According to the text revision of the fourthedition of the Diagnostic and StatisticalManual of Mental Disorders (DSM-IV-TR), theessential feature of the dissociative disordersis a disruption in the usually integratedfunctions ofconsciousness, memory, identity, orperception of the environment.
The DSM-IV-TR dissociative disorders are dissociative identitydisorder, depersonalization disorder, dissociative amnesia, dissociative fugue, and dissociative disorder not otherwise specified(NOS).
the essential feature of dissociative amnesia isan inability to recall important personalinformation, usually of a traumatic or stressfulnature, that is too extensive to be explainedby normal forgetfulness.This disturbance can be based onneurobiological changes in the brain caused bytraumatic stress.
Dissociative amnesia, as defined by DSM-IV-TR, has been reported in approximately 6percent of the general population. No knowndifference is seen in incidence between menand women. Cases generally begin to bereported in late adolescence and adulthood.Dissociative amnesia can be especiallydifficult to assess in preadolescent childrenbecause of their more limited ability todescribe subjective experience
Amnesia and Extreme Intrapsychic ConflictIn many cases of acute dissociative amnesia, thepsychosocial environment out of which theamnesia develops is massivelyconflictual, with the patient experiencingintolerable emotions ofshame, guilt, despair, rage, and desperation.These usually result from conflicts overunacceptable urges or impulses, such asintense sexual, suicidal, or violentcompulsions.
Betrayal trauma attempts to explain amnesiaby the intensity of trauma and by the extentthat a negative event represents a betrayal bya trusted, needed other.This betrayal isthought to influence the way in which theevent is processed and remembered.Information about the abuse is not linked tomental mechanisms that control attachmentand attachment behavior.
The predominant disturbance is one or more episodes ofinability to recall important personal information, usuallyof a traumatic or stressful nature, that is too extensive tobe explained by ordinary forgetfulness. The disturbance does not occur exclusively during thecourse of dissociative identity disorder, dissociativefugue, posttraumatic stress disorder, acute stressdisorder, or somatization disorder and is not due to thedirect physiological effects of a substance (e.g., a drug ofabuse, a medication) or a neurological or other generalmedical condition (e.g., amnestic disorder due to headtrauma). The symptoms cause clinically significant distress orimpairment in social, occupational, or other importantareas of functioning.
CognitiveTherapy Cognitive therapy may have specific benefitsfor individuals with trauma disorders.Identifying the specific cognitive distortionsthat are based in the trauma may provide anentry into autobiographical memory forwhich the patient experiences amnesia. Asthe patient is becomes able to correctcognitive distortions, particularly about themeaning of prior trauma, more detailed recallof traumatic events may occur.
Hypnosis can be used in a number ofdifferent ways in the treatment ofdissociative amnesia. In particular, hypnoticinterventions can be used tocontain, modulate, and titrate the intensityof symptoms; to facilitate controlled recallof dissociated memories; to provide supportand ego strengthening forthe patient; and, finally, to promote workingthrough and integration of dissociatedmaterial.
. A variety of agents have been used for thispurpose, including sodiumamobarbital, thiopental (Pentothal), oralbenzodiazepines, and amphetamines.
During group sessions, patients may recovermemories for which they have had amnesia.Supportive interventions by the groupmembers or the group therapist, orboth, may facilitate integration and masteryof the dissociated material.
the essential feature of depersonalization asthe persistent or recurrent feeling ofdetachment or estrangement from ones self.The individual may report feeling like anautomaton or as if in a dream or watchinghimself or herself in a movie
Transient experiences of depersonalizationand derealization are extremely common innormal and clinical populations. They are thethird most commonly reported psychiatricsymptoms, after depression and anxiety
Persistent or recurrent experiences of feeling detachedfrom, and as if one is an outside observer of, ones mentalprocesses or body (e.g., feeling like one is in a dream). During the depersonalization experience, reality testingremains intact. The depersonalization causes clinically significant distressor impairment in social, occupational, or other importantareas of functioning. The depersonalization experience does not occurexclusively during the course of another mentaldisorder, such as schizophrenia, panic disorder, acutestress disorder, or another dissociative disorder, and is notdue to the direct physiological effects of a substance(e.g., a drug of abuse, a medication) or a general medicalcondition
PsychodynamicTraditional psychodynamic formulations have emphasized thedisintegration of the ego or have viewed depersonalization as anaffective response in defense of the ego.NeurobiologicalTheories The association of depersonalization with migraines andmarijuana, its generally favorable response to selective serotoninreuptake inhibitor (SSRI) drugs, and the increase indepersonalization symptoms seen with the depletion of L-tryptophan, a serotonin precursor, point to serotoninergicinvolvement.
