What are Dissociative Experiences? - Chapter 14

What is Dissociative Amnesia?

Dissociative amnesia is the inability to remember important personal information, which is usually of a stressful or traumatic nature. The DSM-5 criteria for this disorder are:

• Failure to remember important personal information, often related to traumatic or stressful events, other than normal forgetting. This stresses or limits the individual in key areas of function
• The symptoms are not the result of substance use or any other neurological or medical condition
• The disorder is not better explained by other mental disorders, such as dissociative identity disorder, PTSD, or acute stress disorder.

Dissociative amnesia is associated with different types of memory disturbances. Localized amnesia is when an individual cannot remember events that happened during a specific time period. Selective amnesia is when an individual can remember some, but not all, events of a specific time period. Generalized amnesia is a failure of memory that spans a person's entire life. Such people may suddenly report to the police or to a hospital because of disorientation. Continuous amnesia is the inability to remember events from a specific time point to the present. Systematic amnesia means that a specific category of information cannot be remembered, such as family history.

The prevalence of dissociative amnesia is about 1.8%.

Post-crime amnesia can occur when the individual is in a highly adapted physiological state due to extreme anger or the influence of alcohol or substances. However, a criminal has good incentives to fake amnesia symptoms. Symptom validity testing (SVT) is a way to check whether symptoms are real. Questions about the crime must be answered, with a choice of two answers. Individuals who get less than 40% correct are suspected of forgery because they will choose wrong answers on purpose. While an individual should score around chance level (50% good) if there really is amnesia.

What is Dissociative Identity Disorder?

Dissociative identity disorder (DID) is characterized by the display of two or more identities or personality states that take turns regulating behavior (previously known as multiple personality disorder). The DSM-5 criteria for this disorder are:

• Confusion of identity, characterized by at least two different personality states, which is seen in some cultures as being possessed
• Recurrent interruptions in remembering everyday events, personal information, or traumatic events, other than normal forgetting
• The symptoms cause distress or impairment in key areas of function
• The disruption is not a normal part of generally accepted cultural or religious practices
• The symptoms are not the result of substance use or any other neurological or medical condition.

A distinction can be made between the host identity (the identity that existed before the onset of DID) and the alter identities (the identities that evolve after the onset of DID). In the simplest case, two identities alternate, but the average is 13 identities. Often each identity takes on a certain area.

The prevalence of DID is about 1.5%. However, it has become more and more common in recent years. This may be because DID has only been a diagnostic category since the DSM-III, because it was first also diagnosed as schizophrenia, because it has gained more attention (film Sybil), because therapists stimulate multiple personalities through hypnosis and the power of suggestion , because dissociative disorders are associated with trauma and interest in them grew after the Vietnam War and finally because many symptoms can be easily mimicked.

What is Depersonalization Disorder?

A depersonalization disorder is characterized by feelings of detachment or alienation from the self. DSM-5 criteria for this disorder are:

• Recurrent episodes of depersonalization, derealization, or both, causing distress or impairment in major areas of functioning: depersonalization: experiences of detachment or observing one's own thoughts, feelings, body, or actions from a distance, and derealization: experiences of detachment from the environment.
• During these occurrences, the individual can still distinguish real from fake
• The disruption is not direct due to substance use
• The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, or depression.

The 12-month prevalence of depersonalization disorder is approximately 0.8%.

What is the relationship Between Dissociative Disorders and PTSD?

One in three individuals with PTSD also experience high levels of dissociation in the form of dissociative amnesia and depersonalization. PTSD is related to dissociative disorders in three ways. First, persistent dissociative symptoms after a traumatic experience are an important predictor for developing PTSD. Second, dissociation is a hallmark of complex or severe PTSD. Complex PTSD is associated with interpersonal trauma at an early age and dissociative symptoms from that age onwards. Third, there is the possibility that there is a specific dissociative subtype of PTSD.

What are the risk factors for dissociative disorders?

There are several risk factors for developing dissociative disorders. Anxiety and depression for the disorder, child abuse (physical or psychological abuse of a child), and childhood neglect. Dissociative symptoms are also commonly seen in homeless children and children who have run away from home who have experienced various forms of abuse.

What is the psychodynamic perspective?

The general view of psychodynamic theorists is that dissociative symptoms are caused by suppression. This is a defence mechanism that helps suppress painful memories and suppress stressful thoughts.

What is the role of fantasy and dissociative experiences?

There is evidence that dissociative disorders develop more readily in individuals who have previously experienced dissociative or depersonalization experiences. In addition, it is common that individuals with DID often have imaginary friends in childhood, predisposing them to develop DID. Children would learn that they can use such an imagined personality in times of conflict to make it better.

What are the cognitive approaches?

A central question in explaining dissociative symptoms is how it is possible that different components of the conscious mind are detached from each other and how certain memories can be retrieved, and certain memories cannot. Studies suggest that attention is important for individuals to forget trauma, dividing attention among different sources may facilitate the forgetting of emotionally relevant or traumatic information.

An alternative explanation is in terms of how changes in physiological and emotional state can affect memory recall. State-dependent memory is the cognitive phenomenon whereby an individual is better able to remember an event if he or she is in the same physiological state as when the event occurred. Thus, if an individual has experienced severe traumatic events where changes in mood and physiology occurred during the events, they may have difficulty retrieving memories in a less traumatic emotional state. However, there are some problems with this statement. First, associative amnesia is often much more severe than reported in studies of state-dependent memory. Second, there are often problems with information retrieval and information recognition, but state-dependent memory has been found only in information retrieval. Third, it appears that different identities in DID can recall autobiographical material from the other identities on a recognition test, suggesting that dissociative amnesia in DID does not affect inter-identity memory systems or is limited to state-dependent learning.

