DISSOCIATIVE DISORDER

The dissociative disorder is a group of conditions involving disruptions in a

person’s normally integrated functions of consciousness, memory, identity, or perception.
Included here are some of the more dramatic phenomena in the entire domain of
psychopathology: people who cannot recall who they are or where they may have come
from, and people who have two or more distinct identity or personality states that
alternately take control of the individual’s behavior.

I. NATURE

The term dissociation refers to the human mind’s capacity to engage in complex
mental activity in channels split off from, or independent of, conscious awareness.
Dissociative Disorders can be acute or chronic.

II. CAUSAL FACTORS

Moderate or severe forms of dissociation are caused by such traumatic

experiences as childhood abuse, combat, criminal attacks, brainwashing in hostage
situations, or involvement in a natural or transportation disaster.
The causes of dissociative identity disorder have not been identified, but are
theoretically linked with the interaction of overwhelming stress, traumatic antecedents,
insufficient childhood nurturing, and an innate ability to dissociate memories or
experiences from consciousness.

III. SYMPTOMS

There are four major dissociative disorders:

• Dissociative amnesia
• Dissociative identity disorder
• Dissociative fugue
• Depersonalization disorder

Signs and symptoms common to all types of dissociative disorders include:

• Memory loss (amnesia) of certain time periods, events and people

• Mental health problems, including depression and anxiety
• A sense of being detached from yourself (depersonalization)
• A perception of the people and things around you as distorted and unreal
(derealization)
• A blurred sense of identity
Dissociative disorder symptoms (depending on the type of disorder) may include:

• Dissociative amnesia. Memory loss that's more extensive than normal

forgetfulness and can't be explained by a physical or neurological condition is the
main symptom of this condition. Sudden-onset amnesia following a traumatic
event, such as a car accident, is rare. More commonly, conscious recall of
traumatic periods, events or people in your life — especially from childhood — is
simply absent from your memory.
• Dissociative identity disorder. This condition, formerly known as multiple
personality disorder, is characterized by "switching" to alternate identities when
you're under stress. In dissociative identity disorder, you may feel the presence of
one or more other people talking or living inside your head. Each of these
identities may have name, personal history and characteristics, including marked
differences in manner, voice, gender and even such physical qualities as the need
for corrective eyewear. There often is considerable variation in each alternate
personality's familiarity with the others. People with dissociative identity disorder
typically also have dissociative amnesia.
• Dissociative fugue. People with this condition dissociate by putting real distance
between themselves and their identity. For example, you may abruptly leave home
or work and travel away, forgetting who you are and possibly adopting a new
identity in a new location. People experiencing dissociative fugue may be very
capable of blending in wherever they end up. A fugue episode may last only a few
hours or, rarely, as long as many months. Dissociative fugue typically ends as
abruptly as it begins. When it lifts, you may feel intensely disoriented, depressed
and angry, with no recollection of what happened during the fugue or how you
arrived in such unfamiliar circumstances.
• Depersonalization disorder. This disorder is characterized by a sudden sense of
being outside yourself, observing your actions from a distance as though watching
a movie. It may be accompanied by a perceived distortion of the size and shape of
your body or of other people and objects around you. Time may seem to slow
down, and the world may seem unreal. Symptoms may last only a few moments
or may come and go over many years.

IV. TREATMENT

PSYCHOTHERAPY

Adlerian Therapy

Adlerian Therapy is a growth model. It stresses a positive view of human nature and that
we are in control of our own fate and not a victim to it. We start at an early age in
creating our own unique style of life and that style stays relatively constant through the
remained of our life. That we are motivated by our setting of goals, how we deal with the
tasks we face in life, and our social interest. The therapist will gather as much family
history as they can. They will use this data to help set goals for the client and to get an
idea of the clients' past performance. This will help make certain the goal is not to low or
high, and that the client has the means to reach it. The goal of Adlerian Therapy is to
challenge and encourage the clients' premises and goals. To encourage goals that are
useful socially and to help them feel equal. These goals maybe from any component of
life including, parenting skills, marital skills, ending substance-abuse, and most anything
else. The therapist will focus on and examine the clients' lifestyle and the therapist will
try to form a mutual respect and trust for each other. They will then mutually set goals
and the therapist will provided encouragement to the client in reaching their goals. The
therapist may also assign homework, setup contracts between them and the client, and
make suggestions on how the client can reach their goals.

