Dissociative disorders: types, symptoms and causes.

A summary of the characteristics of dissociative disorders and their types.

A few years ago the series "The United States of Tara" was aired, whose main character, Tara, an American housewife, shared a house with her husband, her two children and, in her head, her four other personalities. Tara had dissociative identity disorder.

This disorder is part of the dissociative disorderspsychological conditions in which the person becomes detached from reality, or even, as with Tara, his or her personality may fragment and emerge in the form of new ones.

Next we will see more in depth what these disorders are, what we understand by the idea of dissociation, in addition to the symptoms and possible causers of the same ones.

What are dissociative disorders?

Dissociative disorders are a group of mental disorders in which the main symptom is a disconnection from reality, as well as a lack of continuity between thoughts, memories and conscious experiences of the person.The main symptom is a disconnection from reality, as well as a lack of continuity between the person's conscious thoughts, memories and experiences. People who suffer from this type of disorder escape from reality involuntarily, which causes them serious problems in their daily lives.

The cause of these disorders is usually traumatic, and the appearance of these disorders can be interpreted as a consequence of the brain's difficulties in processing certain contents that have a high aversive emotional charge. On the other hand, it can also be the result of a brain injury or malformations in the brain.

It should be clarified that dissociation from reality is not only of a perceptual or intellectual nature; it is also of an emotional nature. For example, there are people who suffer from a dissociative symptom known as derealization, in which there is the feeling that part or all of what is around us is not real, it is just a shadow of what really exists; in any case, it is an experience difficult to put into words, emotionally rooted and above all subjective.

What do we mean by dissociation?

In essence, we speak of dissociation as the state in which there is a disconnection, more or less severe, between reality and the person's perception. Dissociative experiences are not consciously integrated, implying disturbances in the continuum of the disruptions in the continuum of their thoughts, memory and sense of identity, aspects which, in general, are not integrated consciously.These aspects are usually processed consciously.

All of us, at some point in our lives, have dissociated. For example, it is very common to be reading a book and completely disconnect from what is going on around us. This mechanism is very useful when we want to be aware of what we are reading, but we are in a noisy environment. By disconnecting from the distractions we are completely introduced into the story of the book in front of us.

Another example would be when we are walking to class or to work and we are thinking about our own things, without paying attention to what we find along the way. Since it is a route that we already know, we have it very automated, and we do not pay attention to the details along the way. As in the case of the book, these are situations in which dissociating is not pathological. It saves our cognitive resources, since we do not pay attention to what we do not need.

The real problem comes when this dissociation makes us unable to remember what we are doing, or separates us from our material present, which is beyond our subjectivity.or separates us from our material present, which is beyond our subjectivity. It is as if, for a moment, we had detached ourselves from our body and it acted independently, but without us remembering what it was doing. This automatism occurs even in situations where we should be paying close attention.

Common symptomatology

As there are several dissociative disorders, each one of them has characteristic symptoms. However, they do have common symptomatology:

• Loss of memory of certain periods, events, people or personal information.
• Sensation of being detached from oneself, physically and emotionally.
• Perception that one's surroundings are unreal and distorted.
• Stress and inability to cope with it.
• Relational, personal, work and other important vital areas problems.
• Depression.
• Anxiety.
• Suicidal thoughts and attempts.

Prevalence

The prevalence of dissociative disorders is estimated to be between 2 and 3% in the general population, although there are studies that point to 10%.. Dissociation can occur in acute or chronic forms. The probability of occurrence after a traumatic event is very high, close to 70% of cases, although it is normal for the associated symptoms to last at most a few weeks.

However, it should be borne in mind that the presence of dissociative disorders does not necessarily last a lifetime; they may appear and disappear at a certain point in time.

Types of dissociative disorders

According to the DSM-5, there are three main dissociative disorders, plus a fourth that includes symptoms that are properly dissociative but do not fit in their totality with the other three diagnoses:

1. dissociative amnesia

The main symptom is the loss of memory, much more serious than a simple daily forgetfulness, which cannot be justified by the existence of a previous neurological disease.

The person is not able to remember important information about him/herself, nor about relevant life events and people, especially those that have to do with the person's life.especially those related to the time of the traumatic event.

Sometimes, the person carries out a dissociative fugue, i.e. wanders in a state of confusion without being aware of what is going on around him/her.

The amnesia episode occurs suddenly, and its duration can be very variable, ranging from a few minutes to years. Generally, Patients with dissociative amnesia are aware of their memory loss, which is usually reversible..

This is the most common specific dissociative disorder of the three, and is the one that can be frequently seen in places such as hospital emergency rooms, accompanied by other disorders such as anxiety disorders.

2. Dissociative Identity Disorder

This disorder was formerly known as "multiple personality disorder".and is characterized by alternating between different personalities. It is the most severe and chronic form of dissociation. Personality changes are usually motivated by some environmental effect, especially stressful situations. It is the disorder suffered by the protagonist of "The United States of Tara".

The person feels the presence of two or more persons in his mind, with personalities different from his own and that, in stressful situations or in the presence of certain triggers, one of these personalities possesses him and becomes him. In any case, the main personality, which usually corresponds to the patient's legal name, is not usually aware of the existence of other personalities.

