9.

1 DissoCiative Disorders
The human mind seems capable of dissociating, or separating mental functions. You
can think intensively about a problem while jogging, perhaps not even realizing that
you ran a mile without awareness of your surroundings. In dissociative disorders,the
separation of mental functions occurs to a far more extreme degree. Dissociative dis-
orders raise intriguing questions about the ways in which people's sense of self evolves
over time, memory, and sense of reality can become fragmented. In contrast, somatic
symptom disorders, which are discussed later in this chapter, raise questions about the
mind-body relatiohsip.

Major Forms of Dissociative Disorders

We generally take forgranted the idea that each individual has one personality and
dissociative identity sense of self. However, in dissociative identity disorder
disorder (DID)
(DID), it appears that the
individual has developed more than one personality with its associated sense of seir
A dissociative disorder, formerly Each separate personality seems to have its own
called multiple personality dis- unique characteristic ways of perce
order, in which an individual
ing. relating to, and thinking. By definition, people with DID have at least two distinct
identities and when inhabiting the identity of one, are not aware that they also
develops more than one self or innd
the other identity. As a result, their experiences lack continuity. They have large saps
personality.
in importantmemories about themselves and their lives.
They may torget or as
everyday events, but also experiences they had that are of a traumatic nature
u
victimization or abuse.
nt
dissociative amnesia People with dissociative amnesia are unable to remember information about an e
An inability to remember impor
tant personal details and experi-
or set of events in their lives. Their amnesia is not due to ordinary forgetfulnes.ne ofa
ever. What they typically forget is a specific
from their lives, most ikh they
event
ences; is usually associated with traumatic or stressful nature. Their amnesia may involve a fugue state in wn
traumatic or very stressful events.
travel or wander without knowing their identity.
 MINI CASE
Dissociative ldentity Disorder
Myra is a
young single woman
in a large bookstore. she lives
who works as
out socially except to
see her
by herself, nevera clerk acquaintances and fanily know her However, alters
conservative
a consenvative
manner, which relatives,
manner h atives, and
and dro
qoes
dresses
sresidereside within
within Myra
Myra's body. and they go by other names
s Dou
as orudish. In her
ways "Rita" isotally
her in and behave in
early teens. she associates ridicule
intimate relationship with a was Myra's" personality.
incongruou
flamboyant., outgoing.
uite abusive toward her. middle-aged OIved involved in an
man who uninhibited
and uninhibited in her sexual
seru passions. She has engaged
f this troubled Although others remind was in numerous love
In
numerous affairs with a variety of unsavory
no recollection or
relationship. Myra claims that she her characters she pickedaaup in nightclubs and discotheques.
that person, and she
wondered at times whether has "Rita" is aware of
"Myra" and regards her with etreme
has even
story to annoy her. At
others have disdain.
made up the from Athird personality. "Joe. oCCasio es
eavina herself sexually age for.
25, Myra
says that she is Myra's apartment. Dressed in a man's three-piece

totally uninterested in pursuing marriage, yet she seems business suit. "Joe goes
with men. So far, this any close shopping. According to "Joe."do"Rita " is hio nothing but a
describes Myra as herrelationships"slut" who is heading for "big
trouble
details of somea
work Myra's alters are oblivious to the her life

Your ordinary perception of who you are

vOur own body. Depersonalization is the involves your knowing that you live within depersonalization
detached from their own body. They condition in which
people feel
experiences of unreality, being anthey
may have are Condition in which people feel
observer, or emotional or physical outside detached from their own body.
numbing. Derealization is a condition in which
neople feel a sense of unreality or detachment
from their derealization
derealization disorder is a condition in which surroundings. Depersonalization/ Condition in which people feel a
ences of
depersonalization and people have one or both of the
derealization. experi sense of unreality or detachment
from their surroundings.

Theories and Treatment of Dissociative depersonalization/

Traumatic events
Disorders derealization disorder
A
dissociative disorder in which
lead
can
people experience splitting apart of their conscious
to
experi- the individual
ences, sense of self, feelings of continuity over time. In normal development,
or experiences
integrate the people recurrent
perceptions and memories they have of themselves and their experiences. In episodes ofand persistent
a dissociative depersonalization.
disorder, the individual is trying to block out or
awareness events that caused extreme separate from conscious
psychological, if not physical, pain.

