27.1 Introduction
Dissociative disorders are a group of psychiatric syndromes characterized by disruptions of aspects of consciousness, identity, memory, motor behavior, or environmental awareness. They are not among the more common psychiatric illnesses, and there is a controversy about them, specifically regarding the more dramatic manifestation, dissociative identity disorder (DID). This chapter discusses the phenomenon of dissociation and the disorders subsumed under this DSM category.
The debate over DID arose in the context of the furor over repressed and later recovered memories of childhood sexual abuse, the child sex abuse panic of the 1980s, and associated stories of satanic ritual abuse. It was fueled by the excesses of some mental health clinicians, who began to diagnose and “treat” individuals for DID. In some instances clinicians reported the existence of hundreds of “alter” personalities and claimed that an epidemic of DID was occurring across the United States, Canada, and the United Kingdom. Critics of the disorder assert that the diagnosis was a result of iatrogenesis, where the therapist unintentionally shaped the manifestation of the disorder. Despite an enormous amount of published literature on dissociative disorders, dissociation remains a poorly understood phenomenon and one that is controversial.
Currently, most psychiatric physicians believe that dissociation is a legitimate phenomenon. They also believe that DID, its most dramatic manifestation (formerly known as multiple personality disorder), is a rare condition when it occurs spontaneously but that it is easy to create iatrogenically. Clinicians reading this chapter are urged to keep an open mind and to understand that this area of psychopathology is poorly developed from an empirical standpoint.
Dissociation refers to the situation of altering one’s usual level of self-awareness in an effort to escape an upsetting event or feeling. It is a normal reaction to an emotionally overloaded situation and happens in the service of self-preservation when neither resistance nor escape is possible. This process can include actively pretending to be somewhere or someone else, experiencing amnesia, and having the ability to “cut off” pain perception from parts of the body. The cognitive outcome of dissociation is fragmentation of memory. This fragmentation can result in patchy or disorganized recall, seemingly illogical associations, and seemingly extreme affective reactions such as displaying extreme rage in reaction to relatively minor interpersonal “offenses.” All humans have the capacity to dissociate. Acts of daydreaming or amnestic episodes constitute common types of dissociation.
27.3 Dissociation versus Repression
Conceptually, dissociation differs from the defense mechanism of repression in several different ways. Repression is hypothesized to result from intrapsychic conflicts. Dissociation, in contrast, is hypothesized to result from external trauma with amnestic barriers presumed to divide subunits of memory. Moreover, in dissociation, the information is kept out of awareness for a sharply delimited period, whereas in repression information is kept out of awareness for a variety of experiences across time. In other words, the memories that are “repressed” in dissociation are specific to events. They are not the result of “forgetting” as a way to avoid anxiety associated with intrapsychic conflicts that may have nothing to do with specific events.
Pathologic dissociation occurs when a person experiences more frequent or “deeper” states of dissociation and everyday functioning deteriorates. Dissociation leading to impaired functioning requires treatment. The degree of disruption of the self and the intensity and types of intervention vary in the dissociative disorders. People may not remember their identity and travel far away from home (dissociative fugue), they may lose their memory (dissociative amnesia), they may assume two or more identities or personalities (DID), or they may feel that they are not in touch with their body (depersonalization disorder).
Few good epidemiologic studies have been performed. Some estimate the prevalence at only 1 per 10 000 in the population but some have found people with these disorders to be as high as 1% of the population. Reliable and unbiased statistics are unavailable. Women make up the majority of reported cases, accounting for over 90% of the cases in some studies.
Although dissociative phenomena have occurred around the world, they seem to be more prevalent in the less heavily industrialized, developing countries. Cultural considerations regarding dissociative disorders should bear in mind that trance states are seen in some cultures, including Indonesia, Malaysia, the Arctic, India, and Latin America, and that trance states may be seen or included as part of spiritual belief systems. For diagnostic purposes, however, an individual must be experiencing dysfunction and stress, and the behaviors noted must not be a normal part of a broadly accepted collective cultural or religious practice.
Research shows that DID can be misdiagnosed in the Latino population because “ataque de nervios” is accepted as a diagnosis for this group, yet it has symptoms similar to DID. Amnesia is a predominant symptom of “ataque” and often is a culturally acceptable reaction to stress within the Latino community.
The etiology of dissociative disorders is not known. Results of the few genetic studies examining dissociative disorders have been inconclusive. The ability to dissociate is believed to be partly related to having the capacity to do so when subjected to repeated stress.
27.6.1 Biologic Factors
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