Another cognitive theory involves the concept of reconstructive memory, which posits that autobiographical memory is stored as a series of discrete elements associated with a particular experience (e.g., context, emotional state, sensory and perceptual features). Source-monitoring skill is the ability to retrieve from memory important elements of an autobiographical experience. A disruption in reality monitoring (a form of source monitoring needed to distinguish mental content that comes from experience from that that comes from imagination) can also lead to doubt whether a memory is real. This, together with disturbances in reconstructive memory, can lead to dissociative amnesia.

There are a number of questions that need to be asked when it comes to repressed memories.

Can memories of childhood trauma or abuse be suppressed? Yes, but it is important to look at the nature of the trauma and whether it is a 'normal' forgetting process or active suppression.

Can these repressed memories be restored? This is debatable, during the 1980's and 1990's there was a trend that therapists thought many symptoms were due to childhood abuse, clients were told they were in denial if they could not remember abuse. This makes it almost inevitable that clients will remember things that never happened.

Are these recovered memories accurate? There are many cases where there is false memory syndrome, where erroneous memories are retrieved. Processes that contribute to this are over-directive psychotherapy or hypnotherapy (the client is stimulated to believe that abuse has occurred) and weak source-monitoring skills.

What are the biological explanations?

At first glance, it seems logical that neurological disturbances would underlie dissociative disorders, but this does not seem to be the case. The amnesia is selective and usually transient. The brain abnormalities should therefore be selective and transient. A candidate where this appears to be the case is undiagnosed epilepsy (a disorder of the nervous system characterized by mild, episodic loss of attention or drowsiness or by severe convulsions with loss of consciousness). Epileptic seizures seem to be associated with DID, among other things, but this is unlikely to explain dissociative symptoms. An alternative explanation is that there are abnormalities in the hippocampus, where various elements of autobiographical memory converge.

What about role-playing and therapeutic constructions?

Some theorists argue that the more elaborate symptoms, such as the alter identities in DID, are a form of role-playing to evoke sympathy and escape responsibility for their actions. Therapists can also influence this by having the client give names to the different identities, making these identities therapeutic constructs rather than real symptoms. There are several arguments for this:

• Alter identities are less commonly seen in children and are common in adulthood once treatment has begun with a therapist
• Relatives of the individual with DID rarely report seeing evidence of the alter identities before treatment
• Individuals with DID have strong imaginations and rich imaginations, which facilitate playing different roles
• There is evidence that in many cases DID is only diagnosed by certain clinicians and not other clinicians, so these clinicians may have a therapeutic style where alter identities could easily develop
• Individuals with dissociative disorders are sensitive to suggestion and hypnosis.

Therapists who view DID as a diagnostic category describe a range of symptoms that may be indicative of DID. This justifies constant probing during therapy to confirm a diagnosis, in which therapists can trick clients into believing they have altered identities. In addition, its prevalence has increased since the 1980s.

However, there are also several (counter)arguments for that DID is not a construction of the therapeutic process:

• The rise in DID diagnoses may also be a result of reduced scepticism and a reduction in the misdiagnosis of DID as schizophrenia
• There is little evidence that hypnotherapy contributes to the development of DID symptoms, because only 1/4 clients are diagnosed with DID after hypnotherapy
• Core symptoms of DID are seen before the first treatment session, so DID cannot be completely constructed by therapy
• Clients are often very reluctant to talk about their symptoms, with little mention at all of past abuse or the existence of multiple personalities.

How can dissociative disorders be treated?

The main focuses in the treatment of dissociative disorders are reducing selective amnesia and helping the client get used to recovered memories if they are painful or traumatic and helping clients merge the alter identities into one identity. However, there are some issues that therapists run into:

• Some dissociative disorders are rare, making therapeutic techniques relatively underdeveloped and effectiveness unknown
• Some dissociative disorders sometimes resolve spontaneously, where it is not clear whether the therapeutic methods used are effective or not
• Dealing with recovered memories is often traumatic for the client because the traumatic events are relived (abreaction), which can lead the client into an emotional crisis
• Directive therapeutic styles can lead to the recovery of erroneous memories, which can have negative consequences for the client and the family
• Integrating alter identities into one identity is a very difficult process, clients find the identities a nice way to explain their behavior to others and to absolve the host identity of responsibility
• Dissociative disorders are often comorbid with many other psychiatric disorders, addressing these issues as well is a requirement in therapy

How can psychodynamic therapy be used?

In the first phase of psychodynamic therapy, a trusting relationship is established between the therapist and the client. In the second phase, repressed memories or alter identities are addressed. This second phase is the most challenging because it can be traumatizing to recall memories and because the client often does not want to integrate the multiple personalities. If previous phases have been successful, the client receives training to learn how to deal with the recovered memories or the integrated personality.

What does hypnotherapy involve?

Hypnotherapy is a form of therapy in which the client is put under hypnosis. This can help the client bring up repressed memories. Drugs such as amobarbital sodium and pentobarbital sodium can be used at the same time as hypnotherapy to help you remember. Age regressing is the re-creation of a client's physical and mental state prior to experiencing trauma in order to help the client recall certain events from earlier stages in life.

What is the use of drug treatments?

Since anxiety and depression are common in dissociative disorders, antidepressants, anxiolytic drugs, and tranquilizers are used in treatment. However, drugs seem to have little effect on DID. SSRIs and opioid antagonists have been shown to reduce symptoms in depersonalization disorders.