Chapter 13Dissociative DisordersSteven Jay Lynn, Joanna M. Ber.docx

Chapter 13
Dissociative Disorders
Steven Jay Lynn, Joanna M. Berg, Scott O. Lilienfeld, Harald
Merckelbach, Timo Giesbrecht, Dalena Van-Heugten-Van Der
Kloet, Michelle Accardi-Ravid, Colleen Mundo, and Craig P.
Polizzi
The most recent edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5; American Psychiatric Association
[APA], 2013) defines dissociative disorders as conditions
marked by a disruption of and/or discontinuity in the normal
integration of consciousness, memory, identity, emotion,
perception, body representation, motor control, and behavior”
(p. 291). The presentation of dissociative disorders is often
dramatic, perplexing, and highly variable, both within and
across individuals. The hallmarks of dissociation are profound
and often unpredictable shifts in consciousness, the sense of
self, and perceptions of the environment.
DSM-5 asserts that the dissociative disorders share a common
feature: They are frequently manifested in the wake of trauma
and are influenced by their proximity to trauma (p. 291). Later
in the chapter, we contrast the post-traumatic theory that is
firmly embedded in the DSM-5 account of dissociation with a
competing theory that does not conceptualize trauma as a
necessary precursor to dissociation. In the course of our
discussion, we will present a case study that illustrates the
treatment of a patient with dissociative identity disorder (DID)
and highlight controversies that have dogged the field of
dissociation since the time of Janet's seminal writings on the
topic (Janet, 1889/1973).
The DSM-5 (APA, 2013) identifies three major dissociative
disorders that we discuss in turn—dissociative amnesia,
depersonalization/derealization, and DID. We then present an
overview of dissociation in general, followed by a more detailed
discussion of diagnostic considerations, prevalence, assessment,

and etiology specific to each of the dissociative disorders.
1. Dissociative amnesia is marked by an inability to recall
important autobiographical information, usually of a traumatic
or stressful nature inconsistent with ordinary forgetting. This
condition most often “consists of localized or selective amnesia
for a specific event or events, or generalized amnesia for
identity and life history” (APA, 2013, p. 298).
2. Depersonalization/derealization disorder (DDD), formerly
known as depersonalization disorder, is diagnosed on the basis
of symptoms of persistent depersonalization, derealization, or
both. Depersonalization symptoms include experiences of
unreality; feelings of detachment or being an outside observer
of one's thoughts, feelings, sensations, or actions; an unreal or
absent sense of self; physical and emotional numbing; and time
distortion. In contrast, derealization experiences involve
feelings of unreality or detachment with respect to one's
surroundings that include the experience of individuals or
objects as unreal, dreamlike, foggy, visually distorted, or
lifeless.
3. Dissociative identity disorder (DID; formerly called multiple
personality disorder) is marked by a disruption of identity
characterized by two or more distinct personality states and
recurrent gaps in the recall of everyday events, personal
information, and/or traumatic events that are inconsistent with
ordinary forgetting (APA, 2013, p. 292).
DSM-5 also includes a fourth category of other specified
dissociative disorder, for patients who do not meet full criteria
for any dissociative disorder. The essential features here are
chronic and recurrent clusters of mixed dissociative symptoms,
identity disturbance due to prolonged and intense coercive
persuasion, acute dissociative reactions to stressors, and
dissociative trance. Additionally, DSM-5 includes a fifth
category of unspecified dissociative disorder in which criteria
are not met for a specific dissociative disorder and there is
insufficient information to make a more specific diagnosis.
Finally, DSM-5 currently describes a dissociative subtype of

