Dissociative Disorder

Overview of Dissociative Disorder:

People with dissociative disorders use dissociation, a defense mechanism, pathologically also involuntarily.

In detail; Dissociative disorders are thought to primarily be caused by psychological trauma.

Epidemiology of Dissociative disorder

Indian Epidemiology

Studies on the epidemiology of dissociative disorders in India have shown varying prevalence rates, highlighting the need for further research in this area.

• Chandra et al. (2009): "Dissociative disorders are still commonly diagnosed in both inpatient and outpatient settings." The proportion of patients diagnosed with dissociative disorders ranged between 1.5 and 15.0 per 1,000 for outpatients and between 1.5 and 11.6 per 1,000 for inpatients. Dissociative motor disorders and dissociative convulsions were the most common subtypes. [6]

• Mascarenhas et al. (2019): The frequency of dissociative disorders was found to be 17/796 (2.13%) in 1999, 13/645 (2.01%) in 2009, and 10/1117 (0.9%) in 2018 among inpatients admitted to psychiatric wards. Dissociative disorders were more frequent among females, individuals under 25 years old, those with primary education, married individuals, and those residing in rural areas and of Hindu faith. [7]

These studies suggest that dissociative disorders are not uncommon in India, although their prevalence may vary across settings and populations. It’s important to note that these studies may not be entirely representative of the overall Indian population due to methodological limitations and potential biases.

Further Research

More research is needed to better understand the epidemiology of dissociative disorders in India. This includes studies with larger sample sizes, representative populations, and standardized diagnostic criteria. Additionally, research should explore potential risk factors, cultural influences, and effective treatment approaches for dissociative disorders in the Indian context.

• Dissociative disorders usually develop as a way to cope with trauma.
• The disorders most often form in children subjected to long-term physical, sexual or emotional abuse or, less often, a home environment that’s frightening or highly unpredictable.
• The stress of war or natural disasters also can bring on dissociative disorders.
• Personal identity is still forming during childhood.
• So a child is more able than an adult is to step outside of himself or herself and observe trauma as though it’s happening to a different person.
• A child who learns to dissociate in order to endure an extended period of youth may use this coping mechanism in response to stressful situations throughout life.

Types

The three types of dissociative disorders include:

• Dissociative identity disorder (DID): People with DID have two or more separate identities. These identities (called “alters”) control their behavior at various times. Each alter has its own personal history, traits, likes and dislikes.
• Dissociative amnesia: This condition happens when you can’t remember essential information about your life. The forgetting may be limited to specific aspects of your life or may include much of your life history and/or identity.
• Depersonalization/derealization disorder: This is a condition in which you feel detached from your thoughts, feelings and body (depersonalization), and/or disconnected from your environment (derealization). (2)

• People who experience long-term physical, sexual or emotional abuse during childhood are at greatest risk of developing dissociative disorders.
• In detail, Children and adults who experience other traumatic events, such as war, natural disasters, kidnapping, torture or invasive medical procedures, also may develop these conditions.

Dissociative amnesia:

• n general, The main symptom of this disorder is memory loss that’s more severe than normal forgetfulness and that can’t explained by a medical condition.
• You can’t recall information about yourself or events and people in your life, especially from a traumatic time.
• Besides this, Dissociative amnesia can specific to events in a certain time, such as intense combat, or more rarely, can involve complete loss of memory about yourself.
• Lastly, It may sometimes involve travel or confused wandering away from your life (i.e. dissociative fugue). An episode of amnesia may last minutes, hours, or, rarely, months or years.

Dissociative identity disorder:

• This disorder, formerly known as multiple personality disorder, is characterize by "switching" to alternate identities.
• You may feel the presence of one or more other people talking or living inside your head, also you may feel as though you’re possessed by other identities.
• Each of these identities may have a unique name, personal history and characteristics, including obvious differences in voice, gender, mannerisms and even such physical qualities as the need for eyeglasses. Additionally, There also are differences in how familiar each identity is with the others.
• All in all, People with dissociative identity disorder typically also have dissociative amnesia and often have dissociative fugue.