Behavior Therapy

Behavior therapy is always undergoing refinement and uses learning to overcome specific
behavioral problems. In this type of therapy it is believed that behaviors are learned, that
we are a product of our environment. Focus will be on present and overt behavior. In this
type of therapy it is believed that reinforcement and imitation teaches normal behavior
and that abnormal behavior is a direct result of defective learning. Therapy will be based
on learning theory. The therapy will include a treatment plan, the goals of the treatment
will be laid out up front, and the outcome expected from the therapy will be set right up
front too. To eliminate unwanted behaviors you need to learn new behaviors. This may
include assertion, behavioral rehearsal, coaching, cognitive
restructuring, desensitization, modeling, reinforcement, relaxation methods, self-
management, or new social skills. Both client and therapist need to take an active role in
learning the more desired behavior. Behavior therapy is well suited to deal with
depression, disorders in children's behavior, phobias, sexual disorders of any type, and
stuttering.

Existential Therapy

Focuses on freedom of choice in shaping one's own life. Teaches one is responsible to
shape his / her own life and a need for self-determination and self-awareness. The
uniqueness of each individual forms his / her own unique personality, starting from
infancy. Existential therapy focuses on the present and on the future. The therapist try's to
help the client see they are free and to see the possibilities for their future. They will
challenge the client to recognize that he / she themselves were responsible for the events
in their life. This type of therapy is well suited in helping the client to make good choices
or in dealing with life.

Gestalt Therapy

Gestalt therapy integrates the body and mind factors, by stressing awareness and
integration. Integration of behaving, feelings, and thinking is the main goal in Gestalt
therapy. Client's are viewed as having the ability to recognize how earlier life influences
may have changed their life's. The client is is made aware of personal responsibility, how
to avoid problems, to finish unfinished matters, to experience thing in a positive
light, and in the awareness of now. It is up to the therapist to help lead the client to
awareness of moment by moment experiencing of life. Then to challenge the client to
accept the responsibility of taking care of themselves rather then excepting others to do
it. The therapist may use confrontation, dream analysis, dialogue with polarities, or role
playing to reach their goals. This may include treatment of crisis intervention, marital /
family therapy, problem in children's behavior, psychosomatic disorders, or the training
of mental health professionals.

Person-centered Therapy

Person-centered therapy gives more responsibility to the client in their own treatment and
views humans in a positive manner. Founded by Carl Rogers in the 1940's. Rogers had
great faith that we could and would work out our own problems. The therapist will move
the client towards self awareness, helping the client to experience previously denied
feelings. They will teach the client to trust in themselves and to use this trust to find their
direction in life. The person-centered therapist makes the client aware of their problems
and then guilds them to a means of resolve them. The therapist and client must have faith
that the client can and will find self-direction. The therapist focus on the here and
how. They motivate the client in experiencing and expressing feelings. The person-
centered therapist believes that good mental health is a balance between the ideal self and
real self. This is where the problem lies, the result of difference between what we are and
what we wish to be causes maladjusted behavior.

Psychoanalytic

Psychotherapy focus on the unconscious and believes it influences human behavior. It is

believed that a person is driven by aggressive and sexual impulses. It focus mainly on the
first six years of human life and how the events of this time period determines later
personality. Repressed conflicts from childhood lead to personality problems later in life.
Anxiety is a direct result of the repression of conflicts Psychotherapist believe that the
unconscious motives along with unresolved conflicts lead to maladapted behavior. They
believe that to develop a normal personality, a person successful go through five
psychosexual stages:

• Oral - Birth to 1 year: Sucking.

