Dissociative Disorders

Dissociation is when an individual is able to go through complex cognitive processes without explicit knowledge of what they are doing. Someone might suddenly become self-aware while in a completely unfamiliar place without having any idea of how they got there. The DSM-5 recognizes several types of pathological dissociation: depersonalization/derealization disorder, dissociative amnesia, dissociative fugue, and dissociative identity disorder.

In depersonalization/derealization disorder, one loses track of oneself or environment. Depersonalization is when a person feels disconnected from himself – he might feel like he is floating elsewhere, looking down on his body, or he might feel like events are happening to someone else. In derealization, the individual feels like everything happening to them seems unreal. Everybody feels this way sometimes, for instance after sleep deprivation or during a panic attack, but to be diagnosed with this disorder the individual must lose his ability to function in daily life due to frequent or severe symptoms.

In dissociative amnesia a person forgets very specific events of her life, generally something that is traumatic. To share something very personal, I was raped by my first boyfriend, and I am wracked with self-doubt about what actually happened (and whether it happened) because the memory has become so foggy. (I admit this very personal and humiliating bit of information not because I feel the need to share such things with strangers, but because there is so much stigma attached to women who were raped that it has become necessary to say “this can happen to anyone, it’s wrong, and it’s destructive.”)

I know another person who, while in prison, was continuously attacked verbally and physically by one of the other inmates. At one point, my acquaintance grabbed the throat of her bully and began throttling her while screaming in her face. Afterwards, she left feeling that she had handled herself quite well, and that the argument had ended peacefully. She only discovered her behavior later, when other inmates told her what happened. These events can happen to everyone to some extent, but in order to be diagnosed with dissociative amnesia the symptoms must cause significant troubles in dealing with daily life.

A more serious condition is a dissociative fugue. This is a state in which a person completely dissociates from their consciousness and forgets pieces or all of his past. Days, weeks, or years later the person might find himself in an unfamiliar environment, working another job, or living a whole new life. I know someone who experiences a less extreme case of fugue in which he will lose awareness for hours at a time and suddenly become aware of himself in awkward situations (missing clothes, banged up car, etc.)

During a fugue state, the individual is generally unaware of the amnesia, but his memory of what has happened during the fugue state remains intact. Many times a fugue state will remit on its own, and the memories from before the fugue state return, while the memories of what happened during the fugue state disappear. Like people experiencing conversion disorder, the individual is generally escaping from a highly stressful situation, but in this case they remove themselves from the source of the stress.

Dissociative identity disorder (DID), formerly known as multiple personality disorder (MPD), is another mental illness that is popularized in books and movies – usually with rather trite effects. (I mean come on, how many murder mysteries need to have the murderer be someone’s other personality?) DID is the most extreme of the dissociative disorders. It is characterized by two or more distinct personalities that have different ways of thinking and behaving. They also might have different personal history, self-image, name, sex, handedness, sexual orientation, eyeglass prescription, language, or age. There is generally an identity which most often presents itself, called the “host identity,” which may or may not be the best adjusted of the identities.

One of the reasons the term “multiple personality disorder” was dropped was that it gives the impression that the affected person has separate identities making them more than one person. Actually, it is more like the affected person is fractured and is less than whole. People with DID might exhibit a slew of other symptoms such as depression, self-mutilation, suicidal behavior, headaches, hallucinations, and PTSD.

According to the posttraumatic theory, the cause of fracturing is due to a traumatic event, usually during childhood. DID may be a coping mechanism in which the child can forget that something horrible has happened, or believe that the horrible thing is happening to someone else. Another theory is the sociocognitive theory, in which therapists inadvertently convince highly suggestible, hypnotized, patients that they have more than one personality. One argument for the sociocogntive theory is that “normal” patients can adopt multiple personalities under hypnosis. Also, many patients diagnosed with DID did not show obvious signs of DID before diagnosis. I tend to be a proponent of the sociocognitive theory, though I believe that the posttraumatic theory is probably true for many cases.

Over the years, the prevalence of DID has increased dramatically. One reason for this is the 1973 release of Flora Rhea Schreiber’s Sybil, which depicted a woman with 16 separate personalities. The book, and subsequent movie, made a dramatic splash in popular culture as well as psychological circles. Highly suggestible patients began to wonder if they, themselves, had more than one personality, and these imaginings were encouraged under hypnosis by over-eager psychologists. The case of Sybil was since then discredited – for more information you can read Sybil Exposed, by Debbie Nathan – however, this discovery of fraud came too late for the MPD movement. It was about this time that the DSM-III recognized MPD as a mental illness. The DSM-III also tightened the criteria for schizophrenia so that people who had been previously diagnosed as schizophrenic were now diagnosed with MPD.

