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mental health mondays :: doubt and dissociation

a friend of mine posted a link last week about the controversies surrounding dissociative disorders and how they are treated. i've posted in mhm before about the phenomenon of dissociative identity disorder, or multiple personality disorder, but there are actually a number of different types of dissociative disorder. multiple personalities is just the most extreme and the rarest of them. there are other forms of dissociation, which basically means a break with reality of some sort. some are extremely mild [and not considered signs of a disorder] and others are more serious. one thing that they share is that they are controversial and the more serious the dissociative episodes, the more controversial they become.

one of the reasons for the controversy is that they are difficult to prove. most dissociative conditions aren't a full-time thing. the symptoms can wax and wane, there is no true diagnostic test [although that's true for most mental disorders] and there is always great speculation that people are faking or imagining the condition, especially when it comes to offering a legal defense. many dramatisations have portrayed characters who mimic the symptoms of dissociative disorder in order to escape criminal charges. [face lift, an early episode of csi and the film primal fear are the first examples that spring to mind.] this may create the impression that the defense is raised fairly frequently in order to obtain a not guilty verdict, but in fact, it is attempted in less than 0.1% of felony cases and is successful in only a small fraction of those. [nor does that mean that the symptoms were false. courts have often ruled that the presence of multiple identities is immaterial to criminal guilt.]

in fact, a huge majority of people will experience some sort of dissociative episode in their lives. have you ever realised that you had no memory of several minutes of your life? or had a moment where you felt disconnected from your body? or even a sense of déjà vu? those are all very minor, fleeting forms of dissociation. they're certainly not enough to qualify as a disorder, but it might help you understand the situation of someone who suffers from a full-on condition.

dissociative disorders take several forms: amnesia is a fairly well-known one [although not all amnesia is dissociative- it can be caused by damage to the brain]. there is also the dissociative fugue, which is a temporary "switch" that often results in a person abandoning their home, job and sometimes even their identity for a certain period of time, particularly when they are under acute stress. [mystery writer agatha christie is thought to have experienced and eleven-day dissociative fugue in 1926.] there is also the possibility of depersonalisation/ derealisation, where a person can have an "out of body experience" or feel as if they are constantly dreaming, that nothing around them [or inside them] is real. these states can be transitory, or they can last for years and there isn't a lot of agreement on how they can be treated. therapy is seen as an absolute necessity, but then there is the question of what kind of therapy.

the most common theory on dissociative disorders is that they are linked to trauma [which means that they could be considered an effect of ptsd]. one of the most common examples is that people who are involved in car accidents will often have no recollection of the events immediately preceding and following the event. however, not all trauma will cause dissociation. holocaust survivors remember what happened to them very well. that may indicate that dissociation is more likely in reaction to shock, as opposed to sustained horror, especially in adults.

dissociative disorders are most often the result of early childhood trauma, such as abuse. unlike adults, children cannot understand or cope with what is happening to them [having little or no sense of the world outside their home] and, on a subconscious level, the brain "chooses" to distance itself from what is happening. this results in persistent problems later in life, since it is often not possible to shut this reaction off. dissociative disorders related to early childhood are extraordinarily difficult to treat, because they are usually deeply ingrained by the time they are identified and also because they are the most controversial.

starting in the early 1980s, a wave of stories spread through the american media [and eventually beyond] about children having been subject to horrific physical and sexual abuse. these memories were uncovered through hypnosis when adult patients sought help for a variety of different conditions. none of the people who reported abuse had been consciously aware of it before therapy, but they all exhibited some form of anxiety disorder that couldn't be explained by their current circumstances. the idea that psychologists could retrieve lost or blocked memories in great detail was a revelation. there was only one problem: it was hogwash. these "memories" of violence turned out to be false, an idea planted by the process of therapy itself and then retroactively believed by the patient. [i should note that the theory of recovered memory dates back to freud, it was just in the eighties that it became widely known and a sort of pop culture topic.]

there is no scientific evidence to back the theory of recovered memories. while some children do block instances of abuse, they continue mostly to be aware of what happened, it's just that they're memories aren't clear or continuous. usually, memories will present as snippets, but out of context, associated more with emotions than a connected series of events. nonetheless, the phenomenon of recovered memory made for grisly, prurient news and it was widely covered. as it was debunked, it unfortunately took the reputation of all dissociative disorders with it. since this particular method of addressing dissociation has been discredited, people assume that the whole category of disorders has been discredited as well.

the fact is that the human brain is so complex that we may never understand what causes dissociation and why certain people are affected while others aren't. in the meantime, we fumble to find treatments that help and not to make anymore egregious mistakes along the way.

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