The relationship between dissociation and trauma

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The relationship between dissociation and trauma

• Etzel Cardeña, Ph. D.
• Thorsen Professor
• Lunds Universitet

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(No Transcript)
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Plan for the lecture

• What is dissociation?
• The domain of dissociation
• Epidemiology, comorbidity, etc
• The relationship between dissociation and trauma
• Dissociative disorders
• Assessment

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Spalding Gray

• All that is left of me is this horrid, lingering
  awareness that knows there is no longer any solid
  configuration of me It is a true horror. Its
  the making of a haunted ghost.(1999)

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Narratives from 1989 SFBay Area earthquake

• 1 For the next few seconds I felt totally
  estranged from all things and people... I felt
  dazed and detached from what was going on all
  around me.
• 2 I drove on automatic pilot... didnt really
  realize what had happened or what was happening
• 3 I felt numb...too numb to panic

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Three common uses of the term

• D. as non-integrated mental/behavioral modules
  or systems that should ordinarily be integrated
  into conscious awareness (compartmentalization)
• D. as a consciousness alteration wherein
  disconnection/disengagement from the
  self/environment is experienced (detachment)
• D. as a defense mechanism to ward off pain,
  anxiety, experience of trauma (repression vs.
  dissociation?)
• (Cardeña, 1994 implications for psychotherapy
  (Holmes et al., 2005)

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The domain of dissociation





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Dissociative phenomena

• Alterations in the sense of self or surrounding
  environment (e.g., derealization)
• Alterations in physical sensation and sense of
  agency (e.g., conversion)
• Alterations in emotion (e.g., depersonalization)
• Alterations in memory (e.g., amnesia)
• Alterations in identity (e.g., DID)
• (Butler et al., 1996 Cardeña, 1997)

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Epidemiology

• 38 of inpatient psychiatric patients (Robles
  García et al., 2006)
• 29 of outpatient psychiatric patients (Foote et
  al. 2006)
• 11 in a non-clinical sample (Ross, 1991)
• Lifetime prevalence among psychiatric patients of
  27-44.5 (Ross et al., 2002)
• 10 in Turkish sample (Tutkun et al., 1998)
• 8 in Dutch sample (Friedl Draijer, 2000)

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Misdiagnoses

• On average four previous diagnoses and years
  before DD diagnosis (typically affective
  disorders, personality disorders, schizophrenias
  Coons et al., 1988 Putnam et al., 1986)
• Lack of systematic research on misdiagnoses of
  children, but anecdotal evidence of false
  diagnoses of ADHD, learning and conduct disorders

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Comorbidity

• Affective disorders (and SIB)
• Anxiety
• Somatoform disorders
• Personality disorders (avoidant pd, borderline
  pd)
• Substance abuse and eating disorders
• First rank symptoms
• (Cardeña Spiegel, 1996)
• Conduct, learning disorders (e.g., hypersexual
  behavior) in children?

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Disorders with a dissociative component

• Dissociative amnesia
• Dissociative fugue
• Dissociative identity disorder (DID)
• Depersonalization
• DDNOS (including proposal for dissociative trance
  disorder)
• Acute stress disorder
• Posttraumatic stress disorder
• Somatization disorder
• Conversion disorder
• Panic disorder

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Dissociation and trauma 1

• Association of various dissociative phenomena
  with exposure to trauma (Spiegel Cardeña, 1991)
• Dose relationship between exposure and
  dissociation severity (Koopman, Classen,
  Spiegel, 1996)

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Dissociation and trauma 2

• Comorbidity of posttraumatic and dissociative
  symptomatology (Van der Kolk et al., 1996)
• High hypnotizability of ASD and PTSD patients
  (Spiegel et al., 1988 Bryant, 2004)

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Dissociation and trauma 3

• Hx of severe trauma among DD patients (Coons,
  1994), often corroborated (e.g., Chu, 1998)
• High correlation between dissociation and PTSD
  subscales (Gold Cardeña, 1998)

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Dissociation and trauma 4

• Longitudinal, prospective study of medical
  traumatic treatment and later dissociation
  (Diseth, 2006)
• Peritraumatic dissociation as the strongest
  non-demographic predictor of chronic pathology
  among adults (Ozer et al., 2003) and children
  (Saxe, 2002) also in response to cancer
  diagnoses and treatment

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Morton Prince

• Disintegrated personality is no bizarre
  phenomenon, but in its mild forms an almost
  every-day clinical affair. (1906-1907, 187).

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Dissociative amnesia

• One or more episodes of inability to recall
  important personal information, usually of a
  traumatic or stressful nature, that is too
  extensive to be explained by ordinary
  forgetfulness (DSM-IV).
• Does nor occur exclusively in conjunction with
  other DD disorders, ASD, PTSD, or somatization,
  and is not due to the direct effect of a
  substance or a neurological condition

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Dissociative amnesia

• Topical organization Emotional/episodic
• Type of amnesia Selective/systematized
• Temporal organization Retrograde to the whole
  event (i.e., few problems in new learning), or
  recurrent to specific areas
• Etiology Traumatic event /severe stress
• Acute/severe and/or chronic/recurrent
• Associated symptoms Depression, anxiety,
  conversion, other dissociative symptoms

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Dissociative amnesia-2

• Sometimes indifference to memory loss
• Early life (lt40s) condition
• Secondary gain Typical
• Prognosis Good in isolated events, variable in
  chronic conditions
• Responsive to hypnosis and other suggestive
  techniques.
• Evidence for the validity of both recovered
  accurate memories, and created false memories
  (especially of plausible events)

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Amnestic disorders due to a general medical
condition

• Topical organization Event or time centered
• Extent of amnesia Localized or generalized
• Memory loss Not exclusively episodic (e.g.,
  procedural)
• Temporal organization Anterograde or retrograde
  (e. g., head trauma or intoxication) to the
  event.
• Etiology vascular (e.g., TGA), physical (e.g.,
  concussion), chemical (e.g., alcohol blackout),
  etc.