Some personalities in DID are aware of the other personalities, and know what they know, and some personalities are completely unaware of the other personalities and lack explicit knowledge of events that occurred to the others. However, these personalities that lack explicit knowledge actually have some implicit (unconscious) knowledge. For instance, if you teach word associations to one personality and then ask another personality to repeat the associations, that second personality will be unable to do so. But if given a word and asked to free-associate, the personality that lacks explicit memory of the pairs will often come up with the matching word.

There is a controversy about whether DID is real or faked. Because of episodes like Sybil, and because some people fake DID in order to get out of prison sentences, and because some over-eager therapists might be accidentally planting personalities into the mind of highly suggestible hypnotized patients, DID diagnoses are viewed with skepticism.

Another symptom that clinicians are skeptical of is retrieved memories of abuse. Patients do not remember the abuse before they are treated, but upon probing begin to remember abuse as a child. These memories are real in the mind of the patient, but they might not be grounded in truth. Memory is frighteningly suggestible. Something I was highly suspicious of when I was reading Sybil as a teenager is her recovered memories from the age of 2 and earlier. Really? She suddenly remembers forgotten things that had happened to her when she was 2? Although I hate to discount the horror of sexual abuse, I also hate to see innocent people falsely accused of atrocious acts.

I, myself, am skeptical of DID, as mentioned in an earlier post. It’s not that I don’t believe in DID hands down, only that I tend to think more cases are formed as described by the “sociocognitve theory.” However, due to the fact that part of my goal in this blog is to decrease stigma about mental illness, I now feel a little ashamed of my skepticism, despite the fact that some clinicians express the same skepticism. I think I might read a few books on the subject and reevaluate.

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 8: Somatic Symptom and Dissociative Disorders. Abnormal Psychology, sixteenth edition (pp. 264-292). Pearson Education Inc.

Abnormal Psychology in Contemporary Society

Our class only read part of chapter 17 of Butcher’s Abnormal Psychology: a section about inpatient mental health treatment in contemporary society and another about controversial legal issues and the mentally ill.

Mental health treatment in contemporary society

In the late 19th century, mental hospitals were filled with patients. Many of these patients lived in a horrific environment that was unhealthy both physically and mentally. In those hospitals that had humane treatment of patients, there was a concern that patients would get “institutional syndrome” – in which people lost their ability to socialize and live independently because they had been in a mental hospital for so long.

In the mid-to-late 20th century, a movement to deinstitutionalize the mentally ill gained momentum. It began in the 1950s and 60s, when antipsychotic drugs were developed. These medications made it possible for patients to leave hospitals and live independent lives. Later, a desire to rescue people from inhumane environments and to keep them from getting “institutional syndrome” accelerated the rate of deinstitutionalization. Another consideration in deinstitutionalization was the desire to decrease medical expenditures. As mentioned in my earlier post on Chapter 2, deinstitutionalization was detrimental to many mentally ill people. One third of the homeless population is comprised of mentally ill people, and a horrifying number of the mentally ill are incarcerated with little to no mental health treatment (which, by the way, means that society is still doling out the bucks to pay for the housing of mentally ill).

In contemporary American society, if a person is unable to care for himself, or if he is a danger to himself or others, he can be placed in a psychiatric hospital. Such a commitment can be voluntary, but if someone is considered a danger to himself or society and he refuses hospitalization, civil commitment procedures can be undertaken, and he can be confined involuntarily in a mental hospital.

Such hospitals generally combine traditional forms of therapy with a constructive social environment. A study in 1977 by Gordon L. Paul and Robert L. Lentz compared the relative effectiveness of three treatment approaches.

Milieu therapy, which focuses on providing the patient with a very clear idea of what the staff expectations are and providing feedback about compliance with those expectations, encouraging the patients to be active in their own treatment decisions, and providing social groups for support and “positive” peer pressure.

Social-learning, in which the patients learn socially acceptable behavior through a token economy (they get tokens when they behave well). With tokens, the patients can buy privileges.

Traditional treatments, with pharmacotherapy, occupational therapy, and individual group therapy. For instance, a friend of mine was recently released from a mental health ward which had psychological therapy, psychiatry, yoga, prayer meetings, knitting classes, and all sorts of social groups.

