In-Depth: Understanding Dissociative Disorders
The Five Dissociative Disorders
The SCID-D can identify whether a person is experiencing one of the five types of dissociative disorders. The first four are dissociative amnesia, dissociative fugue, depersonalization disorder and dissociative identity disorder (previously called multiple personality disorder). The fifth type of dissociative disorder, called dissociative disorder, not otherwise specified, occurs when a dissociative disorder is clearly present, but the symptoms do not meet the criteria for the previous four.
The five disorders can be distinguished from one another by the nature and duration of their stressors, as well as the type and severity of the symptoms. A brief review of each dissociative disorder is presented below.
A defining characteristic of dissociative, amnesia is the inability to recall important personal information. This common dissociative disorder is regularly encountered in hospital emergency rooms and is usually caused by a single stressful event. Dissociative amnesia is often seen in the victims of single severe traumas such as an automobile accident (forgotten details might include one’s actions immediately before an auto accident in which the person with the disorder was involved). The condition is often seen in wartime; witnessing a violent crime or encountering a natural disaster may also trigger dissociative amnesia.
Like dissociative amnesia, dissociative, fugue also is characterized by sudden onset resulting from a single severe traumatic event. Unlike dissociative amnesia, however, dissociative fugue may involve the creation of a new, either partial or complete, identity to replace the personal details that are lost in response to the trauma. A person with this disorder will remain alert and oriented, yet be unconnected to the former identity. Dissociative fugue may also be characterized by sudden, unplanned wandering from home or work. Typically, the condition consists of a single episode without recurrence, and recovery is often spontaneous and rapid.
The distinguishing characteristic of depersonalization disorder is the feeling that one is going through the motions of life, or that one’s body or self is disconnected or unreal. Mind or body may be perceived as unattached, seen from a distance, existing in a dream, or mechanical. Such experiences are persistent and recurrent, and lead to distress and dysfunction. Chronic depersonalization is commonly accompanied by “derealization,” the feeling that features of the environment are illusory. It should be noted that characteristics attributed to depersonalization disorder must be independent of any kind of substance abuse. It should also be noted that depersonalization as an isolated symptom may appear within the context of a wide variety of major psychiatric disorders. For example, mild episodes of depersonalization in otherwise normally functioning individuals have been reported following alcohol use, sensory deprivation, mild social or emotional stress or sleep deprivation, and as a side effect to medications. However, severe depersonalization is considered to be present only if the sense of detachment associated with the disorder is recurrent and predominant.
Dissociative Identity Disorder (previously called Multiple Personality Disorder)
Dissociative Identity Disorder (DID) occurs in people with varied backgrounds, educational levels, and from all walks of life. DID is believed to follow severe trauma including persistent psychological, physical, or sexual abuse during one’s childhood. In this condition, distinct, coherent identities exist within one individual and are able to assume control of the person’s behavior and thought (American Psychiatric Association, 1987). Unlike depictions in sensationalistic movies, most people with DID do not have dramatic shifts in personality and only persons very close to them are aware of mood swings. In DID, the patient experiences amnesia for personal information, including some of the identities and activities of alternate personalities. Some people with DID experience subtle memory problems, and may only appear to have memory problems associated with attention deficit disorder.
DID is often difficult to detect without the use of specialized interviews and/or tests, due to: 1) the hidden nature of the dissociative symptoms, and 2) the coexistence of depression, anxiety, or substance abuse which may mask the dissociative symptoms, and 3) feelings of disconnection that are often difficult to verbalize.
Because people with DID may experience depression, mood swings, anxiety, inattention, transient psychotic like states, and may self-medicate with drugs or alcohol, they are frequently diagnosed as having solely bipolar disorder, major depression, attention deficit disorder, anxiety disorders, psychotic or substance abuse disorders. Studies indicate that previous diagnoses in these areas are common to people with DID. It is not uncommon for a decade or more to pass before a correct assessment of DID is made. Research with the Structured Clinical Interview for Dissociative Disorders has identified five distinct dissociative symptoms experienced in individuals who have DID (see section above, Five Dissociative Symptoms.)
Though DID is the most severe of the dissociative disorders, this disorder can respond well to specialized psychotherapy which focuses on understanding the dissociative symptoms and developing new constructive ways of coping with stress. Medication can be used as an adjunct to psychotherapy, but is not the primary form of treatment.
Dissociative Disorder Not Otherwise Specified
Dissociative Disorder Not Otherwise Specified (DDNOS) is an inclusive category for classifying dissociative syndromes that do not meet the full criteria of any of the other dissociative disorders. A person diagnosed with Dissociative Disorder Not Otherwise Specified (DDNOS) typically displays characteristics very similar to some of the previously discussed dissociative disorders, but not severe enough to receive their diagnoses. DDNOS includes variants of Dissociative Identity Disorder in which personality “states” may take over consciousness and behavior but are not sufficiently distinct, and variants of Dissociative identity disorder in which there is no amnesia for personal information. Other forms of DDNOS include possession and trance states, Ganser’s syndrome, derealization unaccompanied by depersonalization, dissociated states in people who have undergone intense coercive persuasion (e.g., brainwashing, kidnapping), and loss of consciousness not attributed to a medical condition.
Steinberg M, Schnall M: The Stranger in the Mirror: Dissociation-The Hidden Epidemic, HarperCollins, 2001, 2000. Translations: Spanish, Italian, Chinese
Steinberg M: Handbook for the Assessment of Dissociation: A Clinical Guide. Washington, D.C., American Psychiatric Press, 1995
Steinberg M: The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D). Washington, D.C., American Psychiatric Press, 1994.
Steinberg M: The Interviewer’s Guide to the Structured Clinical Interview for DSM-IV Dissociative Disorders- Revised. Washington, D.C., American Psychiatric Press, 1994
Steinberg M: Advances in Diagnosing and Treating Dissociative Disorders: The SCID-D-R. Bulletin of the Menninger Clinic. 146-163, Spring 2000
Marlene Steinberg, MD is author of The Stranger in the Mirror: Dissociation: The Hidden Epidemic. She is also the originator of The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), the breakthrough diagnostic test that allows therapists worldwide to diagnose dissociative disorders based on rigorous scientific testing. She has also authored The Handbook for the Assessment of Dissociation: A Clinical Guide, a resource for therapists offering systematic guidelines for assessing dissociative symptoms and disorders. This article is © Copyright 2008 Marlene Steinberg, MD. All rights reserved. Reprinted from www.drmsteinberg.com with permission.
Steinberg, M. (2013). In-Depth: Understanding Dissociative Disorders. Psych Central. Retrieved on November 25, 2015, from http://psychcentral.com/lib/in-depth-understanding-dissociative-disorders/