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Amnestic disorders due to a general medical
condition-2

• Comorbidity Other neurological or medical
  symptoms
• Late life (gt40) condition in the case of vascular
  or some cognitive disorders (e.g., dementias).
• Secondary gain Variable.
• Prognosis Variable.
• Not responsive to hypnosis and other suggestive
  techniques.

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Dissociative fugue

• Sudden, unexpected travel away from home or ones
  customary place of work, with inability to recall
  ones past.
• Confusion about personal identity or assumption
  of a new identity.
• Narrowing of consciousness, dazed look, trance
• A special case of amnesia? (DSM-V?)

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Dissociative fugue

• Distribution No information about a sex
  preponderance.
• Etiology Traumatic event/severe stress.
• Comorbidity Depression, anxiety, other
  dissociative symptoms.
• Duration Typically hours or longer.

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Dissociative fugue-2

• Generally, indifference to memory loss but
  confusion about identity.
• Early life (lt40) condition.
• Secondary gain Typical
• Prognosis Positive for isolated incidents.
• Responsive to hypnosis and other suggestive
  techniques.

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Medically caused fugue (epileptic poriomania)

• Distribution More prevalent among males.
• Etiology Postictal episodes of aimless wandering
  .
• Comorbidity Irritability, emotionality,
  religiosity in some TLE patients. Episodes of
  amnesia, depersonalization.
• Duration Typically some minutes, but it can last
  hours or, more rarely, days.

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Medically caused fugue (epileptic poriomania)-2

• No indifference to memory loss or long-term
  confusion about identity.
• Variable age of onset.
• Secondary gain Variable.
• Prognosis Variable.
• Responsive to antiseizure medication.

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Depersonalization disorder-1

• Persistent or recurrent experiences of feeling
  detached from, and as if one is an outside
  observer of, ones mental processes or body.
• Sense of unreality about the self and/or the
  environment (derealization)
• During depersonalization reality testing remains
  intact (vs. psychoses).

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Depersonalization 2

• Common features (altered sense of self,
  precipitating event, sense of unreality, sensory
  alterations)
• Attentional and memory problems
• Cortical abnormalities in sensory integration and
  body schema areas
• HPA dysregulation.

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Depersonalization disorder-3

• Depersonalization symptom may be the 3rd most
  prevalent psychiatric symptom (e.g., they are
  very common in panic attacks).
• Depersonalization disorder is characterized by
• Ongoing and recurrent interactive dialogue.
• Comorbidity Other dissociative symptoms,
  depression and anxiety

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Depersonalization disorder-4

• Frequency Persistent or recurrent.
• Duration. Chronic and habitual.
• Triggers Not present only in association with
  unusual precipitating factors (e.g., hypnosis,
  drugs, severe stress), but related to an
  emotional precipitant.

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Depersonalization in seizure disorders

• Not associated with interactive dialogue.
• Comorbidity Other seizure symptoms (EEG
  abnormalities, episodes of amnesia).
• Frequency and duration Variable
• Postictal confusion.

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Dissociative identity disorder 1

• The presence of two or more distinct identities
  or personality states, which recurrently take
  control of the persons behavior, and psychogenic
  amnesia.
• Sometimes alternating with DDNOS.
• Frequent comorbidity with depression, anxiety,
  substance abuse, borderline and other personality
  disorders, self-injurious behavior, etc.
  Differential diagnosis with psychosis and seizure
  disorder

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DID 2

• Very scant support for iatrogenic hypothesis
  (e.g., previous symptoms, no use of hypnosis for
  diagnosis, etc.)
• Evidence for diagnostic validity of the disorder
  according to Blashfield et al. criteria
  (literature, diagnostic criteria, interviews,
  reliability, differentiation Gleaves, May,
  Cardeña, 2000)
• Evidence for validity from cognitive (Eich et
  al., 1997) and brain imaging (e.g., Sar et al.,
  2001)

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Differential diagnosis

• Affective disorders
• Borderline personality disorder
• Personality disorders
• Schizophrenias
• Seizure disorder

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DDNOS

• Dissociative disorders that do not meet criteria
  for any specific DD
• In some studies, the most common DD (e.g.,
  Mezzich et al., 1989)
• Examples include partial fulfillment of DID
  criteria, derealization without
  depersonalization, dissociative trance disorder
  (e.g., amok, ataque de nervios), dissociative
  states in those subjected to chronic coercion and
  brainwashing, loss of consciousness or stupor,
  Ganser syndrome.