post-traumatic stress disorder (PTSD) in which persistent or
recurring feelings of depersonalization and/or derealization are
manifested in reaction to trauma-related stimuli. DSM-
5 requires that the symptoms of all dissociative disorders must
cause significant distress, impairment of functioning in major
aspects of daily life, or both, and must not be attributable to the
effects of a substance or another medical condition.
Some epidemiological studies among psychiatric inpatients and
outpatients have reported prevalence rates of dissociative
disorders exceeding 10% (Ross, Anderson, Fleischer, & Norton,
1991; Sar, Tutkun, Alyanak, Bakim, & Barai, 2000; Tutkun,
Sar, Yargiç, Özpulat, Yank, & Kiziltan, 1998), and a study
among community women in Turkey even reported a prevalence
rate of 18.3% for lifetime diagnoses of a dissociative disorder
(Sar, Akyüz, & Dogan, 2007). In contrast, many authors would
take issue with these high prevalence rates in both clinical and
nonclinical samples. Indeed, as our discussion will reveal,
estimates of the prevalence of dissociative disorders vary
widely and are surrounded by considerable controversy.
Although many authors regard symptoms of
depersonalization/derealization and dissociative amnesia as core
features of dissociation, the concept of dissociation is
semantically open and lacks a precise and generally accepted
definition (Giesbrecht, Lynn, Lilienfeld, & Merckelbach, 2008).
This definitional ambiguity is related, in no small measure, to
the substantial diversity of experiences that fall under the rubric
of “dissociation.” Dissociative symptoms range in their
manifestation from common cognitive failures (e.g., lapses in
attention), to nonpathological absorption and daydreaming, to
more pathological manifestations of dissociation, as represented
by the dissociative disorders (Holmes et al., 2005).
This variability raises the possibility that some of these
symptoms are milder manifestations of the same etiology or
have different etiologies and biological substrates, raising
questions about whether dissociation is a unitary conceptual
domain (Hacking, 1995; Holmes et al., 2005; Jureidini, 2003).

Indeed, van der Hart, Nijenhuis, Steele, and Brown (2004, 2006)
have distinguished ostensibly trauma-related or pathological
dissociation, which they term structural dissociation of the
personality, from nonpathological dissociative experiences
(e.g., altered sense of time, absorption). Structural dissociation,
in turn, can be subdivided into levels that encompass primary
dissociation, which is thought to involve one purportedly
apparently normal part of the personality (ANP) and one
emotional part of the personality (EP), secondary structural
dissociation, supposedly associated with a single ANP and
further division of the EP, and tertiary dissociation, ostensibly
limited to DID and characterized by several ANPs and EPs.
Nevertheless, as our review will demonstrate, researchers'
attempts to discriminate pathological from nonpathological
dissociative experiences psychometrically have been subject to
criticism and have been less than uniformly successful
(Giesbrecht et al., 2008; Modestin & Erni, 2004; Waller,
Putnam, & Carlson, 1996; Waller & Ross, 1997).
Other researchers (Allen, 2001; Cardeña, 1994; Holmes et al.,
2005) have proposed two distinct forms of dissociation:
detachment and compartmentalization. Detachment consists of
depersonalization and derealization, which we describe in some
detail later, and related phenomena, like out-of-body
experiences. Psychopathological conditions, which reflect
symptoms of detachment, include depersonalization disorder
and feelings of detachment that occur during flashbacks in
PTSD. Compartmentalization, in contrast, ostensibly
encompasses dissociative amnesia, marked by extensive
forgetting of autobiographical material, and somatoform
dissociation, such as sensory loss and “unexplained”
neurological symptoms (Nijenhuis, Spinhoven, Van Dyck, Van
der Hart, & Vanderlinden, 1998). The core feature of
compartmentalization is a deficit in deliberate control of
processes or actions that would normally be amenable to
control, as is evident in DID or somatization disorder. Although
clinicians may find it helpful to subdivide dissociative

symptoms into two different symptom clusters (Bernstein-
Carlson & Putnam, 1993), attempts to differentiate such clusters
on a psychometric basis have not been consistently successful
(see, for an example, Ruiz et al., 2008).
Dissociation is often presumed to reflect a splitting of
consciousness, although it must be distinguished from the
superficially similar but much debated concept of Freudian
repression. Specifically, dissociation can be described as a
“horizontal” split; that is, consciousness is split into two or
more parts that operate in parallel. In contrast, repression is
more akin to a “vertical” split, in which consciousness is
arranged in levels, and traumatic or otherwise undesirable
memories are ostensibly pushed downwards and rendered more
or less inaccessible.
Although the existence of dissociation as a clinical symptom is
not much in dispute, dissociative disorders are among the most
controversial psychiatric diagnoses. Disagreement generally
centers on the etiology of these disorders, with advocates often
arguing for largely trauma-based origins (e.g., Dalenberg et al.,
2012; 2014; Gleaves, 1996). In this light, dissociative symptoms
are regarded as manifestations of a coping mechanism that
serves to mitigate the impact of highly aversive or traumatic
events (Gershuny & Thayer, 1999; Nijenhuis, van der Hart, &
Steel, 2010). In contrast, skeptics often emphasize the role of
social influences, including cultural expectancies and
inadvertent therapist cueing of symptoms (e.g., Lilienfeld et al.,
1999; Lynn et al., 2015; McHugh, 2008). As we will learn later
in the chapter, the controversies stemming from etiology and
classification of dissociative disorders extend to their
assessment and treatment. We will focus our discussion on
chronic dissociative symptoms, rather than dissociation at the
time of a highly aversive event (i.e., peritraumatic dissociation).
Also, we will not elaborate on the dissociative subtype of PTSD
described in DSM-5 (see, for a critical analysis, Dutra & Wolf,
2017). However, we will present a number of “state” measures
of dissociation because researchers not infrequently consider