The curious thing about this disorder is that each personality may have its own name, personal history, gender, age, differences in voice, accent, and so on.The curious thing about this disorder is that each personality can have its own name, personal history, gender, age, differences in voice, accent, or even use of accessories that the original personality does not normally need, such as glasses.

Actually, these are not fully formed personalities, but rather represent something like a fragmented identity. The amnesia associated with this disorder is asymmetrical, i.e. the different personalities remember different aspects of the patient's life (similar to the Rashomon effect).

Although at the beginning of therapy patients usually present between 2 and 4 different personalities, as the treatment evolves, more than 15 may be revealed.

3. Depersonalization-derealization disorder

In this disorder one or both of the two different situations may occur.

The person suffers a disconnection from him/herself, giving him/her the sensation of observing his/her actions, feelings and thoughts from a certain distance, like someone playing a video game.This symptom is depersonalization, like someone playing a video game in third person perspective. This symptom is depersonalization.

In other cases, one may feel that the things around him/her are distant, unclear, as if he/she were dreaming. This symptom is derealization, or the feeling that reality is not real.

4. Dissociative Disorder Not Otherwise Specified

This label is, in clinical practice, the most common diagnosis.. It refers to those cases in which dissociative symptoms are present but do not correspond completely to one of the three previous disorders. Therefore, it includes cases that present very varied and heterogeneous characteristics, making their treatment complicated due to the lack of referents.

Possible causes

Dissociative disorders are usually considered as a defense mechanism to cope with traumatic events, with the intention of protecting the psychological integrity of the victim.

One of the most common causes is having witnessed or suffered physical, emotional, verbal and sexual abuse during childhood, common acts in situations of family abuse. The child experiences these domestic situations as truly terrifying.The child lives in a constant situation of helplessness and stress, especially due to the fact that the abuser's behavior is very unpredictable. The child lives in a constant situation of helplessness and stress. Other traumatic situations are having lived through a war, a terrorist attack or a natural catastrophe.

Since personal identity is something very moldable in childhood, the experience of stressful situations can affect the child for life, emerging psychopathology once adulthood is reached. Also, because personality and identity are not yet formed, it is easier for a child to detach from him/herself than an adult when observing or being the victim of a traumatic event.

Although, as an adult, what caused the traumatic event will most likely no longer exist or can be coped with because of greater freedom than when a child was a child (p. e.g., the abusive parent is elderly or has died), its use in adulthood is pathological. If the danger no longer exists, there is no objective reason to continue using it, since the individual's psychological integrity would no longer be at risk.

Risk factors

The main risk factor for suffering a dissociative disorder in adulthood is having been a victim of physical, sexual or other abuse in childhood, having witnessed traumatic events or having suffered from a negligent parental style.. Traumatic events, in addition to terrorism, environmental catastrophes and maltreatment, include being kidnapped and tortured, as well as long hospitalizations.

Having a dissociative disorder is also a risk factor for other disorders and health problems:

• Self-injury and mutilation.
• Sexual dysfunction.
• Drug use.
• Depression and anxiety disorders.
• Post-traumatic stress disorder.
• Personality disorders.
• Sleep disturbances.
• Eating disorders.
• Non epileptic seizures.

Treatment

The treatment of dissociative disorders is complicated, given that during the amnestic episode, depersonalization, derealization or the manifestation of another personality the level of consciousness of the individual can be significantly diminished. This makes it difficult to carry out therapy during the time when these symptoms occur. However, certain techniques have been certain techniques have been developed to try to cope with these same symptoms..

In the case of depersonalization, the patient is made to try to establish physical contact with someone in his or her immediate context, or to concentrate on an activity such as reading, exercise or conversation. Also, to counteract the memory of a traumatic event, the patient is made to try to remember a pleasant experience or visualize a place he/she considers safe.

Another technique used, very frequent in anxiety disorders, is deep breathing training, as well as different forms of exposure.. Guided imagery is also used to re-experience traumatic events. These techniques may seem counterproductive, since they seem to increase the strength of the symptoms. However, the main goal of this type of exposure and reimagination is to make the patient change the valence associated with the memory of the traumatic events.

Cognitive restructuring is another procedure that cannot be missed when working with traumatic-based problems.. El objetivo es modificar los pensamientos acerca la vivencia del evento traumático, trabajar sobre los sentimientos de culpa y autocrítica que pueda manifestar el paciente y reinterpretar los síntomas.

Referencias bibliográficas:

• American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• Simeon, D; Abugel, J (2006). Feeling Unreal: Depersonalization Disorder and the Loss of the Self. New York, NY: Oxford University Press. p. 17. ISBN 0195170229. OCLC 6112309
• Maldonando R.J. y Spiegel D. (2009). Dissociative Disorders. In The American Psychiatric Publishing: Board Review Guide for Psychiatry(Chapter 22).
• Sackeim, H. A., y Devanand, D. P. (1991). Dissociative disorders. In M. Hersen & S. M. Turner (Eds.), Adult psychopathology and diagnosis (2nd ed., pp. 279-322). New York, NY: Wiley.
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• Waters, F. (2005). Recognizing dissociation in preschool children. The International Society for the Study of Dissociation News. 23(4): pp. 1 - 4.