What is Dissociative Disorder?

Introduction

Dissociative disorders (DD) are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception.

People with dissociative disorders use dissociation as a defence mechanism, pathologically and involuntarily. The individual experiences these dissociations to protect themselves. Some dissociative disorders are triggered by psychological trauma, but depersonalisationderealisation disorder may be preceded only by stress, psychoactive substances, or no identifiable trigger at all.

The dissociative disorders listed in the American Psychiatric Association’s DSM-5 are as follows:

  • Dissociative identity disorder (formerly multiple personality disorder): the alternation of two or more distinct personality states with impaired recall among personality states. In extreme cases, the host personality is unaware of the other, alternating personalities; however, the alternate personalities can be aware of all the existing personalities.
  • Dissociative amnesia (formerly psychogenic amnesia): the temporary loss of recall memory, specifically episodic memory, due to a traumatic or stressful event. It is considered the most common dissociative disorder amongst those documented. This disorder can occur abruptly or gradually and may last minutes to years depending on the severity of the trauma and the patient. Dissociative fugue was previously a separate category but is now treated as a specifier for dissociative amnesia.
  • Depersonalisation-derealisation disorder: periods of detachment from self or surrounding which may be experienced as “unreal” (lacking in control of or “outside” self) while retaining awareness that this is only a feeling and not a reality.
  • The old category of dissociative disorder not otherwise specified is now split into two: other specified dissociative disorder, and unspecified dissociative disorder. These categories are used for forms of pathological dissociation that do not fully meet the criteria of the other specified dissociative disorders; or if the correct category has not been determined; or the disorder is transient.

The ICD 11 lists dissociative disorders as:

  • Dissociative neurological symptom disorder.
  • Dissociative amnesia.
  • Dissociative amnesia with dissociative fugue.
  • Trance disorder.
  • Possession trance disorder.
  • Dissociative identity disorder.
  • Partial dissociative identity disorder.
  • Depersonalisation-derealisation disorder.

Cause and Treatment

Dissociative Identity Disorder

Cause

Dissociative identity disorder is caused by ongoing childhood trauma that occurs before the ages of six to nine. People with dissociative identity disorder usually have close relatives who have also had similar experiences.

Treatment

Long-term psychotherapy to improve the patient’s quality of life.

Dissociative Amnesia

Cause

A way to cope with trauma.

Treatment

Psychotherapy (e.g. talk therapy) counselling or psychosocial therapy which involves talking about your disorder and related issues with a mental health provider. Psychotherapy often involves hypnosis (help you remember and work through the trauma); creative art therapy (using creative process to help a person who cannot express his or her thoughts); cognitive therapy (talk therapy to identify unhealthy and negative beliefs/behaviours); and medications (antidepressants, anti-anxiety medications, or sedatives). These medications help control the symptoms associated with the dissociative disorders, but there are no medications yet that specifically treat dissociative disorders. However, the medication pentothal can sometimes help to restore the memories. The length of an event of dissociative amnesia may be a few minutes or several years. If an episode is associated with a traumatic event, the amnesia may clear up when the person is removed from the traumatic situation. Dissociative fugue was a separate category but is now listed as a specifier for dissociative amnesia.

Depersonalisation-Derealisation Disorder

Cause

Dissociative disorders usually develop as a way to cope with trauma. The disorders most often form in children subjected to chronic physical, sexual or emotional abuse or, less frequently, a home environment that is otherwise frightening or highly unpredictable; however, this disorder can also acutely form due to severe traumas such as war or the death of a loved one.

Treatment

Same treatment as dissociative amnesia. An episode of depersonalisationderealisation disorder can be as brief as a few seconds or continue for several years.

Dissociative disorders, especially dissociative identity disorder (DID), while being the result of extraordinary abuse and trauma in childhood, it should not be attributed exotic status. DID would be better examined through a more holistic lens, taking into considering the social, cognitive, and neural components, and how they interact with one another.

Medications

There are no medications to treat dissociative disorders, however, drugs to treat anxiety and depression that may accompany the disorders can be given.