Individuals with dissociative identity

disorder have leamed to cope with
extremely stressful life circumstances
by creating "alter personalities that
unconsciously control their thinking and
behavior when they are
expeniencing
stress.
 Clinicians, nevertheless, face a
daunting task both in diagnosing and treating an indi-
idual's dissociative symptoms. In the first place, they determine whether the condi-
must
tion is real or faked (either intentionally or unintentionally). People may deliberately feign
dissociative disorder to gain attention or avoid punishment. They may unwittingly
develop one of these disorders, however, because they are seeking attention for having
movies are written (such as Sybil, or The Three Faces
the type of diagnosis about which
of Eve, for example).
Dissociative Identity Disorder

individual may not be responsible for actione

The possibility that
while one's
an

multiple personalities
are in control of the
person's beha committed
Theoretically. of course, it's possible torleads to
fascinating legal questions. alters, or even the host, is not a
ne
alter to
alter
the other
commit a crime while in control
alter means that the host (alone
Obviously, however, convicting
one
with all the
At another level, however, the ue
other alters) is also put in prison stion become
one related to the legal definition of insanity. Is a person with dissoci

disorder able to control his

her own mind if part of the mind
or has split offidentDnd
mind has

acting independently?
to delending a client who locit.
There are three possible approaches
this diagnosis. In the "alter-in-control
legitimately has
approach, the defendant claime nat an alter
at the time of the offense. In the "each alter
personality was in control sanityapproach
the prosecution must determine whether each personality met the insa
standard. In the "host-alter" approach, the issue is whether the host
hostwhether personality
meets the insanity standard.
Dissociative identity disorder is rarely successtul as a legal defeneo after
public outcry following the ruling in 1974 that serial rapist Billy Milliqan
was
insane due to lack of an integrated personality (S a v Mili an, 1978) ince
that time. cases have had a variety of Outcomes, ranging from the judamont
that multiple personalities do not preclude criminal responsibility (S a
Darnall, 1980) to the ruling that alter personalities are not an excuse for inabilt
to distinguish right from wrong (S a VJn s, 1998). The courts threw out t
two
more recent cases in Washington State (S a v Gr n, 1998) and West
Virginia (S a vL ck ar, 2000) on the grounds that lack of scientific evidence
and/or adequate reliability standards do not exist in the diagnosis of the
disorder (Farrell, 2010). The key issue for forensic psychologists and
psychiatrists is determining the difference between malingering and the actual
disorder (Farrell, 2011).
There are tools now available for expert clinicians to use in aiding accurate
diagnosis. The Structured Clinical Interview for DSM-IV Dissociative Disorders-
Revised (SCID-D-R) (Steinberg. 1994: see Table 9.1), which the profession has
rigorously standardized, includes a careful structuring. presentation, and scoring
of questions. The professionals who developed and conducted research on this
instrument emphasize that only experienced clinicians and evaluators who
understand dissociative diagnosis and treatment issues must administer and
score these.
disorder to be
The DSM-5 considers the diagnosis of dissociative identity
is not admissible
valid. The precedents created by rulings that the diagnosis
thus be overturned.
due to failure to meet scientific standards may, over time,
to
Nevertheless, the diagnosis is, at best, challenging. and potentially easy
if a clinician inadvertently plants the idea of using the diagnosis
feign. particularly
as a defense.

