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The Spectrum of Dissociative
Disorders:
An Overview of Diagnosis and Treatment
by Joan A. Turkus, M.D.
page 2
The dissociative spectrum (Braun, 1988) extends from normal dissociation to
poly-fragmented DID. All of the disorders are trauma-based, and symptoms result
from the habitual dissociation of traumatic memories. For example, a rape
victim with Dissociative Amnesia may have no conscious memory of the attack,
yet experience depression, numbness, and distress resulting from environmental
stimuli such as colors, odors, sounds, and images that recall the traumatic
experience. The dissociated memory is alive and active--not forgotten, merely
submerged (Tasman Goldfinger, 1991). Major studies have confirmed the traumatic
origin of DID (Putnam, 1989, and Ross, 1989), which arises before the age of 12
(and often before age 5) as a result of severe physical, sexual, and/or
emotional abuse. Poly-fragmented DID (involving over 100 personality states)
may be the result of sadistic abuse by multiple perpetrators over an extended
period of time.
Although DID is a common disorder (perhaps as common as one in 100) (Ross,
1989), the combination of PTSD-DDNOS is the most frequent diagnosis in
survivors of childhood abuse. These survivors experience the flashbacks and
intrusion of trauma memories, sometimes not until years after the childhood
abuse, with dissociative experiences of distancing, "trancing out",
feeling unreal, the ability to ignore pain, and feeling as if they were looking
at the world through a fog.
The symptom profile of adults who were abuse as children includes
posttraumatic and dissociative disorders combined with depression, anxiety
syndromes, and addictions. These symptoms include (1) recurrent depression; (2)
anxiety, panic, and phobias; (3) anger and rage; (4) low self-esteem, and
feeling damaged and/or worthless; (5) shame; (6) somatic pain syndromes (7)
self-destructive thoughts and/or behavior; (8) substance abuse; (9) eating
disorders: bulimia, anorexia, and compulsive overeating; (10) relationship and
intimacy difficulties; (11) sexual dysfunction, including addictions and
avoidance; (12) time loss, memory gaps, and a sense of unreality; (13)
flashbacks, intrusive thoughts and images of trauma; (14) hypervigilance; (15)
sleep disturbances: nightmares, insomnia, and sleepwalking; and (16)
alternative states of consciousness or personalities.
Diagnosis
The diagnosis of dissociative disorders starts with an awareness of the
prevalence of childhood abuse and its relation to these clinical disorders with
their complex symptomatology. A clinical interview, whether the client is male
or female, should always include questions about significant childhood and
adult trauma. The interview should include questions related to the above list
of symptoms with a particular focus on dissociative experiences. Pertinent
questions include those related to blackouts/time loss, disremembered
behaviors, fugues, unexplained possessions, inexplicable changes in
relationships, fluctuations in skills and knowledge, fragmentary recall of life
history, spontaneous trances, enthrallment, spontaneous age regression,
out-of-body experiences, and awareness of other parts of self (Loewenstein,
1991).
Structured diagnostic interviews such as the Dissociative Experiences Scale
(DES) (Putnam, 1989), the Dissociative Disorders Interview Schedule (DDIS)
(Ross, 1989), and the Structured Clinical Interview for Dissociative Disorders
(SCID-D) (Steinberg, 1990) are now available for the assessment of dissociative
disorders. This can result in more rapid and appropriate help for survivors.
Dissociative disorders can also be diagnosed by the Diagnostic Drawing Series
(DDS) (Mills Cohen, 1993).
The diagnostic criteria for the diagnosis of DID are (1) the existence
within the person of two or more distinct personalities or personality states,
each with its own relatively enduring pattern of perceiving, relating to, and
thinking about the environment and self, (2) at least two of these personality
states recurrently take full control of the person's behavior, (3) the
inability to recall important personal information that is to extensive to be
explained by ordinary forgetfulness, and (4) the disturbance is not due to the
direct physiological effects of a substance (blackouts due to alcohol
intoxication) or a general medical condition (APA, 1994). The clinician must,
therefore, "meet" and observe the "switch process" between
at least two personalities. The dissociative personality system usually
includes a number of personality states (alter personalities) of varying ages
(many are child alters) and of both sexes.
In the past, individuals with dissociative disorders were often in the
mental health system for years before receiving an accurate diagnosis and
appropriate treatment. As clinicians become more skilled in the identification
and treatment dissociative disorders, there should no longer be such delay.
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