Diagnosis and Prevalence

The lifetime prevalence of dissociative disorders varies from 10% in the general population to 46% in psychiatric inpatients. Diagnosis can be made with the help of structured clinical interviews such as the Dissociative Disorders Interview Schedule (DDIS) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R), and behavioural observation of dissociative signs during the interview. Additional information can be helpful in diagnosis, including the Dissociative Experiences Scale or other questionnaires, performance-based measures, records from doctors or academic records, and information from partners, parents, or friends. A dissociative disorder cannot be ruled out in a single session and it is common for patients diagnosed with a dissociative disorder to not have a previous dissociative disorder diagnosis due to a lack of clinician training. Some diagnostic tests have also been adapted or developed for use with children and adolescents such as the Adolescent Dissociative Experiences Scale, Children’s Version of the Response Evaluation Measure (REM-Y-71), Child Interview for Subjective Dissociative Experiences, Child Dissociative Checklist (CDC), Child Behaviour Checklist (CBCL) Dissociation Subscale, and the Trauma Symptom Checklist for Children Dissociation Subscale.

Dissociative disorders have been found to be quite prevalent in outpatient populations, as well as within low-income communities. One study found that in a population of poor inner-city outpatients, there was a 29% prevalence of dissociative disorders.

There are problems with classification, diagnosis and therapeutic strategies of dissociative and conversion disorders which can be understood by the historic context of hysteria. Even current systems used to diagnose DD such as the DSM-IV and ICD-10 differ in the way the classification is determined. In most cases mental health professionals are still hesitant to diagnose patients with Dissociative Disorder, because before they are considered to be diagnosed with Dissociative Disorder these patients have more than likely been diagnosed with major depressive disorder, anxiety disorder, and most often post-traumatic stress disorder (PTSD). It has been found from interviews with those who may be afflicted with dissociative disorders may be more effective at getting an accurate diagnosis than self-scoring assessments and scales.

The prevalence of dissociative disorders is not completely understood due to the many difficulties in diagnosing dissociative disorders. Many of these difficulties stem from a misunderstanding of dissociative disorders, from an unfamiliarity diagnosis or symptoms to disbelief in some dissociative disorders entirely. Due to this it has been found that only 28% to 48% of people diagnosed with a dissociative disorder receive treatment for their mental health. Patients who are misdiagnosed are often those more likely to be hospitalised repeatedly, and lack of treatment can result in intensive outpatient treatment and higher rates of disability.

An important concern in the diagnosis of dissociative disorders in forensic interviews is the possibility that the patient may be feigning symptoms in order to escape negative consequences. Young criminal offenders report much higher levels of dissociative disorders, such as amnesia. In one study it was found that 1% of young offenders reported complete amnesia for a violent crime, while 19% claimed partial amnesia. There have also been cases in which people with dissociative identity disorder provide conflicting testimonies in court, depending on the personality that is present. The world-wide prevalence of dissociative disorders is not well understood due to different cultural beliefs surrounding human emotions and the human brain

Children and Adolescents

Dissociative disorders (DD) are widely believed to have roots in adverse childhood experiences including abuse and loss, but the symptoms often go unrecognised or are misdiagnosed in children and adolescents. However, a recent western Chinese study showed an increase in awareness of dissociative disorders present in children These studies show that DD’s have an intricate relationship with the patient’s mental, physical and socio-cultural environments. This study suggested that dissociative disorders are more common in Western, or developing countries, however, some cases have been seen in both clinical and non-clinical Chinese populations. There are several reasons why recognising symptoms of dissociation in children is challenging: it may be difficult for children to describe their internal experiences; caregivers may miss signals or attempt to conceal their own abusive or neglectful behaviours; symptoms can be subtle or fleeting; disturbances of memory, mood, or concentration associated with dissociation may be misinterpreted as symptoms of other disorders.