temporary changes in dissociation in the context of research on
more chronic presentations of dissociation.
Dissociative Amnesia
The diagnosis of dissociative amnesia requires that the memory
loss is extensive and not attributable to substance use or to a
neurological or other medical condition such as age-related
cognitive loss, complex partial seizures, or closed-head brain
injury and that the symptoms are not better explained by DID,
PTSD, acute stress disorder, somatic symptom disorder, or
major or mild neurocognitive disorder (APA, 2013, p. 298).
This disorder, formerly referred to as psychogenic amnesia,
often presents as retrospective amnesia for some period or
series of periods in a person's life, frequently involving a
traumatic experience.
DSM-5 lists several subtypes of dissociative amnesia. In
localized amnesia, the individual cannot recall any information
from a specific period of time, such as total forgetting of a
holiday week. Selective amnesia involves the loss of memories
for some, but not all, events from a specific period of time. In
generalized amnesia, individuals cannot recall anything about
their entire lives, and in continuous amnesia, individuals forget
each new event as it occurs. Finally, systematized amnesia
consists of the “loss of memory for specific categories of
information” (e.g., sexual abuse, a particular person). These last
three types of dissociative amnesia—generalized, continuous,
and systematized—are much less common than the others, and
may be manifestations of more complex dissociative disorders,
such as DID rather than dissociative amnesia alone.
Lynn et al. (2014a) argued that the central diagnostic criterion
for dissociative amnesia is vague and subjective in stipulating
that one or more episodes of inability to recall important
information must be “…inconsistent with ordinary forgetting”
(APA, 2013, p. 298). The reliability of judgments of what
constitutes “ordinary forgetfulness” is questionable, and what is
“ordinary” hinges on a variety of factors, including the
situational context and presence of comorbid conditions. A

similar point was raised by Read and Lindsay (2000), who
demonstrated that when people are encouraged to remember
more about a selected target event, they report their forgetting
to be more extensive, compared with individuals who are asked
to simply reminisce about a target event.
Epidemiology
Because rates of reporting vary so widely, it is difficult to
obtain reliable epidemiological information regarding
dissociative amnesia. Questions concerning the validity of
dissociative amnesia as a diagnostic entity are fueled by
markedly different prevalence rates in the general population
across cultures: 0.2% in China, 0.9% and 7.3% in Turkey, and
3.0% in Canada (Dell, 2009). These varying prevalence
estimates could reflect genuine cultural differences, but they
could just as plausibly reflect different interviewer criteria for
evaluating amnesia.
The DSM-5 states that dissociative amnesia can present in any
age group, although it is more difficult to diagnose in younger
children due to their difficulty in answering questions about
periods of forgetting and possible confusion with a number of
other disorders and conditions, including inattention, anxiety,
oppositional behavior, and learning disorders. There may be just
one episode of amnesia, or there may be multiple episodes, with
each episode lasting anywhere from minutes to decades. Other
sources (e.g., Coons, 1998) suggest that most cases occur in
individuals in their 30s or 40s, and that 75% of cases last
between 24 hours and 5 days. The prevalence of dissociative
amnesia is approximately equal between genders. Still others
argue that the scientific evidence for the existence of
dissociative amnesia is unconvincing, and that barring brain
injury or substance abuse or dependence, individuals who have
experienced trauma do not forget those events (e.g., McNally,
2003; Pope, Hudson, Bodkin, & Oliva, 1998).
Certain cases of purported traumatic amnesia are in fact
attributable to organic or other nondissociative causes. For
example, when critiquing a “convincing demonstration of