Traumatic StressA substantial proportion, typically one third toone half, of patients in clinicaldepersonalization case series report historiesof significant trauma. Several studies ofaccident victims find as much as 60 percent ofthose with a life-threatening experiencereport at least transient depersonalizationduring the event or immediately thereafter.
Depersonalization after traumaticexperiences or intoxications commonlyremits spontaneously after removal from thetraumatic circumstances or ending of theepisode of intoxication. Depersonalizationaccompanying mood, psychotic, or otheranxiety disorders commonly remits withdefinitive treatment of these conditions.
depersonalization disorder respond at bestsporadically and partially to the usual groups ofpsychiatric medications, singly or incombination: antidepressants, moodstabilizers, typical and atypicalneuroleptics, anticonvulsants, and so forth. Many different types of psychotherapy havebeen used to treat depersonalization disorder:psychodynamic, cognitive, cognitive-behavioral, hypnotherapeutic, and supportive
sudden, unexpected travel away from homeor ones customary place of dailyactivities, with inability to recall some or all ofones past.This is accompanied by confusionabout personal identity or even theassumption of a new identity.
Traumatic circumstances(i.e., combat, rape, recurrent childhoodsexual abuse, massive socialdislocations, natural disasters), leading to analtered state of consciousness dominated bya wish to flee, are the underlying cause ofmost fugue episodes.
The predominant disturbance is sudden, unexpectedtravel away from home or ones customary place ofwork, with inability to recall ones past. Confusion about personal identity or assumption ofa new identity (partial or complete). The disturbance does not occur exclusively duringthe course of dissociative identity disorder and is notdue to the direct physiological effects of a substance(e.g., a drug of abuse, a medication) or a generalmedical condition (e.g., temporal lobe epilepsy). The symptoms cause clinically significant distress orimpairment in social, occupational, or otherimportant areas of functioning.
The disorder is thought to be more commonduring natural disasters, wartime, or times ofmajor social dislocation andviolence, although no systematic data existon this point. No adequate data exist todemonstrate a gender bias to this disorder;however, most cases describe men, primarilyin the military. Dissociative fugue is usuallydescribed in adults.
Dissociative fugues have been described toSome patients report multiple fugues. Afterthe termination of a fugue, the patient mayexperience perplexity, confusion, trance-likebehaviors, depersonalization, derealization,and conversion symptoms, in addition toamnesia. Some patients may terminate afugue with an episode of generalizeddissociative amnesia
Most fugues are relatively brief, lasting fromhours to days. Most individuals appear torecover, although refractory dissociativeamnesia may persist in rare cases. Somestudies have described recurrent fugues inmost individuals presenting with an episodeof dissociative fugue. No systematic moderndata exist that attempt to differentiatedissociative fugue from dissociative identitydisorder with recurrent fugues
Dissociative fugue is usually treated with aneclectic, psycho dynamically orientedpsychotherapy that focuses on helping thepatient recover memory for identity andrecent experience. Hypnotherapy andpharmacologically facilitated interviews arefrequently necessary adjunctive techniques toassist with memory recovery. Patients mayneed medical treatment for injuries sustainedduring the fugue, food, and sleep.
Dissociative identity disorder, previously calledmultiple personality disorder, characterizedby the presence of two or more distinctidentities or personality states thatrecurrently take control of the individualsbehavior accompanied by an inability to recallimportant personal information that is tooextensive to be explained by ordinaryforgetfulness.
Few systematic epidemiological data exist fordissociative identity disorder. Clinical studiesreport female to male ratios between 5 to 1and 9 to 1 for diagnosed cases.
Dissociative identity disorder is strongly linked tosevere experiences of early childhoodtrauma, usually maltreatment. The rates ofreported severe childhood trauma for child andadult patients with dissociative identity disorderrange from 85 to 97 percent of cases. Physicaland sexual abuse are the most frequentlyreported sources of childhood trauma. Thecontribution of genetic factors is only now beingsystematically assessed, but preliminary studieshave not found evidence of a significant geneticcontribution.
The presence of two or more distinct identities orpersonality states (each with its own relatively enduringpattern of perceiving, relating to, and thinking aboutthe environment and self). At least two of these identities or personality statesrecurrently take control of the persons behavior. Inability to recall important personal information that istoo extensive to be explained by ordinary forgetfulness. The disturbance is not due to the direct physiologicaleffects of a substance (e.g., blackouts or chaoticbehavior during alcohol intoxication) or a generalmedical condition (e.g., complex partial seizures).