Another resource, Beacon House, informs us of dissociative disorder in children, suggesting that it is a survival mechanism that often goes unnoticed in children that have been traumatised. Dr. Shoshanah Lyons suggests that traumatised children often continue to dissociate even though they might not be in any danger, and that they are often unaware that they are dissociating. In addition to developing diagnostic tests for children and adolescents (see above), a number of approaches have been developed to improve recognition and understanding of dissociation in children. Recent research has focused on clarifying the neurological basis of symptoms associated with dissociation by studying neurochemical, functional and structural brain abnormalities that can result from childhood trauma. Others in the field have argued that recognising disorganised attachment (DA) in children can help alert clinicians to the possibility of dissociative disorders. In their 2008 article, Rebecca Seligman and Laurence Kirmayer suggest the existence of evidence of linkages between trauma experienced in childhood and the capacity for dissociation or depersonalisation. They also suggest that individuals who are able to utilise dissociative techniques are able to keep this as an extended strategy to cope with stressful situations.

Clinicians and researchers stress the importance of using a developmental model to understand both symptoms and the future course of DDs. In other words, symptoms of dissociation may manifest differently at different stages of child and adolescent development and individuals may be more or less susceptible to developing dissociative symptoms at different ages. Further research into the manifestation of dissociative symptoms and vulnerability throughout development is needed. Related to this developmental approach, more research is required to establish whether a young patient’s recovery will remain stable over time.

Current Debates and the DSM-5

A number of controversies surround DD in adults as well as children. First, there is ongoing debate surrounding the aetiology of dissociative identity disorder (DID). The crux of this debate is if DID is the result of childhood trauma and disorganized attachment. A proposed view is that dissociation has a physiological basis, in that it involves automatically triggered mechanisms such as increased blood pressure and alertness, that would, as Lynn contends, imply its existence as a cross-species disorder. A second area of controversy surrounds the question of whether or not dissociation as a defence versus pathological dissociation are qualitatively or quantitatively different. Experiences and symptoms of dissociation can range from the more mundane to those associated with PTSD or acute stress disorder (ASD) to dissociative disorders. Mirroring this complexity, the DSM-5 workgroup considered grouping dissociative disorders with other trauma/stress disorders, but instead decided to put them in the following chapter to emphasize the close relationship. The DSM-5 also introduced a dissociative subtype of PTSD.

A 2012 review article supports the hypothesis that current or recent trauma may affect an individual’s assessment of the more distant past, changing the experience of the past and resulting in dissociative states. However, experimental research in cognitive science continues to challenge claims concerning the validity of the dissociation construct, which is still based on Janetian notions of structural dissociation. Even the claimed etiological link between trauma/abuse and dissociation has been questioned. Links observed between trauma/abuse and DD are largely only present from a Western cultural context. For non-Western cultures dissociation “may constitute a “normal” psychological capacity”. An alternative model proposes a perspective on dissociation based on a recently established link between a labile sleep-wake cycle and memory errors, cognitive failures, problems in attentional control, and difficulties in distinguishing fantasy from reality.

Debates around DD also stem from Western versus non-Western lenses of viewing the disorder, and associated views of causes of DD. DID was initially believed to be specific to the West, until cross-cultural studies indicated its occurrence worldwide. Conversely, anthropologists have largely done little work on DD in the West relating to its perceptions of possession syndromes that would be present in non-Western societies. While dissociation has been viewed and catalogued by anthropologists differently in the West and non-Western societies, there are aspects of each that show DD has universal characteristics. For example, while shamanic and rituals of non-Western societies may hold dissociative aspects, this is not exclusive as many Christian sects, such as “possession by the Holy Ghost” share similar qualities to those of non-Western trances.

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What is the Dissociative Experiences Scale?

Introduction

The Dissociative Experiences Scale (DES) is a psychological self-assessment questionnaire that measures dissociative symptoms.

Background

It contains twenty-eight questions and returns an overall score as well as four sub-scale results.

DES is intended to be a screening test, since only 17% of patients with scores over 30 will be diagnosed with having dissociative identity disorder. Patients with lower scores above normal may have other post-traumatic conditions.