Should dissociative identity disorder be considered admissa-

Q: not?
ble in criminal cases? Why or why

the
In true cases of dissociative disorder, when the symptoms do not appear e al

current consensus is that these individuals were subjected to emotional or p

demonstrated that people with disso
trauma. One large psychiatric outpatient study sexual abuse in n d i
symptoms had high prevalence
rates of both physical and
However, many people witno
(Foote, Smolin, Kaplan, Legatt, & Lipschitz, 2006).
2005)
-

(Kihlstrom,
think of traumatic events from their early lives
sociative disorder can
 9.1 Oiesociative Disorders 221

TABLE 9.1 Items from the SCID-D-R

Scale
Items
Have you ever telt as it
Amnesia

there were
memory? large gaps in your

Depersonalization Have you ever felt that

from a point outside of you were watching yourself
your body, as if
seeing yourselt from you were
a distance (or
of yourself)7 watching a novie
Have you ever felt as if a
whole being part of your body or
was
foreign to your
Have you ever felt
you?
as if you were
two
people, one going through the motions different
of life and
other part observing quietly? the

Derealization Have you ever felt if

as familiar
surroundings or
people you knew seemed unfamiliar or unreal?
Have you ever felt
puzzled
what's unreal in your
as to what is real
and
surroundings?
Have you ever felt as if
people were fading away? surroundings or other
your

ldentity confusion Have you ever felt as if there

on inside of you?
was a
struggle going
Have you ever felt confused as to who
you are?
ldentity alteration Have you ever acted as if you
different person?
were a
completely
Have you ever been told by others that you seem like
a different person?
Have you ever found things in your possession Cfor
instance, shoes) that belong to you, but you could
not remember how you got them?

SOURCE: Steinberg. 1994

ilong similar lines, traumatic experiences in childhood can lead to other types of disor-
ders so why would some individuals exposed to trauma develop a dissociative disorder,
but others do not?
reacting to trauma with dissocia-
ASSuming that people with dissociative disorders are
e
ve symptoms, the treatment goal becomes primarily to integrate the disparate parts

MINI CASE
Eersonalization/Derealization Disorder
forces: "I look at my hands
in a state of
machine controlled by outside
Rocert entered the psychiatrist's office the and feet and wonder what
makes them move." However,
extreme He described delusions. He is aware that his
agitation, almost panic. Robert's thoughts are not
which began
temi
ying nature of his "nervous attacks," altered perceptions
are not normal. The only relief he
se ere years ago, but had now reached catastrophic from symptoms
nis comes when he strikes
Dr "attacks," Robert
feels as experiences
heavy object until the pain finally penetrates
ions. During these watching
himself with a
harming himself
air, above his body,
gh he is floating in the his consciousness.
is
ear of seriously mind
disconnected from orry that he
islosing his
every he does, but feeling totally adds to his
main

hi g S . He reports that he feels as if his body is

a
within the person's consciousness of self, memory, and time. Clinicians mau s...
therapy to help clients recall the traumatic experiences that seem to have se hypno-
dissociation. Gradually, through post-hypnotic suggestion, clients caused the
may be able to
those experiences back into conscious awareness. Alternatively, clinicians can bring
se cogni
tive-behavioral techniques to help clients develop a coherent sense of themselves and +
experiences. Clients who are dissociating traumatic experiences may be able their
le toto benef.
benefit
from questioning their long-held core assumptions about themselves that are contribu
to their symptoms. For example, they may believe they are responsible for their abuseting
that
or that it is wrong for them to show anger toward their abusers, or that they cantc
ope
with their painful memories.
Treatment of dissociative disorders often involves not only these disorders them. m-
selves, but also associated disorders of mood, anxiety, and post-traumatic stress.
 CHAR
Rose Marston
Case Report:
escalated to
ic
Demographic
information: B7-year-old Cau- the past year they had
stomach was
the point where her
casian female pain. She
and severe
referred for causing her constant
problem: Rose was a
multitude of rernedies. all
senting
by her physician, reported having tried a

chological
evaluat
of them unsuccessful.
who b e c a m e
concerned that she
DoStewart, she felt
suffer from symptoms of a During the evaluation, Rose stated that
beer
have her
may
disorder. For the past year, Rose "devastated" about how her worry concerning
but
psychological
Stewart had interfered with her life
appointments with Dr. as physical symptoms
made weekly health
made we

practitioners due to her con that she felt she had to focus on finding diagno-
a
well as other
Rose's boyfriend
she was suffering from a severe physi- sis. In addition to losing her job,
that
cem

