Dissociative Symptoms

Researchers have routinely identified several different dissociative symptoms; some of these symptoms are required criteria for diagnosis in the DSM psychiatric manual, but many are common in Dissociative Disorders, but not described with the diagnostic criteria. ^[1]

Dissociative identity disorder

The individual as a whole is subject to the following symptoms: Amnesia, which is experienced differently in the different disorders. Dissociative identity disorder is the only disorder where "true amnesia" exists. True amnesia is a loss of time between two distinct states, and dissociative identity disorder is the only disorder that has two or more distinct states. Amnesia between a distinct state and a less than distinct state is dissociative amnesia, and that is also experienced in dissociative identity disorder. Other symptoms include voices heard, self alteration, derealization, depersonalization, flashbacks, trance, identity confusionDefined as "a feeling of uncertainty, puzzlement, or conflict about one's own identity. "{{Rp|13}}. The structured clinical interview for the dissociative disorders and other diagnostic tools assess identity confusion. {{See also| Identity confusion}} {{See also| Diagnosis}}, and awareness of other states. They also experience the Schneiderian first-rank symptoms that include voices arguing, voices commenting, thought withdrawal, thought insertion, made impulsesThese impulses for action are imposed on the person and do not feel like they belong to the person, who feels like the impulses are "coming from somewhere else or someone else". In dissociative disorders this can some other part is trying to overrule the host/apparently normal part of the personality. A Schnieder first-rank symptom often present in schizophrenia but common in DID.{{Rp|231}}In schizophrenia or psychosis the impulses may be given a delusional explanation, for example naming a person or object who the impulses appear the be coming from., made feelings'Made' or intrusive feelings and emotions are unexpected surges of feeling-pain, hurt, anger, fear, shame, and so on. Often these surges of feeling are inexplicable and frankly puzzling". A Schnieder first-rank symptom often present in schizophrenia. These tend to be partially dissociated intrusions from another self-state, fairly common in "PTSD, borderline personality disorder, bipolar disorder, panic disorder and ADHD."{{Rp|231}} and made actions. Finally these individuals will struggle with auditory hallucinations and visual hallucinations, which are not psychotic, but the symptoms imitate psychotic symptoms. ^[2]:228-234

Other specified dissociative disorder

In other specified dissociative disorder the amnesia is between the one distinct state and the less than distinct states it directly switches with. This is "dissociative amnesia." Other symptoms include voices heard, self alteration, derealization, depersonalization, flashbacks, trance, identity confusion, and awareness of other states. They also experience the Schneiderian first-rank symptoms that include voices arguing, voices commenting, thought withdrawal, thought insertion, made impulses, made feelings and made actions. These individuals will also have auditory hallucinations and visual hallucinations which are not psychotic, but the symptoms imitate psychotic symptoms. ^[2]:228-234

DepersonalizationA sense of detachment from the self. Depersonalization disorder includes derealization, since the two often co-occur. {{See also| Depersonalization disorder}} / DerealizationDepersonalization disorder includes derealization, since the two often co-occur. disorder

The dissociative symptoms these individuals experience are highly generalized feelings of depersonalization and derealization, accompanied by dissociative amnesia and somatic pain. ^[1]

Dissociative amnesia

Amnesia caused by dissociation between a distinct state and a less than distinct state is the primary symptom of this disorder, but somatic pain can be involved. ^[1]

Definition of dissociation by Ellert Nijenhuis

Dissociation in trauma entails a division of an individual’s personality, i.e., of the dynamic, biopsychosocial system as a whole that determines his or her characteristic mental and behavioral actions. This division of personality constitutes a core feature of trauma. It evolves when the individual lacks the capacity to integrate adverse experiences in part or in full, can support adaptation in this context, but commonly also implies adaptive limitations. The division involves two or more insufficiently integrated dynamic, that is changeable, but excessively rigid subsystems. These subsystems exert functions, and can encompass any number of different dynamic configurations of brain, body, and environment. These different configurations manifest as dynamic actions and implied dynamic states. The dissociative subsystems can be latent, or activated in a sequence or in parallel. Each dissociative subsystem, i.e., dissociative part of the personality includes its own, at least rudimentary person perspectives, that is, its own epistemic pluralism and epistemic dependency. As each dissociative part, the individual can interact with other dissociative parts and other individuals, at least in principle. Dissociative parts maintain permeable biopsychosocial boundaries that keep them divided, but that they can in principle dissolve. Phenomenologically, this division of the personality manifest in dissociative symptoms that can be categorized as negative or positive, and cognitive-emotional or sensorimotor. ^[3]

Psychotic-like symptoms

While they are not the primary symptoms, psychotic-like symptoms are common in dissociative disorders. ^[1]

Schneiderian first-rank symptoms

These symptoms have been historically used to help describe and diagnosis schizophrenia, but they are not the sole diagnostic criteria for it. These are experienced as "autonomous intrusions into a person’s executive functioning and sense of self." ^[1]:8 The presence of these symptoms alone should not be used to diagnose a Dissociative Disorder, since they do not form the diagnostic criteria, and some may present due to other diagnoses.

