Dissociative disorders unclear? Think ‘rainbows from pain blows’ Visual metaphor answers the question, “What’s ‘dissociated’ in dissociative disorders?” ® Dowden Health Media r. D, age 45, presents to his primary care physi- cian with panic attacks, nausea, shortness of Mbreath, nightmares,Copyright and dizzinessFor 6 months personal after use only being assaulted and robbed at an ATM. Following a rou- tine medical workup, the physician diagnoses posttrau- matic stress disorder (PTSD) and refers Mr. D for exposure and response prevention therapy. PSYCHIATRY During graded exposure sessions, Mr. D’s eyes some- times glaze over and he seems to “fl oat away” from the CURRENT discussion. When the therapist asks about these symp- FOR toms, Mr. D reports having had them as long as he can remember. In school, he says, teachers thought he was a slow learner, a daydreamer, or had attention-defi cit/ MORGENSTERN hyperactivity disorder. From what he can recall of his MICHAEL childhood, he describes a history of trauma and neglect with a violent, drug-abusing father and absent mother. Kai MacDonald, MD Assistant clinical professor Neuropsychiatry and behavioral medicine unit Patients with a history of early abuse or neglect are at risk Department of psychiatry for dissociative phenomena and other trauma-related University of California, San Diego psychiatric disorders.1 The heterogeneous dissociative disorders are often hidden and unrecognized2 —as in Mr. D’s case—or present with unfamiliar or atypical symptoms. Understanding and identifying dissociative symptoms is important because: • Dissociative symptoms worsen prognosis, wheth- er patients have conversion disorders1 or psychogenic seizures3 or are in psychotherapy.4 • Dissociative states may impair memory encoding5 and decrease patients’ ability to remember therapeutic Current Psychiatry information. Vol. 7, No. 5 73 continued For mass reproduction, content licensing and permissions contact Dowden Health Media. 073_CPSY0508 073 4/17/08 11:50:11 AM Table 1 DSM-IV-TR classifi cation of dissociative disorders Disorder Symptoms Dissociative amnesia A reversible loss of memory, typically preceded by a stressor Dissociative fugue Loss of memory and identity, along with travel away from home Dissociative Dissociative identity Presence of different identity states, often with lack of connection disorders disorder (formerly multiple between them; current models highlight the presence of recurrent personality disorder) dissociative intrusions into many aspects of executive function and self Depersonalization Detachment from oneself as a present, feeling person disorder (depersonalization) and the world (derealization) Dissociative identity Functionally disturbing dissociative symptoms that do not fi t into any disorder NOS of the above NOS: not otherwise specifi ed Source: Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000 Clinical Point Like colors in a beam of white • Symptoms (such as hearing voices in One paired component is a detached multiple personality disorder) can be con- “observer” and a more embodied, feeling light, dissociable fused with those of disorders with differ- “experiencer.” The observer is a perspective components ent treatment strategies (such as psychotic that begets metacognition (thinking about of experience disorders).6 one’s inner world) and self-observation; constitute normal • Peritraumatic dissociation may be a it resides in the same body as soma-based risk factor for PTSD.7 “feelings” that unconsciously contribute to consciousness This article presents a practical model the sense of “being present” with oneself for understanding dissociation, reviews and the world in the moment.9 clinical characteristics of this family of A second component is voluntary ac- symptoms, and offers suggestions for as- cess to one’s autobiographical memories sessing and treating patients with dissocia- (memories about the self in time), which tive disorders. are constantly “updated” and integrated with current experiences. This component allows one to distinguish between remem- Coming together, falling apart bered (past) experiences and “fi rsthand” Since Pierre Janet’s fi rst reports on disso- (present) experience. ciative disorders, a number of theories and Three other components of normal con- models of dissociation have been proposed,8 sciousness are: including empirically based, taxonomic • a sense of agency and voluntary con- models that address DSM-IV-TR categories trol over one’s mental contents, mental ac- (Table 1). The model I propose—which at- tivity, and bodily movements taches a visual metaphor to dissociative • an ongoing connection with one’s phenomena—answers the question, “What body and mind and an understanding