• Anal - 1 to 3 years: Holding and releasing urine and feces.
• Phallic - 3 to 6 years: Pleasure in genital stimulation.
• Latency - 6 to 11 years: Sexual instincts develop.
• Genital - Adolescence: Sexual impulses return.

Inadequate resolution of any of these stages lead to flawed personality development. The
client with the therapist help will make repressed conflicts conscious, making the
unconscious conscious. Making this conflicts conscious to the client will help them in
working through them, awareness. Psychotherapy is not useful in clients that are self-
centered, impulsive, or severely psychotic. The therapist should have extensive training
and expense. The therapist when working with minorities, should focus on the clients
family dynamics. Treatment will be long term.
Rational-emotive and Cognitive-behavioral Therapy

Rational-emotive therapy is a highly action-oriented and deals with the client's cognitive
and moral state. This therapy stresses the clients ability of thinking on their own and in
their ability to change. The rational-emotive therapist believes that we are born with the
ability of rational thinking but that my fall victim to irrational thinking. They stress the
clients ability to think, in making good judgments, and in taking action. The therapist
will use directed therapy. The therapist believes that a neurosis is a result of irrational
behavior and irrational thinking. The Rational-emotive and Cognitive-behavioral
therapist believe the clients problems are rooted in childhood and in their belief
system, that was formed in childhood. Therapy will include method is solving and
dealing with emotional or behavior problems. The therapist will help the client to
eliminate any self-defeating outlooks they may have and to view life in a rational way.
The therapist will never have a personal relationship with the client. The therapist will
think of the client as a student and themselves as the teacher.

Reality Therapy

The reality therapist teaches the client ways to control the world around them and how to
meet their personal needs. They believe that the client can and will change their life for
the better. The reality therapist focuses on the what and the why of the clients actions.
They point out what the client doing and in getting them to evaluate it. A behavioral or
emotional problem is a direct result of the clients believe and feelings about themselves.
The therapist will help the client evaluate their behaviors and feelings, to challenge them
to become more effective at meeting their needs.

Transactional Analysis

Transactional analysis focus on the clients cognitive and behavior functioning. The
therapist helps the client evaluate their past decisions and how those decisions affect their
present life. They believe self-defeating behavior and feelings can be overcome by an
awareness of them. The therapist believes that the clients personality is made up of the
parent, adult, and child. They believe that it is important for the client to examine past
decisions to help their make new and better decisions.
SEXUAL DISORDER

Sexual dysfunctions are disorders related to a particular phase of the sexual

response cycle. For example, sexual dysfunctions include sexual desire disorders, sexual
arousal disorders, orgasm disorders, and sexual pain disorders. If a person has difficulty
with some phase of the sexual response cycle or a person experiences pain with sexual
intercourse, he/she may have a sexual dysfunction.

I. CAUSAL FACTORS

ORGANIZATION OF SEXUAL DISORDER

1. Paraphilias
2. Gender Identity Disorders
3. Sexual Dysfunctions

Causal Factors for Paraphilias

· Almost always diagnosed in males

· Typically patients referred by others, rather than seeking help
· Perhaps this is why Pedophilia, Voyeurism, and Exhibitionism are more commonly
diagnosed than sadism or masochism.
· Paraphilias often co-occur, i.e. are co-morbid
· The interplay between biological, psychological, and cultural factors is complex

Causal factors in sexual dysfunctions

1. Dysfunctional learning

a. Sexual techniques and attitudes are often learned informally

b. Social attitudes about sex may promote inhibitions and anxiety
c. Female sexual learning may have emphasized a passive role
d. Male's masturbatory experiences may be counter-productive to love
relationships

