Written by Ashwati Ramaswamy Dissociative Identity Disorder (formerly known as Multiple Personality Disorder) has a reputation for being a mysterious territory. With its representation in the media and lack of awareness in the general population, it is often misunderstood. Its prevalence rate (frequency within a population) globally is 1.5%, being considered a rare disorder (Mitra and Jain, 2022). However, beyond just DID, numerous other disorders stem from the condition of dissociation. Dissociative disorders are often misdiagnosed and require long and tedious assessments for an accurate diagnosis (Mychailyszyn et. al., 2020). However, in the last 30 years, research surrounding dissociative disorders has progressed significantly. The DSM-5 describes dissociation as a “discontinuity in the normal integration of consciousness, memory, identity, emotions, perception, body representation, motor control and behaviour” (American Psychiatric Association, 2013). Through that definition emerges a disorder that can disrupt every area of the mind. In this article, I wish to outline all the important aspects of dissociative disorders that I believe need more awareness. What Are Dissociative Disorders? Dissociation is a disconnection between the physical and mental. It can be described as the separation between one’s thoughts, identities and memories. It is usually the brain’s brilliant way to overcome traumatic experiences by tolerating memories that would usually be too overwhelming. There are three main types of dissociative disorders: dissociative identity disorder, dissociative amnesia, and depersonalisation/derealisation disorder. (American Psychiatric Association, 2022) An example case of a dissociative disorder would include the case of Karen Overhill outlines dissociative identity disorder (Mirror, 2007). The trauma she underwent at a young age led to a dissociative identity disorder. Dissociative Amnesia Dissociative amnesia is the condition of not being able to recall information about oneself. It goes beyond just regular forgetting since amnesia is often related to a stressful event. There are three key types of amnesia. Localised (unable to remember an event or a specific period), selective (unable to remember a specific part of an event or some events over time), and generalised (complete loss of identity and life history). Dissociative amnesia is the brain's way of coping with experiences of childhood trauma. Depersonalisation/Derealisation Depersonalisation is described as the experience of detachment from your mind or body. It is as if one is witnessing their own life from a third person’s point of view. Derealisation is the experience of being detached from surroundings. These can be very distressing experiences, as the individual is fully aware that what they are feeling is unusual. Dissociative Identity Disorder DID is associated with traumatic events and/or abuse that an individual suffers in their childhood. The trauma leads to memory gaps from the amnesia, leading to the formation of distinct identities from different behaviour, memory and thinking. The majority of the people who develop dissociative disorders have experienced repetitive trauma in childhood. The aforementioned case of Karen Overhill falls under these symptoms. There is no clear limit on the ‘identities’ that can form, and some can be more overpowering than others (Mirror, 2007). Of all the stigma surrounding dissociation, DID is subject to the most stigma. Not only is this disorder stigmatised by the general public, but there is also a lot of professional stigma and clinical stigma surrounding it due to scepticism about its legitimacy (Gleaves and Reisinger, 2023). What Are the Possible Causes? As discussed before, dissociative disorders are often developed as a coping mechanism to catastrophic events and long-term stress, abuse or trauma (Mychailyszyn et. al., 2020). This is also true when trauma and high levels of stress have occurred in early childhood, as at that young age with a lack of stable support and resources, one mentally removes themselves from a traumatic situation as an escape. However, this becomes an issue once it begins to separate an individual from reality and creates memory gaps (Cleveland Clinic, 2022). How Does the Diagnosis Work? Dissociative disorders can be very distressing to live with and can lead to a lot of problems with functioning. In addition to this, one of the major downfalls in the clinical treatment of dissociative disorders is misdiagnosis. Specialised interventions have a positive response, but the misdiagnosis leads to further distress and poor quality of life. Thus, a strong assessment for diagnosis is crucial for clients. The most recent and relevant measure for dissociative disorders is