How many types of Dissociation do you know?

Dissociation takes many different forms, some effect everyday life or affect people every now and then, and other forms of dissociation can lead to distress and/or problems in everyday life. If these other forms of dissociative experiences happen several times – or once, but for an extended period of time – then they become problematic (pathological).

Dissociation can be seen as a spectrum, or more recently tends to be categorized as Normal/Normative, or Pathological Dissociation (i.e., the diagnosable/problematic kind).

How many types of Dissociation do you know? Which are types of normal Dissociation? Which are types of problematic Dissociation?

Types of Normal Dissociation
– Day dreaming
– Spacing out (briefly)
– Absorption (e.g., in a book)
– Highway hypnosis (expected travel with gaps in memory)

Types of Pathological Dissociation
– Numbing (emotional and/or physical) – a symptom of PTSD, Depression and others
Freeze Response – a symptom of PTSD and DID and others, common during trauma
– Out of Body Experiences (form of Depersonalization) – common during trauma, sometimes happens during near-death experiences, may also happen in BPD, and DID
– ‘Wall staring’ (spacing out, common in Depression)
– Trance states (e.g., Dissociative Trance Disorder in the ICD-10 manual, can happen in other disorders)
– Maladaptive day dreaming*
Derealization (either you/the world doesn’t feel real) – a separate diagnosis but also a symptom of BPD, Dissociative PTSD, and DID
Depersonalization (part of all of you doesn’t seem like you) – also symptom of BPD, Dissociative PTSD, and DID
Amnesia (without a physical cause) -a separate diagnosis but also a symptom of PTSD and DID
Fugue states (unexpected travel, sometimes with loss of or change in identity)
– Identity alterations/switching – a symptom of Dissociative Identity Disorder, and OSDD
– Catatonia (can be present in Schizophrenia)
Pseudo Seizures/Psychogenic Non-Epileptic Seizures – dissociative reactions to stressors
Dissociative movement or sensation problems – also known as Functional Neurological Symptom Disorder (FND), or Conversion Disorder
* not currently a diagnosis

Problematic types of dissociation are recognized as mental health problems – and can be either a Dissociative Disorder or a common symptom/experience involved in another kind of mental health problem, such as depression.
Can you think of any which are missing? Leave a comment if you can.

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DDNOS1 and Dissociative Identity Disorder – Do you know the differences?

Dissociative Disorder Not Otherwise Specified (DDNOS) and Other Specified Dissociative Disorder (OSDD)

Dissociative Disorder Not Otherwise Specified was the most commonly diagnosed Dissociative Disorder in the DSM-IV diagnostic manual.[1] DDNOS is a complex dissociative disorder which includes many different groups of dissociative symptoms. The most common presentations of DDNOS are numbered, for example DDNOS1, DDNOS2, etc. The DSM-5 changed the name of DDNOS to Other Specified Dissociative Disorder (OSDD); DDNOS-1 was renamed to OSDD-1.

DDNOS-1 and Other Specified Dissociative Disorder

Dissociative Disorder Not Otherwise Specified (DDNOS) and DID. DDNOS is any significant mix of dissociative symptoms that don't fully fit another Dissociative Disorder - It was renamed to Other Specified Dissociative Disorder in the DSM-5 - DDNOS-1 (DDNOS presentation 1) is very similar to DID. DDNOS 1 is either DDNOS-1a - identity disturbance with less distinct parts than in DID (alter personalities may exist but can't physically take control of the person's body, but strongly influence the person's thoughts and actions and amnesia is present), or DDNOS-1b - distinct dissociative parts (alters identities) exist and can take executive control, but without amnesia, less common - DDNOS may be diagnosed if symptoms are not quite clear enough for DID criteria but are similar - the amnesia needed for DID in the DSM5 has been broadened to "recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting", meaning amnesia for past trauma alone is enough - symptoms (including alters and amnesia) can be self-reported in the DSM5. height=

DDNOS1 and Dissociative Identity Disorder differences explained and DSM-5 changes to DID.
Information taken from DSM-5 (APA, 2013) and Dissociative Disorders: The DSM-V and beyond (2011).