Blackouts or time lossDisremembered behaviorFuguesUnexplained possessionsInexplicable changes in relationshipsFluctuations in skills, habits, and knowledgeFragmentary recall of entire life historyChronic mistaken identity experiencesMicro dissociations
These include symptomexaggeration, lies, use of symptoms to excuseantisocial behavior (e.g., amnesia only for badbehavior), amplification of symptoms whenunder observation, refusal to allow collateralcontacts, legal problems, and pseudologiafantastica. Patients with genuine dissociativeidentity disorder are usuallyconfused, conflicted, ashamed, and distressedby their symptoms and trauma history
Co morbidity versus differential diagnosisAffective disordersPsychotic disordersAnxiety disordersPosttraumatic stress disorderPersonality disordersCognitive disordersNeurological and seizure disordersSomatoform disordersFactitious disordersMalingeringOther dissociative disordersDeep-trance phenomena, such as the hiddenobserver or ego states
Prognosis is poorer in patients with comorbid organicmental disorders, psychotic disorders (not dissociativeidentity disorder pseudopsychosis), and severe medicalillnesses. Refractory substance abuse and eatingdisorders also suggest a poorer prognosis. Other factorsthat usually indicate a poorer outcome includesignificant antisocial personality features, currentcriminal activity, ongoing perpetration of abuse, andcurrent victimization, with refusal to leave abusiverelationships. Repeated adult traumas with recurrentepisodes of acute stress disorder may severelycomplicate the clinical course.
psychotherapyThese modalities include psychoanalyticpsychotherapy, cognitive therapy, behavioraltherapy, hypnotherapy, and a familiarity withthepsychotherapyandpsychopharmacological management of the traumatized patient.
Many cognitive distortions associated withdissociative identity disorder are onlyslowly responsive to cognitive therapytechniques, and successful cognitiveinterventions may lead to additionaldysphoria. A subgroup of patients withdissociative identity disorder does notprogress beyond a long-term supportivetreatment entirely directed towardstabilization of their multiple multiaxialdifficulties
Hypnotherapeutic interventions can oftenalleviate self-destructive impulses or reducesymptoms, such as flashbacks, dissociativehallucinations, and passive-influenceexperiences. Teaching the patient self-hypnosis may help with crises outside ofsessions. Hypnosis can be useful for accessingspecific alter personality states and theirsequestered affects and memories
SSRI, tricyclic, and monamine oxidase (MAO)antidepressants, clonidine(Catapres), anticonvulsants, and benzodiazepinesin reducing intrusive symptoms, hyperarousal, andanxiety in patients with dissociative identitydisorder. The atypical neuroleptics, such asrisperidone (Risperdal), quetiapine(Seroquel), ziprasidone (Geodon), and olanzapine(Zyprexa), may be more effective and bettertolerated than typical neuroleptics foroverwhelming anxiety and intrusive PTSDsymptoms in patients with dissociative identitydisorder.
For some patients, ECT is helpful inameliorating refractory mood disorders anddoes not worsen dissociative memoryproblems. Clinical experience in tertiary caresettings for severely ill patients withdissociative identity disorder suggests that aclinical picture of major depression withpersistent, refractory melancholic featuresacross all alter states may predict a positiveresponse to ECT.
GroupTherapyFamilyTherapySelf-HelpGroupsExpressive and OccupationalTherapies
The category of dissociative disorder NOScovers all of the conditions characterized bya primary dissociative response that do notmeet diagnostic criteria for one of the otherDSM-IV-TR dissociative disorders.Dissociative disorder NOS cases must alsofail to exclusively meet diagnostic criteria foracute stress disorder, PTSD, or somatizationdisorder, which all include dissociativesymptoms among their criteria
Dissociative trance disorder is manifest by atemporary, marked alteration in the state ofconsciousness or by loss of the customarysense of personal identity without thereplacement by an alternate sense of identitycharacterized by the exchange of the personscustomary identity by a new identity usuallyattributed to a spirit, divine power, deity, oranother person. In this possessed state, theindividual exhibits stereotypical and culturallydetermined behaviors or experiences beingcontrolled by the possessing entity
It implies that under conditions of adequatestress and duress, individuals can be made tocomply with the demands of those inpower, thereby undergoing major changes intheir personality, beliefs, and behaviors.Persons submitted to such conditions canundergo considerable harm,including loss ofhealth and life, and they typically manifest avariety of posttraumatic and dissociativesymptoms
Under hypnosis or during psychotherapy, a patientmay recover a memory of a painful experience orparticularly of sexual or physical that is etiologicallysignificant. When the repressed material is broughtback to consciousness, the person not only mayrecall the experience but may reliveit, accompanied by the appropriate affectiveresponse (a process called abreaction). If the eventrecalled never really happened but the personbelieves it to be true and reacts accordingly, it isknown as false memory syndrome
Dissociative amnesiaThe general criteriafor dissociative disorder must be met. There must be amnesia, partial orcomplete, for recent events or problems thatwere or still are traumatic or stressful. The amnesia is too extensive and persistentto be explained by ordinary forgetfulness(although its depth and extent may varyfrom one assessment to the next) or byintentional simulation
The general criteria for dissociative disordermust be met. The individual undertakes an unexpected yetorganized journey away from home or from theordinary places of work and socialactivities, during which self-care is largelymaintained. There is amnesia, partial or complete, for thejourney, which also meets Criterion C fordissociative amnesia.