done through a structured clinical interview for the DSM (SCID). The SCID for dissociative disorder is based on the DSM IV and it tests for five scales: amnesia, depersonalisation, derealisation, identity infusion, and identity alteration. Each scale ranges from a score of 1 to 4, and a higher score is an indication of higher and recurrent psychopathology. This means that a higher score indicates more distress to the individual. Overall, it was found the structured clinical interview addressed the five core dimensions of dissociation (Mychailyszyn et. al., 2020). A strength of this assessment strategy is that it goes beyond asking the client ‘yes’ and ‘no’ questions regarding their dissociation, nor does it simply give the client a rating scale of 1-4. The interview questions require the clients to elaborate on their experiences of dissociation and provide examples. This allows the clinicians to narrow down on the disorder, and rule out possible disorders that may have comorbidity with dissociation such as PTSD. Mychailyszyn et. al. (2020) conducted a meta-analysis on the SCID and studied the effect size over several cultures. It was found that overall, structured clinical interviews for dissociative disorders are currently the most reliable and valid form of assessment. What Are the PossibleTreatments? While dealing with dissociation, some of the skills to develop are interpersonal, emotional regulation and distress tolerance (Subhramanyam et. al., 2020). One of the main treatments is talking therapy such as: Cognitive behavioural therapy: A structured therapy to unlearn negative thoughts and behaviours. Dialectical Behaviour Therapy: A therapy adapted for emotionally charged clients. They work towards building skills in emotional regulation using validation (American Psychiatric Association, 2022). There are, additionally, self-help techniques to reduce symptoms involving grounding exercises (Quest 2021). The individual can focus on their breathing, naming ten things they can see around them, and be mindful of the physical feelings they feel. This can allow them to ground themselves in reality, and pull them out of their dissociation. While this may not work as a treatment solution, it helps the individual regulate and manage their symptoms on a regular basis (Quest, 2021). Conclusion In recent years, dissociative disorders have had significant research done. However, with the stigma that still surrounds this subject, there have been gaps in the literature (Mychailyszyn et. al., 2020). The professional stigma around dissociative disorders has had an impact on the way clinicians approach them (Gleaves and Reisinger, 2023). It is important to note that the presence of a dissociative disorder does not mandate a positive response. Oftentimes, people suffering from it get an overwhelmingly negative response. From the traumatic roots that this rare disorder is formed from, people need to have the proper knowledge and understanding of it. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders(5th ed.). American Psychiatric Publishing.
American Psychiatric Association. (2022). What are dissociative disorders? https://www.psychiatry.org/patients-families/dissociative-disorders/what-are-dissociativedisorders Cleveland Clinic. (2022). Dissociative Disorders. https://my.clevelandclinic.org/health/diseases/17749-dissociative-disorders Gleaves, D. H. & Reisinger, B. A. (2023). Stigma Regarding Dissociative Disorders. Journal of Trauma and Dissociation, 24(3). Pp. 317-320. https://doi-org.ezproxy.is.ed.ac.uk/10.1080/15299732.2023.2191240 Mirror. (25 October, 2007). The woman who has 17 people living in her head. In: Mirror.co.uk [Internet]. Available at: https://www.mirror.co.uk/news/uk-news/the-woman-who-has-17-people-living-516210 Mitra P, Jain A. (17 May, 2022). Dissociative Identity Disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK568768/ Mychailyszyn, M.P., Brand, B.L., Webberman, A.R., Sar, V., Draijer, N. (2020). Differentiating Dissociative from Non-Dissociative Disorders: A Meta-Analysis of the Structured Clinical Interview for DSM Dissociative Disorders (SCID-D). Journal of Trauma and Dissociation, 22(1), 19-34. https://doi-org.ezproxy.is.ed.ac.uk/10.1080/15299732.2020.1760169 Subramanyam, A. A., Somaiya, M., Shankar, S., Nasirabadi, M., Shah, H. R., Paul, I., & Ghildiyal, R. (2020). Psychological Interventions for Dissociative disorders. Indian journal of psychiatry, 62(2), S280–S289. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_777_19. Quest. (14 April, 2021). Dissociation & Trauma, How to reduce symptoms. In: Quest Psychology Services [Internet]. Available at: https://questpsychologyservices.co.uk/dissociation-Mtrauma-how-to-reduce-symptoms/
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