The DES-II contains the same questions but with a different response scale.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Dissociative_Experiences_Scale >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

On This Day … 25 January

People (Births)

  • 1923 – Shirley Ardell Mason, American psychiatric patient (d. 1998).

Shirley Ardell Mason

Shirley Ardell Mason (25 January 1923 to 26 February 1998) was an American art teacher who was reputed to have dissociative identity disorder (previously known as multiple personality disorder).

Her life was purportedly described, with adaptations to protect her anonymity, in 1973 in the book Sybil, subtitled The True Story of a Woman Possessed by 16 Separate Personalities. Two films of the same name were made, one released in 1976 and the other in 2007. Both the book and the films used the name Sybil Isabel Dorsett to protect Mason’s identity, though the 2007 remake stated Mason’s name at its conclusion.

Mason’s diagnosis and treatment under Cornelia B. Wilbur have been criticised, with allegations that Wilbur manipulated or possibly misdiagnosed Mason.

On This Day … 25 January

People (Births)

  • 1923 – Shirley Ardell Mason, American psychiatric patient (d. 1998).

Shirley Ardell Mason

Shirley Ardell Mason (25 January 1923 to 26 February 1998) was an American art teacher who was reputed to have dissociative identity disorder (previously known as multiple personality disorder).

Her life was purportedly described, with adaptations to protect her anonymity, in 1973 in the book Sybil, subtitled The True Story of a Woman Possessed by 16 Separate Personalities. Two films of the same name were made, one released in 1976 and the other in 2007. Both the book and the films used the name Sybil Isabel Dorsett to protect Mason’s identity, though the 2007 remake stated Mason’s name at its conclusion.

Mason’s diagnosis and treatment under Cornelia B. Wilbur have been criticised, with allegations that Wilbur manipulated or possibly misdiagnosed Mason.

Biography

Mason was born and raised in Dodge Centre, Minnesota, the only surviving child of Walter Wingfield Mason (a carpenter and architect) and Martha Alice “Mattie” Atkinson. In regard to Mason’s mother: “…many people in Dodge Centre say Mattie” – “Hattie” in the book – “was bizarre,” according to Bettie Borst Christensen, who grew up across the street. “She had a witch-like laugh….She didn’t laugh much, but when she did, it was like a screech.” Christensen remembers Mason’s mother walking around after dark, looking in the neighbours’ windows. At one point, Martha Mason was reportedly diagnosed with schizophrenia.

Mason graduated from Dodge Centre High School in 1941 and became an art student at Mankato State College, now Minnesota State University, Mankato. In the early 1950s, Mason was a substitute teacher and a student at Columbia University. She had long suffered from blackouts and emotional breakdowns, and finally entered psychotherapy with Cornelia B. Wilbur, a Freudian psychiatrist. Their sessions together are the basis of the book. From 1970-1971, she taught art at Rio Grande College in Rio Grande, Ohio (now the University of Rio Grande).

Some people in Mason’s home town, reading the book, recognised Mason as Sybil. By that time, Mason had severed nearly all ties with her past and was living in West Virginia. She later moved to Lexington, Kentucky, where she lived near Wilbur. She taught art classes at a community college and ran an art gallery out of her home for many years.

Wilbur diagnosed Mason with breast cancer in 1990, and she declined treatment; it later went into remission. The following year, Wilbur developed Parkinson’s disease, and Mason moved into Wilbur’s house to take care of her until Wilbur’s death in 1992. Mason was a devout Seventh-day Adventist. When her breast cancer returned Mason gave away her books and paintings to friends. She left the rest of her estate to a Seventh-day Adventist TV minister. Mason died on 26 February 1998.

Over one hundred paintings were found locked in a closet in Mason’s Lexington home when it was being emptied after her estate sale. These paintings, often referred to as the “Hidden Paintings”, span the years 1943, eleven years before starting psychotherapy with Dr. Wilbur, to 1965, the year of her successful integration. Several of the paintings were signed by Shirley. However, many remained unsigned, and include examples of some of the artwork presumably created by, and signed by the alternate personalities.