DDNOS-1 is the most common form of DDNOS, and can be thought of as “partial DID”. [1] The improved wording of the Dissociative Identity Disorder criteria in the DSM-5 will help those incorrectly diagnosed as DDNOS, for instance because of not obviously switching to an alter identity in front of the psychiatrist, be correctly classed as Dissociative Identity Disorder. [1, 2]

References

  1. Dell, P. F., & O’Neil, J. A. (Eds.). (2010).Dissociation and the dissociative disorders: DSM-V and beyond. Routledge. ISBN 1135906033.
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association. ISBN 0890425574.

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Polyfragmented Dissociative Identity Disorder facts

Polyfragmented Dissociative Identity Disorder

See https://traumadissociation.wordpress.com/2015/02/22/polyfragmented-did1/ for words
DID (or the similar form of DDNOS) sometimes involves a very large number of alternate identities (also known as alters, alternate personalities, personalities, dissociated personality states or parts, dissociated self-states or multiple personalities, [5]:118).

Some professionals state this involves over one hundred alters, while others refer to “dozens” of alters. [1]:4, [4]. The alters may include fragments. Such large numbers of alters are likely to be caused by cult abuse, ritual abuse, or another form of extreme, sadistic abuse which extends over long periods of time and often involves multiple abusers. [1]:4, [3]:133

A larger number of alters results in less obvious physical signs of switching. [3]:27 Polyfragmented DDNOS can be particularly difficult to diagnose. [3]

DID became known as Multiple Personality Disorder with the release of the DSM-III in 1980, until the name changed to Dissociative Identity Disorder in the 1990s. During this time Polyfragmented DID was referred to as Complex Multiple Personality Disorder (Complex MPD).[2]:306

References

1 Haddock D, (2001). The Dissociative Identity Disorder Sourcebook. McGraw-Hill, ISBN 0737303948.
2 Kluft, R. P. & Fine, C. G. (1993). Clinical Perspectives on Multiple Personality Disorder. American Psychiatric Pub, ISBN 0880483652.
Miller, A. (2014). Becoming Yourself: Overcoming Mind Control and Ritual Abuse. Karnac Books. ISBN 1782412182.
3 Miller, A. (2011). Healing the unimaginable: Treating ritual abuse and mind control. Karnac Books. ISBN 1780499094.
4 Chu, James A. (2011). Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders, 2nd edition. John Wiley & Sons, ISBN 1118015061.
5 International Society for the Study of Trauma and Dissociation. (2011). [Chu, J. A., Dell, P. F., Van der Hart, O., Cardeña, E., Barach, P. M., Somer, E., Loewenstein, R. J., Brand, B., et al.] Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12, 115–187. DOI: 10.1080/15299732.2011.537247.

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What is Dissociative Identity Disorder?

Dissociation is a “the disruption of the normal integrative processes of consciousness, perception, memory, and identity that define selfhood.”[1] Dissociative identity disorder it is the most complex of the Dissociative Disorders. This mental disorder is included in both the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) , and the ICD-10. It has been recognized “for centuries”[2] and first became a separate diagnosis in the DSM-III as “multiple personality disorder.”[2]

What is Dissociative Identity Disorder?

The DSM-5 Guidebook provides this helpful description

Individuals with dissociative identity disorder may first present with symptoms of emotional and behavioral turmoil. Some may notice memory gaps and incidents of out-of-character behavior. These systems result from different “alters,” or alternative identities, controlling an individual’s behavior for varying lengths of time. Switches have been observed in stressful situations, disputes among alters, and other psychological conflicts.[2]

References:
[1] Waseem M. “Dissociative Identity Disorder”, Medscape. (2014).
[2] DSM-5 Guidebook: The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders. ISBN 9781585624652.p 192-193

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Myths which prevent people seeking trauma therapy

An excellent blog about the myths preventing some people from seeking trauma therapy.

Myths which prevent people seeking trauma therapy

http://www.goodtherapy.org/blog/treatment-of-trauma-in-therapy-part-i-five-common-myths-0513145

Considerations for survivors of extreme trauma and ritual abuse

Timescales for healing
The treatment guidelines for Complex PTSD by the ISTSS give a longer healing than the article above – between 18 months and 2 years is suggested, but this will depend on the degree of trauma and your current situation in life. If you are one of the many survivors who is still living with domestic violence or experience a bereavement during treatment, for example, then it may take longer.