Only 8 of the 11 Schneiderian first-rank symptoms occur in dissociative identity disorder. Those that do occur in dissociative identity disorder are listed below.

'Made' actions'Made' or intrusive actions are also called 'made volitional acts'; a person's actions are "from and are controlled by an external agent; the person is a passive participant in the action". {{Rp|1434}} A Schnieder first-rank symptom often present in schizophrenia, but common in DID.In dissociative identity disorder the behavior does not feel like it belongs to the person, they make be unaware of the actions or may "see" another part take control of the body. In dissociative identity disorder there are three types of experience of made actions:
1. Depersonalized stance - inside or outside of the body just passively watching or observing your actions
2. feeling as if you are being suddenly being "overpowered, taken over, controlled, or even possessed"
3. observing a part of your body which suddenly seems to have a mind of its own, and performs an unintended action.{{Rp|230}}

Common in DID. The person may be unaware of the actions or may "see" another part take control of the body (co-consciousness).

1. depersonalized stance - inside or outside of the body just passively watching or observing your actions
2. feeling as if you are being suddenly being "overpowered, taken over, controlled, or even possessed"
3. observing a part of your body which suddenly seems to have a mind of its own, and performs an unintended action.

Voices arguing or conversing

Also known as an internal dialogue or internal struggle. Referring to dissociative identity disorder, Dell et al. (2009)^:230 writes that "these form the person's awareness that different parts of the mind are autonomously conversing or competing for control: hearing two or more voices that discuss or ague about what should be done, feelings a force or an other that tries to take control or change what the person does; feeling or hearing an angry other that tries to control one, etc.".

Voices commenting

Dell (2009) states "Dissociative individuals almost always hear the voice of a child", and often have a visual image of the child that they are hearing, this can be a frank visual hallucination or an imaginative picture. Child voices may be happy, sad, crying or angry and can be commenting, arguing or simply crying.

'Made' feelings

These feelings are often puzzling and not understood by the person; they tend to be partially-dissociated intrusions from another self-state (alter personality). Angry intrusions are particularly common in DID, and are a sign of pathological (non-normative) dissociation; angry intrusions involve either sudden, unexpected surges of anger and/or partially dissociated seizures of executive controlThe state that has control of an individual at that moment has executive control, and the dissociated state most often in executive control is commonly called the host. {{Rp|27}} where a person is consciously aware of "being invaded and/or taken over by an autonomous other"

Thought withdrawal

Thought withdrawal can take different forms, including your mind suddenly going 'blank'; as a thought seems to disappear. In dissociative identity disorder this would be puzzling and unexplained, rather than given a delusion explanation.

Thought insertionThe person believes that thoughts that are not his/her own thoughts have been inserted into his/her mind. {{Rp|45}}This is a symptom of schizophrenia, but either thought withdrawal and thought insertion are also very common in people with Dissociative Identity Disorder. {{Rp|527}}

This is also known as 'Thoughts ascribed to others'. These can be strong thoughts which seem to come out of nowhere, e.g., the intrusive thoughts common in posttraumatic stress disorder (PTSD) are partially dissociated, and are often distressing. ^[2]

'Made' impulsesThese impulses for action are imposed on the person and do not feel like they belong to the person, who feels like the impulses are "coming from somewhere else or someone else". In dissociative disorders this can some other part is trying to overrule the host/apparently normal part of the personality. A Schnieder first-rank symptom often present in schizophrenia but common in DID.{{Rp|231}}In schizophrenia or psychosis the impulses may be given a delusional explanation, for example naming a person or object who the impulses appear the be coming from.

The impulses are a strong desire to act in a particular way, which appear to not "belong" to the person experiencing them and may not make sense to them. ^{[1]:1 [2]:231}

First-rank symptoms not associated with Dissociative Disorders

Some Schneiderian first-rank symptoms are not associated with Dissociative Disorders. The three that do not occur in dissociative identity disorder are thought broadcasting, audible thoughtsA person's thoughts being spoken aloud. A Schniederian first-rank symptom often associated with schizophrenia.{{Rp|1434}} but not associated with DID.{{Rp|391}}, and delusional perception. ^[1] In schizophrenia, the intrusions take a psychotic form such as the person explaining them using a delusional explanation. Dell (2006) gives the example of "Marilyn Monroe is controlling my thoughts". In dissociative identity disorder, these intrusions take a non-psychotic form; they are noticed and described by the person, but without a delusional explanation. The person may describe, eg, "I know this sounds crazy, but sudden strong thoughts come into my mind and they feel like they are not mine".^[1]:8

References

1. ^ a b c d e f g h Dell, Paul F.. A New Model of Dissociative Identity Disorder. The Psychiatric Clinics of North America, volume 29, issue 1, page 1-26. (doi:10.1016/j.psc.)
2. ^ a b c d Dell, Paul F., O'Neil, John A. (Eds) (2009). Dissociation and the dissociative disorders: DSM-V and beyond. Taylor & Francis..
3. ^ Nijenhuis, Ellert. TEN REASONS FOR CONCEIVING AND CLASSIFYING POSTTRAUMATIC STRESS DISORDER AS A DISSOCIATIVE DISORDER. Psichiatria e Psicoterapia, volume 33, issue 1.