2. Feelings of fear, anxiety, and inadequacy

a. Research evidence shows the importance of anxiety in dysfunctions

b. Fears of inadequacy can lead to pretending to have orgasms
c. Masters and Johnson focus on faulty learning and poor communication

3. Interpersonal problems

a. Lack of emotional closeness can lead to sexual dysfunctions

b. Hostility and antagonistic feelings are related to sexual functioning
 4. Changing male-female roles and heterosexual relationships

a. The new female role has challenged many males

b. The female's active role in sexuality has stressful consequences
c. Sexually transmitted disease has produced anxiety

II. SUBTYPES AND SYMPTOMS

1. Hypoactive sexual disorder

A persistently reduced sexual drive or libido, not attributable to depression where there is
reduced desire, sexual activity and reduced sexual fantasy.

2. Sexual aversion disorder

An avoidance of or aversion to genital sexual contact

3. Female sexual arousal disorder

A failure of arousal and lubrication/swelling response.

4. Male erectile disorder

Inability to gain an erection or inability to maintain an erection once it has occurred.

5. Female orgasmic disorder

A lengthy delay or absence of orgasm following a satisfactory excitatory phase. The GP

must take into account the patient's age, previous sexual experience and adequacy of
sexual stimulation.

6. Male orgasmic disorder

A lengthy delay or absence of orgasm following normal excitation, erection and adequate
stimulation.
7. Premature ejaculation

Ejaculation occurring with only minimal stimulation, either before penetration or soon
afterwards, in either case ceratinly before the patient wishes it. Again the GP must take
into account the patient's age, previous sexual experience, extent of sexual stimulation
and 'novelty' of the sexual partner.

8. Dyspareunia (not due to general medical condition)

Recurrent pain associated with intercourse, but in women not due to vaginismus, poor
lubrication, and in women and men not due to drugs or other physical causes

9. Vaginismus

An involuntary or persistent spasm of the muscles of the outer third of the vagina, again
not attributable to physiological effects of physical causes. Vaginismus may be either
lifelong or recent; generalised to all sexual encounters or specific to certain partners or
situations.

10. Secondary sexual dysfunction

Dysfunction secondary to illness eg hypothyrodism, mental disorder eg depression, or

drugs eg fluoextine.

11. Paraphilias

Exhibitionism (exposure of genitals to strangers). Fetishism (finding nonliving objects

erotic eg women's underwear). Paedophilia. Frotteurism (fantasies, urges or behviour
centred around rubbing self against non-consenting other).Transvestic festishism (cross-
dressing for erotic pleasure). Voyeurism (fantasies, urges or behviour centred around
watching non-consenting others undressing, or having sex).

12. Gender identity disorder

Strong and persistent identification of the self with another gender. Persistent
dissatisfaction with own sex. Desire to participate in stereotyped games and pastimes of
opposite sex. Preference for cross-dressing. May insist that they are wrong sex. May
occur in children, adolescents and adults. Not concurrent with physical intersex
condition. Aetiology was thought to involve aberrant psychological conditioning, but
gender identity may be more defined by organic causes in the brain than the postnatal
environment.
DISORDERS OF CHILDHOOD AND ADOLESCENT

Children and adolescents may present with symptoms of the other diagnostic
categories and be diagnosed accordingly, and adults may on occasion be diagnosed with
this group of disorders. However, there is a group of disorders generally first diagnosed
in infancy, childhood or adolescence and it is this feature which warrants inclusion in this
group.

Mental Retardation is characterized by significantly below average intellectual

functioning and deficits in adaptive functioning. An IQ of 70 or below is used as the
diagnostic indicator. Mental Retardation is classified as

• Mild : IQ level of 50-55 to approximately 70

• Moderate : IQ level of 35-40 to 50-55
• Severe : IQ level of 20-25 to 35-40
• Profound : IQ level below 20-25

Learning Disorders are characterized by academic functioning that is

significantly below that expected given the child's age, IQ and educational background.
The learning disorders include:

• Reading Disorder
• Mathematics Disorder
• Written Expression Disorder

Developmental Coordination Disorder is characterized by a marked impairment

in the development of motor coordination that results in motor skills substantially below
those expected for a child of a given age and IQ and significantly interferes with
academic achievement or activities of daily living.