dissociative amnesia” (Brown, Scheflin, & Hammond, 1997),
McNally (2004) discussed a study (Dollinger, 1985) of two
children who witnessed a playmate struck and killed by
lightning, and who were later diagnosed with dissociative
amnesia. Yet as McNally noted, this diagnosis was clearly
mistaken, because the children had also been struck by lightning
and knocked unconscious.
Amusingly, and perhaps tellingly, Pope, Poliakoff, Parker,
Boynes, and Hudson (2007) offered a reward of $1,000 to “the
first individual who could find a case of dissociative amnesia
for a traumatic event in any fictional or nonfictional work
before 1800” (p. 225) on the basis that, whereas the vast
majority of psychological symptoms can be found in literature
or records dating back centuries, dissociative amnesia appears
only in more modern literature beginning in the late 1800s.
Over 100 individuals came forward with examples, but none met
the diagnostic criteria for the disorder (although the prize later
went to someone who discovered a case of dissociative amnesia
in a 1786 opera, Nina, by the French composer Nicholas
Dalayrac). Although Pope and colleagues' challenge does not
“prove” anything regarding the validity of the disorder, its
relative scarcity, and apparently recent (perhaps after the late
18th century) development, raise troubling questions about its
existence as a natural category or entity.
A special form of dissociative amnesia is crime-related amnesia.
Many perpetrators of violent crimes claim to experience great
difficulty remembering the essential details of the crime they
committed (Moskowitz, 2004). Memory loss for crime has been
reported in 25–40% of homicide cases and severe sex offenses.
Nevertheless, skeptics believe that genuine dissociative amnesia
in these cases is rare. They have pointed out that trauma victims
(e.g., concentration camp survivors) almost never report
dissociative amnesia (Merckelbach, Dekkers, Wessel, & Roefs,
2003). For example, Rivard, Dietz, Matell, and Widawski
(2002) examined a large sample of police officers involved in
critical shooting incidents and found no reports of amnesia.

Also, recent laboratory research shows that when participants
encode information while in a “survival mode,” this
manipulation yields superior memory effects (Nairne &
Pandeirada, 2008). This finding is difficult to reconcile with the
idea of dissociative amnesia while committing a crime. Thus, it
is likely that feigning underlies most claims of crime-related
amnesia (Van Oorsouw & Merckelbach, 2010), and the recent
literature provides detailed case studies illustrating this point
(Marcopolus, Hedjar, & Arredondo, 2016).
Dissociative Fugue
Dissociative fugue (previously called psychogenic fugue) is
arguably the most controversial dissociative phenomenon after
DID. In DSM-IV-TR, dissociative fugue (i.e., short-lived
reversible amnesia for personal identity, involving unplanned
travel or wandering) was listed as a separate diagnosis. In DSM-
5, dissociative fugue—defined therein as apparently purposeful
travel or bewildered wandering associated with amnesia
for identity or other important autobiographical information—is
no longer diagnosed as a disorder in its own right, but is instead
coded as a condition that can accompany dissociative amnesia.
In a fugue (“fugue” has the same etymology as the word
“fugitive”) episode, amnesia for identity may be so extreme that
a person physically escapes his or her present surroundings and
adopts an entirely new identity. If and when this identity
develops, it is often characterized by higher levels of
extraversion than the individual displayed pre-fugue, and he or
she usually presents as well integrated and nondisordered.
Periods of fugue vary considerably across individuals, both in
duration and in distance traveled. In some cases, the travel can
be a brief and relatively short trip, whereas, in more extreme
cases, it can involve traveling thousands of miles and even
crossing national borders. While in the dissociative fugue state,
individuals often appear to be devoid of psychopathology; if
they attract attention at all, it is usually because of amnesia or
confusion about personal identity. Again, it is doubtful that
fugues constitute a fixed and cross-cultural diagnostic category.