The general criteria for dissociative disorder mustbe met.There is profound diminution or absence ofvoluntary movements and speech and of normalresponsiveness to light, noise, and touch.Normal muscle tone, static posture, and breathing(and often limited coordinated eye movements) aremaintained.
The general criteria for dissociative disordermust be met. Either of the following must be present: Trance.There is temporary alteration of thestate of consciousness, shown by any two of thefollowing:▪ Loss of the usual sense of personal identity▪ Narrowing of awareness of immediate surroundings orunusually narrow and selective focusing onenvironmental stimuli▪ Limitation of movements, postures, and speech torepetition of a small repertoire
Possession disorder.The individual is convincedthat he or she has been taken over by a spirit,power, deity, or other(1) and (2) of Criterion B must be unwanted andtroublesome, occurring outside, or being aprolongation of, similar states in religious orother culturally accepted situations
Most commonly used exclusion clause. Thedisorder does not occur at the same time asschizophrenia or related disorders, or mood(affective) disorders with hallucinations ordelusions.
The general criteria for dissociative disordermust be met. Either of the following must be present: Complete or partial loss of the ability to performmovements that are normally under voluntarycontrol (including speech) Various or variable degrees of in coordination orataxia, or inability to stand unaided
The general criteria for dissociative disordermust be met. The individual exhibits sudden and unexpectedspasmodic movements, closely resembling anyof the varieties of epileptic seizure but notfollowed by loss of consciousness. The symptoms in Criterion B are notaccompanied by tongue biting, serious bruisingor laceration due to falling, or urinaryincontinence.
The general criteria for dissociative disordermust be met. Either of the following must be present: Partial or complete loss of any or all of the normalcutaneous sensations over part or all of the body(specify: touch, pin prick, vibration, heat, cold) Partial or complete loss of vision, hearing, or smell(specify)
Ganser syndrome is a poorly understoodcondition characterized by the giving ofapproximate answers (paralogia) togetherwith a clouding of consciousness, andfrequently accompanied by hallucinationsand other dissociative, somatoform, orconversion symptoms.
Cases have been reported in a variety ofcultures, but the overall frequency of suchreports has declined with time. Menoutnumber women by approximately 2 to 1.Three of Gansers first four cases wereconvicts, leading some authors to consider itto be a disorder of penal populationsand, thus, an indicator of potentialmalingering.
Some case reports identifyprecipitating stressors, such aspersonal conflicts and financialreverses, whereas others noteorganic brain syndromes, headinjuries, seizures, and medical orpsychiatric illness
The symptom of passing over (vorbeigehen)the correct answer for a related, but incorrectone, is the hallmark of Ganser syndrome. Theapproximate answers often just miss themark but bear an obvious relation to thequestion, indicating that it has beenunderstood.
Given the reported frequent history of organic brainsyndromes, seizures, head trauma, and psychosis inGanser syndrome, a thorough neurological andmedical evaluation is warranted. Differentialdiagnoses include organic dementia, depressivepseudodementia, the confabulation of Korsakoffssyndrome, organic dysphasias, and reactivepsychoses. Patients with dissociative identitydisorder occasionally may also exhibit Ganser-likesymptoms
In most case reports, the patient has beenhospitalized and has been provided with aprotective and supportive environment. In someinstances, low doses of antipsychotic medicationshave been reported to be beneficial. Confrontationor interpretations of the patients approximateanswers are not productive, but exploration ofpossible stressors may be helpful. Hypnosis andamobarbital narcosynthesis have also been usedsuccessfully to help patients reveal the underlyingstressors that preceded the development of thesyndrome, with concomitant cessation of theGanser symptoms.
The ICD-10 dissociative [conversion] disordersinclude dissociative amnesia, dissociativefugue, dissociative stupor, trance and possessiondisorder, and dissociative disorders ofmovement and sensation (roughly equivalent tothe DSM-IV-TR conversion disorder diagnosis).The latter includes dissociative motordisorders, dissociative convulsions, anddissociative anesthesia and sensory loss. Gansersyndrome and multiplex personality disorder areclassified under other dissociative disorders.Depersonalization disorder is classifiedseparately.