Paul and Lentz studied 28 schizophrenic patients for resocialization, learning new roles, and reducing bizarre behavior. From the social learning program, 90 percent of the patients remained in the community after release; compared to the 70 percent who’d had milieu therapy, and the less than 50 percent who’d had traditional therapy. I haven’t read it, but there’s a review of Paul and Lentz’s study available here.

All of these programs seem like a positive change from the early 20th century, but in order to voluntarily get into one of these hospitals, the patient must have both resources and mindfulness of illness. In order to get involuntarily committed, the patient must have an advocate willing to report his danger. Most of the homeless do not have such advocates, and thus they slip between the cracks.

Controversial legal issues and the mentally ill

In recent years news reports have sensationalized grizzly murders committed by sociopaths and psychotic people. In fact, one such grizzly murder was just discovered in the Twin Cities (where I live). It’s easy to say that if only the mental health system were better, we could prevent such tragedies. But how do you really know when someone is dangerous before they actually do anything? A mental health professional is authorized to make such a judgement call, though the dangerous person must first be seeing a mental health professional before any judgement can be made. And often a patient gives no hint of his violent thoughts.

If the patient does give a hint of violent thoughts, the mental health worker (or even a priest during confession), has the duty to report the dangerous individual to the authorities, and in some states to warn the individual who has been threatened.

One huge controversy about dangerous mentally ill people is the insanity defense (or not guilty by reason of insanity, NGRI). Someone can be successful with this plea if he is thought to not know right from wrong or if he was compelled irresistibly to perform the violent act. The defense attorney must obtain the testimony of a mental health professional who convincingly claims that the accused was insane at the time of the crime.

Because it is very difficult to be acquitted as NGRI some people plea “guilty but mentally ill (GBMI).” With success of this plea, the convicted would be found guilty but placed in a mental institution instead of a prison. Many hope that this plea will decrease the number of patients who are found not guilty by reason of insanity, are confined to a mental institution, soon judged to be in recovery, and are unconditionally released into society. When a person is found guilty but mentally ill, he remains for his entire sentence in the mental institution.

A third way that a mentally ill person can protect himself from unethical treatment is to claim incompetence to stand trial. If a person is charged with a crime but is unable to understand the proceedings due to mental health, he can postpone the trial until they have recovered sufficiently to understand. Such people can be hospitalized until they are deemed competent.

An interesting point that the authors brought up was about patients diagnosed with disassociative identity disorder, DID – formerly known as multiple personality disorder. If one personality commits a crime, is it ethical to punish all personalities? This is a question that first occurred to me several years ago while reading A Fractured Mind, by Robert B. Oxnam. Oxnam gave a few examples of when one personality did something “wrong,” and Oxnam implied that he, himself, was not guilty of those transgressions, because it was his other self that committed them. The two examples I remember are when one of his personalities cheated on his wife and when one of his personalities stole a bunch of stuff from a boating store. It peeved me that Oxnam thought it was ok to brush off those acts by saying “the other (bad) me did it.” But perhaps that is because I’m skeptical of true multiple personalities that are unaware of, and unable to control, the others’ actions. If it does exist, I’m sure it’s very, very rare.

On the other hand, I do know someone who has disassociative episodes and was caught doing something illicit during an episode. But my friend has never blamed the “other” guy – he seems quite willing to step up and take the blame. Somehow that willingness to accept the blame makes him seem less culpable, in my eyes, than Oxnam.

What do you think? Do you believe that people with DID can have completely separate identities that are unaware of, and unable to control, each others’ actions? Do you think the entire set of identities should be punished if one personality commits a crime?

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 17: Contemporary and Legal Issues in Abnormal Psychology. Abnormal Psychology, sixteenth edition (pp. 583-607). Pearson Education Inc.

Iron House, by John Hart

2012 Book 5: Iron House, by John Hart (1/9/2012)

Iron House is a beautifully written mystery/suspense novel that delves into the psychological effects of a childhood of violence and abuse. Michael is an orphan who, after running away from a violent scene at an orphanage, grows up to be an enforcer for a powerful mobster. When he falls in love with a beautiful waitress and retires from organized crime, he is suddenly thrown into a violent mystery leading him to explore things he had left behind. Despite my need to suspend disbelief a few times (and to frown upon a few clichés), I feel that Hart kept up the action (and mystery) throughout the book, making for an engaging read. This is an excellent book for people who enjoy mystery/thrillers (assuming they don’t mind violence). I gave the book 3.5/5 stars…it lost points for violence and small clichés.