Depersonalization-derealization disorder:

• This disorder involves an ongoing or episodic sense of detachment or being outside yourself — observing your actions, feelings, thoughts and self from a distance as though watching a movie (i.e. depersonalization).
• Other people and things around you may feel detach and foggy or dreamlike, and the world may seem unreal (i.e. derealization).
• You may experience depersonalization, derealization or both.
• Lastly, Symptoms, which can be profoundly distressing, may last only a few moments or come and go over many years.

Pathogenesis of Dissociative Disorder

• Trauma: The most significant risk factor for dissociative disorders is a history of childhood trauma, particularly severe and chronic abuse (physical, sexual, or emotional). Trauma overwhelms the child’s capacity to cope, leading to dissociation as a defense mechanism to escape the overwhelming emotional pain and distress.

• Neurobiological Factors: Trauma can disrupt the development of neural pathways involved in memory, emotion regulation, and identity integration. This can lead to alterations in brain structure and function, particularly in areas like the hippocampus, amygdala, and prefrontal cortex.

• Psychological Factors: Dissociation serves as a way to cope with unbearable experiences by creating a psychological distance from the traumatic events. This can lead to the development of distinct identities or personality states to compartmentalize the trauma.

• Environmental Factors: In addition to trauma, other environmental factors like insecure attachment, neglect, and an invalidating family environment can contribute to the development of dissociative disorders. [8]

Pathophysiology 

• Dissociation is a psychophysiological process that alters a person’s thoughts, feelings, or actions so that, for a time, certain information is not associated with other information as it normally is.
• This process produces a range of clinical and behavioral phenomena involving alterations in memory and identity. D.I.D is caused by infant disorganized attachment in the orbitofrontal cortex.
• Because of the childhood trauma, the limbic system is also highly affected, this controls our emotions and personality along with frontal lobe. (1)

Clinical Features of Dissociative disorder

• Identity: Individuals with dissociative disorders may experience a fragmented sense of self, feeling detached from their thoughts, feelings, and actions. They may have multiple distinct personality states (as in dissociative identity disorder) or a sense of being an outside observer of their own life.

• Memory: Dissociative amnesia is a hallmark of dissociative disorders, where individuals have gaps in their memory for personal information, traumatic events, or everyday experiences. These memory gaps can be localized (specific to a particular time period) or generalized (affecting the entire life history).

• Consciousness: Depersonalization and derealization are common experiences in dissociative disorders. Depersonalization involves feeling detached from one’s body or mental processes, while derealization is a sense of unreality or detachment from the external world.

• Emotional and Behavioral Symptoms: Individuals with dissociative disorders may exhibit a range of emotional and behavioral symptoms, including depression, anxiety, flashbacks, self-harm, suicidal ideation, and difficulties in interpersonal relationships. [8]

Signs and symptoms of dissociative disorders i.e.:

• Memory loss (in other words; amnesia) of certain time periods, events and people
• Mental health problems, e.g. depression, anxiety, and suicidal thoughts and attempts
• Furthermore; A sense of being detached from yourself
• A perception of the people also things around you as distorted and unreal
• A blurred sense of identity
• Lastly; Significant stress or problems in your relationships, work or other important areas of your life

Clinical Examination of Dissociative Disorder

• Psychiatric History: A detailed psychiatric history is essential, focusing on the onset, duration, and nature of dissociative symptoms. The clinician should inquire about traumatic experiences, history of abuse or neglect, and any coexisting mental health conditions.

• Mental Status Examination: The mental status examination assesses the individual’s current mental state, including appearance, behavior, mood, affect, thought process, thought content, perception, cognition, and insight. Specific attention should be paid to signs of dissociation, such as changes in identity, memory gaps, depersonalization, or derealization.

• Structured Clinical Interviews: Standardized clinical interviews, such as the Structured Clinical Interview for DSM-5 Dissociative Disorders (SCID-D), can aid in the diagnosis of dissociative disorders. These interviews systematically assess the presence and severity of dissociative symptoms.

• Psychological Testing: Psychological tests, such as the Dissociative Experiences Scale (DES), can provide additional information about the severity and nature of dissociative symptoms. These tests may also help differentiate dissociative disorders from other psychiatric conditions.

• Medical Evaluation: A medical evaluation is necessary to rule out any underlying medical conditions that may mimic or contribute to dissociative symptoms. This may include neurological examinations, neuroimaging, and laboratory tests.