Dr. Stewart was unable

of two years had recently ended their relationship
cal condition. However, herself fromn
disease or syndrome that and she admitted she had distanced
detect any actual
him since the c o n c e r n s about her physical symp-
to
have caused
Rose's frequent stomach pains
her
She found, in addition, that
may

complained of having. During

the evaluation, toms began.
she concen about her physical symptoms overshad
she was dissatisfied with
Rose reported
insistence that she was not suffer
owed any thoughts about her relationship.
Dr. Stewart's
asked
condition, and she consulted The clinician conducting the evaluation
ing from a physical in
with alternative health
care practitioners such ass Rose to describe any recent major stressors

homeopathic physicians and even a Reiki

master.
She admitted she had been hoping
that one of
the practitioners would discover she suffered
from a diagnosable medical condition, and many
had even suggested she receive a psychological
evaluation, which she refused. She finally agreed
to Dr. Stewart's recommendation after much
persistence from him.
Rose reported she had recently lost her job after
calling in sick nearly every day over the past three
months. She stated she felt it was more important
to spend her time consulting health care practitio-
ners and she also preferred not to leave her house
Tor fear of exacerbating her symptoms. Rosee
stated she was distressed about the amount of
her life, and she reported she had lost her favorite
uncle to c a n c e r in the previous year. When
describing this loss, Rose immediately became
tearful and admitted she felt she had n e v e r
mourned her uncle and instead pushed away her
feelingsabout his death most of the timne.
clinician contacted
Following the evaluation, the
Dr. Stewart to consult about her case, which
Rose had consented to by signing a release of
information. Dr. Stewart told the clinician he
believed Rose's physical symptoms seemed too
be indicative of a late onset lactose intolerance.
but that she had refused to accept this diagnosis.
Her symptoms may have worsened as a result of
a failure for her to get the proper
treatment.

time she had spent worrying about her stomach Dr. Stewart also remarked that Rose seemed to

pain, but she also was overwhelmed by feelings of have been acting very differently since the death
guit if she did not direct her activities toward of her uncle.
tying to determine the cause of her physical Relevant history: Rose had previously seen

ymptoms. Rose described that her symptoms a psychiatrist for depression in her late twenties.
Onginated as mild stomach irritation. and that over
 Somatic

and
D i s s o c i a t l v e

Chapter9
216

Case eport contin

trom criteia for symptoms of this disorder. The

began after Rose graduated
her symptoms is severe and persistent Kiety about
ne depression

it varied in severity
until she
endured an

than sixm months), and she has devoted an

(lastinc longer
and suicide. She
college,
intense she had contemplated excessive
e amount of time
x c e s s i v e amount time and e
energy
ne to he
obje ctively
episode s o that had
had received a course of antidepressants
Rose had symptoms. The onset of Rose's symptoms hysical
evaluation,
originates from the distress caused by the death bly
time of the
been effective. At the
medications for approxi- of er
not been on any psychiatric uncle. due to her report that she engaged in her
mately five years because
she had felt the previous
for of processing her reaction. voidance
cOurse of medicationhad been effective enough
Treatment plan: Following the evaluation and
her to discontinue.
tation with Dr. Stewart. the clinician referred
onsul
Case formulation: Rose meets criteria for
somatic Rose to a
moderate to severe, with predomi
therapist specializing in cognitive-behavioral treatme
symptom disorder,
for somatic disorders. In this evidence-based
nant pain. This diagnosis is based
her heightened on
Rose's therapist should focus on
approach
evaluating her exces.
to her physical
anxiety, which is excessive, in response
has been signiti- sive concens about her physical condition with coan
symptoms, to the point where her life
tive restucturing and also behavioral strategies to
gn
romantic
cantly disrupted (i.e., loss of her job and her
increase her engagement with recommendations from
relationship). Her concerns about her symptoms are Dr. Stewart to improve her physical symptoms.
both persistent and disproportionate to the actual sever
ity physical symptoms, and her refusal to accept
of her a
Sarah Tobin, PhD
relatively mild diagnosis of lactose intolerance meets