Myth No. 2: No therapist can handle all of my trauma and emotions. It is just too much.

Firstly, in common with the Complex PTSD treatment guidelines, the Dissociative Identity Disorder treatment guidelines describe the first stage in treatment as focusing on Safety and Stability – learning more ways to cope with difficult emotions and trauma symptoms before trauma is discussed directly. Ways to contain existing trauma memories for a time may be needed. Therapists should also be comfortable working with clients who have additional diagnoses, self-injure and have previously had multiple suicide attempts. These are all common in survivors of severe and prolonged trauma.

Secondly, it is true that many therapists cannot manage the severity of trauma that many people with Dissociative Identity Disorder, Other Specified Dissociative Disorder (DDNOS) or extreme abuse have experienced. It can be particularly difficult because both disorders are caused with very early repeated trauma, typically at pre-school age or younger. Consequences can be either the vicarious traumatization of the therapist, or denial and minimization because he/she can’t face the reality of it. Things that help include:
1. Looking for a therapist who has worked with similar disorders or trauma before, rather than someone mostly familiar with simple PTSD. E.g. try Find a Therapist on http://isst-d.org or Trauma / Dissociation professional organizations, and ask for recommendations if none are close by/or available for very long term work.

  1. A therapist who has a supervisor with experience in the same field can help your therapist by spotting very early signs of difficulty and suggesting ways to handle this without while continuing therapy, this won’t you involve directly. An old publication by Kluft (1989) provides a way for therapists to handle this if it happens and includes indicators of when continuing therapy could be harmful (generally avoidable if earlier action is taken).
    The rehabilitation of therapists overwhelmed by their work with MPD patients.
  2. Therapists working with such complex clients need to be available for long term work, and willing to spend additional time on professional development. Therapists considering working with ritual abuse survivors can find valuable guidance in Dr Alison Miller’s book, Healing the Unimaginable (2012). Chapter 7 by survivor Stella Katz describes her ‘job’ in the cult, containing graphic descriptions of her role in torturing children, and explaining why she did this before she left the cult and ultimately healed. The ISST-D ritual abuse special interest group (for professionals) may be helpful.

Therapists who are suitable may be very difficult find, but some exist.

Myth No. 5: The therapist will judge me if I tell him or her what happened.

A trauma therapist’s role is to help guide and support someone who has experienced trauma, not to criticize or blame.
The DSM-5 diagnostic criteria for PTSD (criteria D) include distorted thinking surrounding the trauma resulting in self-blame, persistent shame, guilt, horror and/or anger, and negative beliefs about yourself,  example ‘I am bad’. A therapist will be able to work through these with you, along with the additional symptoms of Complex PTSD and Dissociation.

All victims have been forced to perpetrate against others, usually since early childhood. All perpetrators are victims of severe abuse. Keeping this in mind is critical in treating survivors. Black-white or evil-good frameworks feed into survivors’ fears that they are irredeemably evil.
Dr Ellen P. Lacter, clinical psychologist

If you experienced ritual abuse then it is extremely likely that you were forced or tricked into doing things which horrify you and carry immense shame. You may have been forced to harm or kill others (forced perpetration) or have been forced to make impossible ‘choices’ such as choosing between having another child harmed or being harmed (double binds). These are common ways that abusive groups use to damage children and vulnerable adults – it is one way that abusers use to keep survivors silent, they often blame you or pretend ‘choice’ when you were not free choose to do normal childhood things or to leave. This is so awful and unbearable that it commonly creates different alter identities to do what abusers demand, an identity lacking empathy may be needed. Feeling intense guilt and shame now shows that you regret what happened, a sign that you are not truly ‘bad’.
Therapy should be able to help you understand why you acted as did, the effect of previous trauma on your mind, and help you reinterpret the trauma with an adult perspective.

Lastly, the no particular type of therapy is recommended above others for complex Dissociative Disorders, a good alliance between therapist and client leads to the most effective therapy. According to Kluft, Dissociative Identity Disorder will not spontaneously resolve without treatment (a small number of cases of PTSD without a dissociative disorder do resolve without treatment).

More information about ritual abuse

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