Hacking (1995) provides a detailed historical and critical
analysis of fugue showing that they first appeared in the 19th
century and since that time fluctuated in apparent prevalence
and acceptance by the psychiatric community.
Diagnostic Considerations
Although DSM-5 notes that dissociative fugue, with travel, is
not uncommon in DID, dissociative fugue may manifest with
other symptoms, including depression, anxiety, dysphoria, grief,
shame, guilt, stress, and aggressive or suicidal impulses (APA,
2013). Reportedly, the condition often develops as a result of
traumatic or stressful events, which has led to controversy and
ambiguity regarding the relation between dissociative fugue and
PTSD. Precipitants associated with the development of
dissociative fugue include war or natural disasters, as well as
the avoidance of various stressors, such as marital discord or
financial or legal problems (Coons, 1998). Such avoidance
suggests that clinicians must be certain to rule out malingering
and factitious disorders before diagnosing dissociative fugue.
Staniliou and Markowitsch (2014) discuss basic memory
mechanisms that might be involved in fugue states.
Certain culture-bound syndromes exhibit similar symptoms to
dissociative fugue. These include amok, present in Western
Pacific cultures (which has given rise to the colloquialism
“running amok”), pibloktok, which is present in native cultures
of the Arctic, and Navajo “frenzy” witchcraft, all of which are
marked by “a sudden onset of a high level of activity, a
trancelike state, potentially dangerous behavior in the form of
running or fleeing, and ensuing exhaustion, sleep, and amnesia”
for the duration of the episode (APA, 2000, p. 524; Simons &
Hughes, 1985).
Epidemiology
DSM-IV-TR places the population prevalence estimate of
dissociative fugue at 0.02%, with the majority of cases
occurring in adults (APA, 2000, p. 524). Ross (2009b) observed
that in the approximately 3,000 individuals he treated in his
trauma program over a 12-year period, he encountered fewer

than 10 individuals with pure dissociative amnesia or pure
dissociative fugue, although he noted that symptoms of amnesia
and fugue were common in the patients he admitted.
Depersonalization/Derealization Disorder
Depersonalization/derealization disorder (DDD) is one of the
most common dissociative disorders and perhaps the least
controversial. In DDD, reality testing remains intact (APA,
2013, p. 302): Individuals are aware that the sensations are not
real and that they are not experiencing a break from reality akin
to psychosis. In a departure from DSM-IV, in which
depersonalization and derealization were diagnosed
separately, DSM-5 created a new diagnostic category of DDD.
This “lumping” of formerly separate conditions is supported by
findings (Simeon, 2009a) that individuals with derealization
symptoms do not differ significantly from those with
depersonalization accompanied by derealization in salient
respects (e.g., illness characteristics, comorbidity,
demographics).
Greatly contributing to our knowledge about depersonalization
symptoms has been the development of well-validated screening
instruments, notably the Cambridge Depersonalization Scale
(CDS; Sierra & Berrios, 2000; Sierra, Baker, Medford, & David,
2005). Depersonalization episodes are not uncommonly
triggered by intense stress and are often associated with high
levels of interpersonal impairment (Simeon et al., 1997).
Episodes of depersonalization or derealization are also
frequently associated with panic attacks, unfamiliar
environments, perceived threatening social interactions, the
ingestion of hallucinogens, depression, and PTSD (Simeon,
Knutelska, Nelson, & Guralnik, 2003). Individuals with DDD
are also more likely than healthy individuals to report a history
of emotional abuse. In contrast, general dissociation scores are
better predicted by a history of combined emotional and sexual
abuse (Simeon, Guralnik, Schmeidler, Sirof, & Knutelska,
2001).

Nearly 50% of adults have experienced at least one episode of
depersonalization in their lifetimes, usually in adolescence,
although a single episode is not sufficient to meet criteria for
the disorder (Aderibigbe, Bloch, & Walker, 2001). Because
depersonalization and derealization are common, DDD should
be diagnosed only if these symptoms are persistent or recurrent
and are severe enough to cause distress or impairment in
functioning, or both. The distress associated with DDD may be
extreme, with sufferers reporting they feel robotic, unreal, and
“unalive.” They may fear becoming psychotic, losing control,
and suffering permanent brain damage (Simeon, 2009a).
Individuals with DDD may perceive an alteration in the size or
shape of objects around them. Other people may appear
mechanical or unfamiliar, and affected individuals may
experience a disturbance in their sense of time (Simeon &
Abugel, 2006).
Although symptoms of depersonalization often occur in the
presence of psychotic symptoms (e.g., Gonzalez-Torres et al.,
2010; Goren et al., 2012; Vogel, Braungardt, Grabe, Schneider,
& Klauer, 2013), a diagnosis of DDD requires that the
symptoms do not occur exclusively in the course of another
mental disorder, nor can they be attributable to substance abuse
or dependence or to a general medical condition. Furthermore,
DDD should not be diagnosed solely in the context of
meditative or trance practices.
Symptoms of other disorders, such as anxiety disorders, major
depression, somatoform disorders, substance use disorders, and
certain personality disorders (especially avoidant, borderline,
and obsessive-compulsive), may also be present in the context
of DDD (Belli, Ural, Vardar, Yesilyrt, & Oncu, 2012; Lynn et
al., 2014b; Simeon et al., 1997). Depersonalization and
derealization symptoms are also commonly part of the symptom
picture of acute stress disorder (ASD; APA, 2013), which is
often a precursor to PTSD.
Epidemiology
DSM-5 estimates the lifetime prevalence of DDD in the United