of is ‘dissociated’ in dissociation disorders?” where sensations and images come from • a sense of sequential experience, with 5 components of consciousness. Just as relatively smooth transitions (from self at separable wavelengths compose a beam work to self at home, self a week ago to self of white light, dissociable “colors” or today, etc) that have a singular referent (an components of subjective experience con- identity). stitute a normal state of consciousness. Five implicit components of normal con- Pathologic dissociation occurs when a sciousness—present in various degrees, at prism of distress disperses one of these different times—are seamlessly integrated component “wavelengths” from the main Current Psychiatry 74 May 2008 and associated in real time. “beam” of consciousness. For example: 074_CPSY0508 074 4/17/08 11:50:17 AM Box Dissociation’s neurobiology: Evidence of brain ‘disconnections’ rom a neurophysiologic perspective, fi ner temporal resolution than functional Fmental states may be viewed as arising imaging studies, Kirino et ale showed from synchronized integration of the activity reversible attenuation of a specifi c EEG of functionally specialized brain regions. signal within 300 msec during dissociative Functional neuroimaging of dissociation episodes. This ultra-rapid neural refl ex was supports an understanding of these correlated with allocation of attentional and symptoms as ‘disconnection syndromes.’ working memory resources, perhaps with Functional neuroimaging. Different the goal of minimizing memory activation ‘identities’—sometimes called a traumatic and resurgence of affect-laden memories.e personality state and neutral personality Hormonal. Stress-related disorders cause state—demonstrate different patterns of perturbations in neurohormonal function. cerebral blood fl ow, subjective reports, and Simeon et alf found a distinct pattern of peripheral physiologic parameters (blood stress-induced HPA axis dysregulation in a pressure, heart rate). dissociative patients compared with PTSD Clinical Point Functional imaging of traumatic patients and healthy controls. Similar dissociation shows active suppression of results were seen in patients with borderline Personality traits that limbic regions (amygdala) and increased personality disorder and dissociative may predispose to activity in dorsolateral prefrontal areas.b symptoms.g Similarly, neuroimaging of depersonalization Structural imaging. Stress-related dissociation include disorder show increased neural activity neurohormonal perturbations are known mental absorption, in prefrontal regions associated with to affect critical neural structures, including suggestibility, affect regulation and decreased activity in the hippocampus. Using MRI, Vermetten et emotion-related areas.c,d alh found signifi cantly decreased amygdala and a tendency Speed. Dissociative responses occur and hippocampal volumes in patients with to fantasize extremely rapidly. Using EEG, which allows dissociative identity disorder. EEG: electroencephalography; HPA: hypothalamic-pituitary-adrenal; PTSD: posttraumatic stress disorder Source: For reference citations, see this article at CurrentPsychiatry.com • separation of the “observer” and “ex- thought to include the individual pa- periencer” occurs in depersonalization tient’s temperamental or constitutional disorder predispositions11 as well as a strong con- • reversible loss of ability to access tribution of environmental trauma (early memories characterizes dissociative abuse, neglect).12 amnesia • disconnection between sequential ex- Constitutional predisposition for de- periences is a part of dissociative iden- veloping a dissociative disorder may tity disorder. include personality traits such as being This modular perspective of dissocia- easily hypnotized, mental absorption, tive disorders parallels a neurophysiologic suggestibility, and a tendency to fanta- perspective of mental states as arising from size.13 These characteristics fueled con- the synchronized integration of the activ- cerns in the 1990s that therapists may ity of separate, functionally specialized contribute to dissociative identity disor- brain regions.10 Functional neuroimaging der by “digging” for repressed memo- of dissociation supports an understanding ries in susceptible patients and creating of these symptoms as “disconnection syn- “pseudomemories” of events that did not dromes” (Box). happen.14 The issue of repressed traumatic mem- ory and its role in therapy is extremely Causes of dissociative disorders controversial and contributes to the com- As with many psychiatric disorders, the plexity of psychotherapeutic treatment of Current Psychiatry etiology of dissociative phenomena is dissociation.15