• Collateral Information: Gathering information from family members, friends, or other relevant individuals can provide valuable insights into the individual’s history and current functioning. [9]

Diagnosis of Dissociative Disorder

Healthcare providers diagnose dissociative disorders by assessing your symptoms and personal history.

Your provider may order tests to rule out possible medical conditions that can cause similar symptoms (such as memory loss), including:

• Head injury.
• Brain tumors.
• Sleep deprivation.
• Substance and/or alcohol use.

Once they rule out possible causes, they’ll likely refer you to a mental health specialist, such as a psychologist, to make a diagnosis through clinical interview and observations.

Mental health professionals use criteria in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders to diagnose specific dissociative disorders.(2)

Differential diagnosis of Dissociative Disorder

• Unreasonable schizophrenia
• Borderline personality disorder
• Hysteria
• Stimulation and false memory syndrome (3)

Complications

• People with a dissociative disorder are at increased risk of complications and associated disorders, such as:
• Self-harm
• Suicidal thoughts and attempts
• Sexual dysfunction, including sexual compulsions or avoidance
• Alcoholism and drug use disorders
• Depression and anxiety disorders
• Post-traumatic stress disorder
• Personality disorders

Other complications

• Sleep disorders, including nightmares, insomnia and sleepwalking
• Eating disorders
• Severe headaches

Investigations for Dissociative disorder

• Physical Examination and Neurological Assessment: A thorough physical examination and neurological assessment can help identify any underlying medical conditions that may be causing or exacerbating dissociative symptoms. This may include tests of reflexes, cranial nerves, motor and sensory function, and coordination.

• Neuroimaging: Neuroimaging techniques, such as MRI or CT scans, may be used to rule out structural brain abnormalities or lesions that could explain neurological symptoms. However, these scans are not typically helpful in diagnosing dissociative disorders themselves.

• Electroencephalogram (EEG): An EEG measures electrical activity in the brain and can be used to identify any abnormal brainwave patterns that may be associated with certain neurological conditions. While not specific to dissociative disorders, an EEG can help rule out other potential causes of symptoms.

• Laboratory Tests: Blood tests may be ordered to rule out metabolic or endocrine disorders, vitamin deficiencies, or infections that could contribute to dissociative symptoms. These tests may include complete blood count, thyroid function tests, and tests for vitamin B12 deficiency.

• Toxicology Screening: Toxicology screening may be performed to rule out the presence of drugs or alcohol that could be causing or exacerbating dissociative symptoms. [9]

Treatment of Dissociative Disorder

Dissociative disorders are managed through various therapies including:

• Psychotherapies such as cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT)
• Talk Therapy
• Eye movement desensitization and reprocessing (EMDR)
• Medications such as antidepressants, antipsychotics and mood stabilizers can treat symptoms of related conditions.

Prevention of Dissociative Disorder

• Due to the fact that the cause of Dissociative Disorder in most patients with the condition is related to the patient’s exposure to a traumatic event, the prevention of this condition lies in minimizing the exposure that children have to trauma, especially in the form of physical and sexual abuse and helping the trauma survivor to deal with their past in a healthy and beneficial way.(4)

Homeopathic Treatment of Dissociative Disorder

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis. 

Which includes 

• The medical history of the patient, 
• Physical and mental constitution, 
• Family history, 
• Presenting symptoms, 
• Underlying pathology, 
• Possible causative factors etc. 

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions. 

What Homoeopathic doctors do? 

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’? 

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition. 

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines. 

Homeopathic Medicines for Dissociative Disorder 

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor. 

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).  

Medicines:

• Anacardium:
• Medorrhinum
• Natrum muriaticum
• Phosphorus
• Staphysagria
• Thuja

Diet & Regimen of Dissociative Disorder

Five food groups: fruit, vegetables, grains, dairy, and protein. The key recommendations in the federal guidelines include

•  A variety of vegetables from all of the subgroups—dark green, red, and orange, legumes (beans and peas), starchy, and other
• Fruits, especially whole fruits
• Grains, at least half of which are whole grains
• Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages
• A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products.
• Oils
• Limited saturated fats, trans fats, added sugars, and sodium. (5)

Do’s:

1. Be Patient and Understanding: Individuals with dissociative disorders may experience fluctuations in their memory, identity, and emotions. Be patient and understanding of their experiences, even if they seem confusing or illogical.