Communication Disorders are characterized by difficulties with speech and

language and include:

• Expressive Language Disorder

• Mixed-Receptive-Expressive Language Disorder
• Phonological Disorder
• Stuttering

Pervasive Developmental Disorders are characterized by severe deficits and

pervasive impairment in multiple areas of development including social interaction,
communication and the presence of stereotyped behavior, interests and activities. The
Pervasive Developmental Disorders include:

• Autistic Disorder
• Rett's Disorder
• Childhood Disintegrative Disorder
 • Asperger's Disorder

Attention-Deficit Disorders are characterized by symptoms of inattention and/or

hyperactivity- impulsivity. Disorders in this category include:

• Attention-Deficit/Hyperactivity Disorder
• Attention-Deficit/Hyperactivity Disorder Predominantly Inattentive Type
• Attention-Deficit/Hyperactivity Disorder Predominantly Hyperactive Type

Disruptive Behavior Disorders are characterized by symptoms of antisocial behavior

and/or negative, hostile or defiant behavior. Disorders in this category include:

• Conduct Disorder
• Oppositional Defiant Disorder

Feeding and Eating Disorders of Infancy or Early Childhood

Tic Disorders

Elimination Disorders include inappropriate elimination whether involuntary or

intentional.

• Encopresis is the repeated passage of feces into inappropriate places.

• Enuresis is the repeated passage of urine into inappropriate places.

Other Disorders of Infancy, Childhood, or Adolescence includes those not specifically

covered in other sections such as:

• Separation Anxiety
• Selective Mutism
• Reactive Attachment Disorder
• Stereotypic Movement Disorder

MULTIAXIAL SYSTEM

A multiaxial system involves an assessment on several axes, each of which refers

to a different domain of information that may help the clinician plan treatment and
predict outcome.

AXIS I.

The particular clinical syndromes or other conditions that may be a focus of

clinical attention. This would include schizophrenia, generalized anxiety disorder, major
depression, and substance dependence. Axis I conditions are roughly analogous to the
various illness and diseases recognized in general medicine.
AXIS II.

Personality disorders. A very broad group of disorders that encompasses a variety

of problematic ways of relating to the world, such as histrionic personality disorder,
paranoid personality disorder, or antisocial personality disorder. The last of these, for
example, refers to an early-developing, persistent, and pervasive pattern of disregard for
accepted standards of conduct, including legal strictures. Axis II provides a means of
coding for long-standing maladaptive personality traits that may or may not be involved
in the development and expression of an Axis I disorder. Mental retardation is also
diagnosed as an Axis II condition.

AXIS III.

General medical conditions. Listed here are any general medical conditions
potentially relevant to understanding or management of the case. Axis III of DSM-IV-TR
may be used in conjunction with an Axis I diagnosis qualified by the phrase “Due to
[specifically designated general medical condition]”-for example, where a major
depressive disorder is conceived as resulting from unremitting pain associated with some
chronic medical disease.

AXIS IV.

Psychosocial and environmental problems. This group deals with the stressors
that may have contributed to the current disorder, particularly those that have been
present during the prior year. The diagnostician is invited to use a checklist approach for
various categories of problems- family, economic, occupational, legal, etc. for example,
the phrase “Problems with Primary Support Group” may be included where a family
disruption is judged to have contributed to the disorder.

AXIS V.

Global assessment of functioning. This is where clinicians indicate how well the
individual is coping at the present time. A 100-point Global Assessment of Functioning
(GAF) Scale is provided for the examiner to assign a number summarizing a patient’s
overall ability to function.

Submitted by:

Roxanne H. Galban

BS Psychology