Sybil

Flora Rheta Schreiber’s non-fiction book Sybil: The True Story of a Woman Possessed by 16 Separate Personalities told a version of Mason’s story with names and details changed to protect her anonymity. The book, whose veracity was challenged (e.g. Sybil Exposed by Debbie Nathan), stated that Mason had multiple personalities as a result of severe child sexual abuse at the hands of her mother, who, Wilbur believed, had schizophrenia.

The book was made into a highly acclaimed TV movie starring Sally Field and Joanne Woodward, in 1976. The TV movie was remade in 2007 with Tammy Blanchard and Jessica Lange.

Controversy

Mason’s diagnosis had been challenged. Psychiatrist Herbert Spiegel saw Mason for several sessions while Wilbur was on vacation and felt that Wilbur was manipulating Mason into behaving as though she had multiple personalities when she did not. Spiegel suspected Wilbur of having publicised Mason’s case for financial gain. According to Spiegel, Wilbur’s client was a hysteric but did not show signs of multiple personalities; in fact, he later stated that Mason denied to him that she was “multiple” but claimed that Wilbur wanted her to exhibit other personalities. Spiegel confronted Wilbur, who responded that the publisher would not publish the book unless it was what she said it was.

Spiegel revealed that he possessed audio tapes in which Wilbur tells Mason about some of the other personalities she has already seen in prior sessions. Spiegel believes these tapes are the “smoking gun” proving that Wilbur induced her client to believe she was multiple. Spiegel made these claims 24 years later, after Schreiber, Wilbur and Mason had all died and he was finally asked about the topic.

In August 1998, psychologist Robert Rieber of John Jay College of Criminal Justice stated that the tapes belonged to him and that Wilbur had given them to him decades earlier. He cited the tapes to challenge Mason’s diagnosis. Rieber had never interviewed or treated Mason but asserted that she was an “extremely suggestible hysteric.” He claimed Wilbur had manipulated Mason in order to secure a book deal.

In a review of Rieber’s book, psychiatrist Mark Lawrence asserts that Rieber repeatedly distorted the evidence and left out a number of important facts about Mason’s case to advance his case against the validity of the diagnosis.

Debbie Nathan’s Sybil Exposed draws upon an archive of Schreiber’s papers stored at John Jay College of Criminal Justice and other first-hand sources. Nathan claims that Wilbur, Mason, and Schreiber knowingly perpetrated a fraud and describes the purported manipulation of Wilbur by Mason and vice versa and that the case created an “industry” of repressed memory. Nathan hypothesizes that Mason’s physical and sensory issues may have been due to untreated pernicious anaemia, the symptoms of which were mistaken at the time for psychogenic issues. She notes that after Mason was treated with calf’s-liver supplements for chronic blood disorders as a child and young woman, her psychological symptoms likewise went into remission for years at a time, and that Wilbur herself noted that “Sybil” suffered from pernicious anaemia later in life. Nathan’s writing and her research methods have been publicly criticised by Mason’s family and by Dr. Patrick Suraci, who was personally acquainted with Shirley Mason.

In addition, Suraci claims that Spiegel behaved unethically in withholding tapes which supposedly proved Wilbur had induced Mason to believe she had multiple personalities. Spiegel also claimed to have made films of himself hypnotising Mason, supposedly proving that Wilbur had “implanted false memories” in her mind, but when Suraci asked to see the films Spiegel said he had lost them. Although Wilbur’s papers were destroyed, copies and excerpts within Flora Rheta Schreiber’s papers at the Lloyd Sealy Library of John Jay College were unsealed in 1998.

In 2013, Nancy Preston published After Sybil, a personal memoir which includes facsimile reproductions of Mason’s personal letters to her, along with colour plates of her paintings. According to Preston, Mason taught art at Ohio’s Rio Grande College, where Preston was a student. The two became close friends and corresponded until a few days before Mason’s death. In the letters, Mason claimed that she had had multiple personalities.