2. Validate Their Feelings: Acknowledge and validate their feelings, even if you don’t fully understand them. Let them know that their experiences are real and that you believe them.

3. Offer Support and Encouragement: Let them know that you are there to support them and encourage them to seek professional help if needed. Offer to accompany them to appointments or help them find resources.

4. Maintain a Calm and Supportive Environment: Create a safe and supportive environment where they feel comfortable expressing their feelings and experiences without judgment or criticism.

5. Educate Yourself: Learn about dissociative disorders to better understand what they are going through. This can help you communicate more effectively and offer more meaningful support.

Don’ts:

1. Don’t Minimize or Dismiss Their Experiences: Avoid saying things like "It’s all in your head" or "Just snap out of it." These comments can be invalidating and hurtful.

2. Don’t Pressure Them to Remember: Don’t push them to remember traumatic events or details they may have forgotten. This can be overwhelming and retraumatizing.

3. Don’t Blame or Shame Them: Avoid blaming or shaming them for their symptoms or experiences. Dissociative disorders are not their fault, and they deserve compassion and understanding.

4. Don’t Try to "Fix" Them: Don’t try to diagnose or treat them yourself. Encourage them to seek professional help from a qualified mental health provider.

5. Don’t Give Up: Supporting someone with a dissociative disorder can be challenging, but it’s important not to give up on them. Your support can make a significant difference in their journey toward healing and recovery.

Terminologies and Their Meanings

• Dissociation: The core mechanism in dissociative disorders, where a person’s thoughts, feelings, memories, or sense of self become disconnected. It’s a defense mechanism to cope with overwhelming trauma.
• Dissociative Disorders: A group of mental health conditions characterized by persistent or recurrent episodes of dissociation.
• Dissociative Amnesia: Inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
• Dissociative Identity Disorder (DID): Formerly known as Multiple Personality Disorder, it involves the presence of two or more distinct personality states that recurrently take control of behavior.
• Depersonalization/Derealization Disorder: Persistent or recurrent experiences of feeling detached from one’s body or mental processes (depersonalization) or feeling that surroundings are unreal or detached (derealization).
• Alters: The distinct personality states present in DID, each with its own pattern of perceiving, relating to, and thinking about the environment and self.
• Fugue: A rare type of dissociative amnesia involving sudden, unexpected travel away from home or one’s customary place of work, with inability to recall one’s past.
• Pathogenesis: The origin and development of a disease or disorder. In the context of dissociative disorders, it refers to the factors (trauma, neurobiology, psychology, environment) that contribute to their onset.
• Pathophysiology: The functional changes associated with or resulting from a disease or injury. In dissociative disorders, this may refer to changes in brain structure or function due to trauma.
• Epidemiology: The study of the distribution and determinants of health-related states or events in specified populations.
• Prevalence: The proportion of a population found to have a condition at a specific time.
• Differential Diagnosis: The process of differentiating between two or more conditions that share similar signs or symptoms.

Reference of Dissociative Disorder

1. Pathophysiology – Dissociative Identity Disorder (weebly.com)
2. Dissociative Disorders: Causes, Symptoms, Types & Treatment (clevelandclinic.org)
3. differntial diagnosis of dissociative Disorders – Search (bing.com)
4. Treatment, prognosis and prevention of dissociative identity disorder (mymed.com)
5. Dissociated Diet: Pros, Cons, and How It Works (verywellfit.com)

6. Chandra et al. (2009): Dissociative disorders in a psychiatric institute in India–a selected review and patterns over a decade. Int J Soc Psychiatry. 2010 Sep;56(5):533-9. doi: 10.1177/0020764009347335. Epub 2009 Sep 17.

7. Mascarenhas et al. (2019): Clinical Patterns of Dissociative Disorder in In-Patients from Dakshina Kannada District across Two Decades. International Journal of Health Sciences & Research (www.ijhsr.org) Vol.9; Issue: 8; August 2019.

8. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association in 2013
9. Kaplan & Sadock’s Synopsis of Psychiatry, 12th Edition (2022), by Benjamin J. Sadock, Virginia A. Sadock, and Pedro Ruiz

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