, these explanations fail to explain all aspects of these disorders

46. State-dependent learning If people learn something when they are in a particular state of mind, they are likely to remember it best when they are in the same condition This link between state and recall is called state-dependent learning This model has been demonstrated with substances and mood and may be linked to arousal levels

47. State-dependent learning People who are prone to develop dissociative disorders may have state-to- memory links that are unusually rigid and narrow; each thought, memory, and skill is tied exclusively to a particular state of arousal, so that they recall a given event only when they experience an arousal state almost identical to the state in which the memory was first acquired

48. Self-hypnosis Although hypnosis can help people remember events that occurred and were forgotten years ago, it can also help people forget facts, events, and their personal identity Called “hypnotic amnesia,” this phenomenon has been demonstrated in research studies with word lists The parallels between hypnotic amnesia and dissociative disorders are striking and have led researchers to conclude that dissociative disorders may be a form of self-hypnosis

49. How Do Therapists Help Individuals With DID? Recognizing the disorder Once a diagnosis of DID has been made, therapists try to bond with the primary personality and with each of the subpersonalities As bonds are forged, therapists try to educate the patients and help them recognize the nature of the disorder Some use hypnosis or video as a means of presenting other subpersonalities Many therapists recommend group or family therapy

50. How Do Therapists Help Individuals With DID? Recovering memories To help patients recover missing memories, therapists use many of the approaches applied in other dissociative disorders, including psychodynamic therapy, hypnotherapy, and drug treatment These techniques tend to work slowly in cases of DID

51. How Do Therapists Help Individuals With DID? Integrating the subpersonalities The final goal of therapy is to merge the different subpersonalities into a single, integrated identity Integration is a continuous process; fusion is the final merging Many patients distrust this final treatment goal and their subpersonalities see integration as a form of death Once the subpersonalities are integrated, further therapy is typically needed to maintain the complete personality and to teach social and coping skills to prevent later dissociations

53. Quiz True/False 1) Dissociative Identity Disorder is directly related to Schizophrenia.

54. Quiz True/False 1) Dissociative Identity Disorder is directly related to Schizophrenia. False: Schizophrenia is mainly characterized by hearing or seeing things that aren't real (hallucinations) and thinking or believing things with no basis in reality (delusions).

55. Quiz True/False 2) One of the symptoms of DID is known as an “alter”.

56. Quiz True/False 2) One of the symptoms of DID is known as an “alter”. True

57. Quiz True/False 3) Every one of us has experienced some mild form of dissociation.

58. Quiz True/False 3) Every one of us has experienced some mild form of dissociation. True

59. Quiz Multiple Choice 1) Which of the following are NOT symptoms of DID? a)mood swings b)suicidal tendencies c)eating disorders d)hallucinations

60. Quiz Multiple Choice 1) Which of the following are NOT symptoms of DID? a)mood swings b)suicidal tendencies c)eating disorders d)hallucinations

61. Quiz Multiple Choice 2) Which of the following is a known treatment for DID? a)psychotherapy b)medication c)hypnotherapy d)all of the above

62. Quiz Multiple Choice 2) Which of the following is a known treatment for DID? a)psychotherapy b)medication c)hypnotherapy d)all of the above

63. Quiz Multiple Choice 3) Which of the following symptoms does NOT distinguish DID from other mental disorders? a)delusions b)memory disruption c)separate identities d)amnesia

64. Quiz Multiple Choice 3) Which of the following symptoms does NOT distinguish DID from other mental disorders? a)delusions b)memory disruption c)separate identities d)amnesia

65. Questions?