Dissociative disorders are a group of psychiatric conditions that are characterized by dissociation. Dissociation is defined as forgetting or abandoning one’s own identity and the loss of certain autobiographical memories in the process. Based on this definition, the most important dissociative disorders to study are dissociative identity disorder, dissociative amnesia, and fugue. Multiple personality disorder with dissociation or amnesia is now known as dissociative disorder, non-specified.
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Image: “Mirar atrás / Look back” By Hernán Piñera. License: CC BY-SA 2.0


Dissociative Identity Disorder

Definition of Dissociative Identity Disorder

Dissociative identity disorder is a condition that is characterized by the presence of two or more distinct personalities. The mere presence of distinct personalities is not enough for the diagnosis, as dissociation is needed for the diagnosis to be made.

Therefore, patients should show amnesia of certain life events that are not expected to be forgotten, impaired behavior, affect, consciousness and cognitive impairment. Memory loss and memory gaps are also essential for the diagnosis.

Etiology of Dissociative Identity Disorder

The most likely etiology for dissociative identity disorder is childhood trauma. Sexual abuse, physical abuse or other forms of trauma need to be continuous and intense for dissociation to happen. On the other hand, rape victims who have one acute episode of significant trauma can also have dissociation symptoms and dissociative amnesia but rarely dissociative identity disorder.

The exact brain changes in dissociative identity disorder are not known but recent structural and functional brain imaging studies have pointed towards hippocampal, temporal, prefrontal and medial frontal lobe abnormalities.

Management of Dissociative Identity Disorder

Some psychiatrists believe that the identification of the traumatic event in any case of dissociation is essential. Therefore, hypnosis or drug-assisted interviews can be used to identify the traumatic event that might have caused dissociation. Patients with dissociative identity disorder should undergo psychodynamic therapy with the aim of fusing as many personalities as possible in one coherent personality that the patient can later assume.

Stable fusion is dependent on the patient’s doctor rapport and long-term treatment. Therefore, continuous support and treatment are recommended. Stable fusion has been reported in one-third of the cases after a decade of successful fusion.

Dissociative Amnesia

Definition of Dissociative Amnesia

Dissociative amnesia is a condition that is characterized by the loss of certain autobiographical memories that the patient is not expected to forget. Dissociative amnesia can be localized to certain traumatic life events or very rarely generalized.

Generalized amnesia is more common after natural disasters and at wartime, whereas localized amnesia can be seen after rape.

Etiology of Dissociative Amnesia

The exact etiology of dissociative amnesia is unknown but acute trauma or stress are usually involved. The most common stressors include rape, wars and natural disasters.

Certain communities have a higher prevalence of dissociative amnesia compared to the general population such as sex workers and strippers. This can be explained by the increased risk of experiencing sexual or physical abuse in these lines of work. Drug addicts are also more likely to develop dissociative amnesia compared to the general population.

Management of Dissociative Amnesia

The management of dissociative amnesia is dependent on the identification of the cause of the dissociation. Drug-assisted interviews or hypnosis might be needed to help the patient recall the traumatic events. Once the patient remembers the causative events, he or she might be overwhelmed and the risk of suicide becomes very high.

Antidepressants and anxiolytic therapy have been used in patients with dissociative amnesia. The goal is to treat the associated depression and anxiety but these treatments will not fix the dissociation. Psychotherapy and remembering the traumatic events are the only ways to recover from dissociative amnesia.

Patients with severe dissociative amnesia might create a completely new identity to compensate for the lost identity.

Dissociative Fugue

Definition of Dissociative Fugue

A dissociative fugue is a severe form of dissociative amnesia that is characterized by the complete loss of one’s own identity and fleeing from one’s normal surroundings. Wandering and traveling are very essential for fugue to be diagnosed. Therefore, patients with complete loss of identity but without fleeing behavior cannot be diagnosed with fugue but may be diagnosed with severe dissociative amnesia.

Etiology of Dissociative Fugue

Dissociative fugue has been also linked to severe traumatic life events such as rape, wars or other stressors. Patients with fugue have been found to have abnormal frontal and temporal function on brain imaging studies.

Dissociative fugue is very rare compared to localized dissociative amnesia. Recovery from dissociative fugue and acute severe dissociative amnesia is good.

Treatment of Dissociative Fugue

Patients with dissociative fugue should be admitted to the hospital. Electroconvulsive therapy is not very useful in such cases. Instead, emphasis should be put on helping the patient remember the traumatic event that led to this state in the first place.

Psychodynamic therapy, drug-assisted interviews, and hypnosis can be used to define the trigger. Once the patient recalls the traumatic event, he or she might be overwhelmed and the risk of suicide is high.

Patients with fugue can also have post-traumatic stress disorder or other anxiety disorders. Therefore, benzodiazepines might be needed. Additionally, such patients might be depressed.

Common Differential Diagnoses of Dissociative Disorders

Major Depressive Disorder

Patients with dissociative disorders very commonly have depressive symptoms. Major depressive disorder might present with amnesia. The main difference between depression-related amnesia and a dissociative disorder is that the information lost in the later is inconsistent with forgetting.

Bipolar Disorders

Patients with dissociative personality disorder might be misdiagnosed with bipolar disorders. Patients with bipolar disorders have significant fluctuations in their personality and mood. They can present with psychosis and mania. However, dissociation is not present in bipolar disorders.

Psychotic Disorders

Patients with dissociative personality disorder might be misdiagnosed with schizophrenia. It is important to understand that patients with a dissociative personality disorder do not hallucinate, do not have severe and bizarre delusions and most importantly cannot remember what they do or did when another personality takes over.

Drug Abuse and Alcohol Intoxication

We have explained that the risk of dissociative disorders is higher among drug addicts, but it is also important to note that patients with dissociative symptoms might be simply intoxicated. Alcohol intoxication can cause blackouts and memory gaps. Cocaine use and the use of other recreational drugs have been also linked to dissociative symptoms.

Seizure’s Related Disorders

Focal seizures with dyscognitive impairment can resemble dissociative disorders in that the patient fails to recall certain events during the seizure. Patients with a history of blackouts but without any other symptoms or signs suggestive of a dissociative disorder should be evaluated for the possibility of a seizure disorder.

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