States at 2%, with a range of 0.8– 2.8% (see also Ross, 1991),
suggesting that DDD might be as common as or more common
than schizophrenia and bipolar disorder. DDD is diagnosed
almost equally in women and men (Simeon et al., 2003). It
frequently presents for treatment in adolescence or adulthood,
even as late as the 40s, though its onset may be earlier.
Estimates of the age of onset of DDD range from 16.1 (Simeon
et al., 1997) to 22 years (Baker et al., 2003).
The onset and course of DDD vary widely across individuals.
Some people experience a sudden onset and others a more
gradual onset; some experience a chronic form of the disorder,
whereas others experience it episodically. In about two-thirds of
people with DDD, the course is chronic, and symptoms of
depersonalization are present most of the time, if not
continually. Episodes of depersonalization may last from hours
to weeks or months, and in more extreme cases, years or
decades (Simeon, 2009a).
Dissociative Identity Disorder
According to DSM-5, “the defining feature of DID is the
presence of two or more distinct personality states or
experiences of possession” (APA, 2013, p. 292). Thus, the
requirement that people diagnosed with DID must experience
distinct identities that recurrently take control over one's
behavior is no longer present. Importantly, in DSM-5 “distinct
personality states” replaces the term identities. The diagnostic
language in DSM-5 represents a marked departure from DSM-
II (APA, 1968), which used the term multiple personalities, and
from DSM-IV (APA, 1994), which labeled the condition DID to
underscore alterations in identity, rather than fixed and/or
complete “personalities.”
These shifts in diagnostic criteria may prove to be problematic
and result in changes in the prevalence rates of DID. For
example, what constitutes a personality state or an experience
of possession may be open to greater interpretation compared
with previous iterations of DSM. Moreover, in DSM-5, signs
and symptoms of personality alteration may be not merely

“observed by others,” but also “reported by the individual”
(APA, 2013; p. 292), further expanding opportunities for the
diagnosis of DID. In cases in which alternate personality states
are not witnessed, in DSM-5 it is still possible to diagnose the
disorder when there are “sudden alterations or discontinuities in
sense of self or agency…and recurrent dissociative amnesias”
(APA, 2013; p. 293), creating even more latitude and
subjectivity in the diagnosis of DID. Moreover, amnesia is no
longer restricted to traumatic events and may now be diagnosed
in relation to everyday events, which may also increase the base
rates of diagnosed DID. Although DSM-5 no longer defines DID
in terms of “distinct identities that recurrently take control of
the individual's behavior” (DSM-IV, p. 519), in the remainder
of the chapter, we will not refrain from using the
terms personalities and identities, insofar as these terms (a)
continue to be widely used in the extant literature and (b)
encompass “personality states.”
To meet diagnostic criteria for DID, an individual's symptoms
cannot be attributable to substance use or to a medical
condition, and the “disturbance is not a normal part of a broadly
accepted cultural or religious practice” (APA, 2013; p. 292).
When the disorder is assessed in children, the symptoms must
not be confused with imaginary play. To recognize cultural
variants of dissociative phenomena, DSM-5 refers to a
“possession form” of DID, which is “typically manifest as
behaviors that appear as if a ‘spirit,’ supernatural being, or
outside person has taken control, such that the individual begins
speaking or acting in a distinctly different manner” (APA, 2013,
p. 293). Because such manifestations are not uncommon in
different cultures (see, for a discussion of trance/possession
phenomena, Cardeña, van Duijl, Weiner, & Terhune, 2009), to
warrant a diagnosis of DID, the identities must be present
recurrently, be unwanted or …
11 Feeding, Eating and Elimination Disorders

The diagnostic criteria for the Feeding and Eating Disorders in
this chapter are categorized by recurrent disordered eating
activities and attitudes that are mutually exclusive, with the
exception of pica, which results in significant physical and/or
psychosocial impairment (APA, 2013). Research demonstrates
that eating disorders often originate in childhood or adolescence
with the average age of onset between 8 and 21 years (Hudson,
Hiripi, Pope, & Kessler, 2007). Approximately 20 million
women and 10 million men in the United States suffer from a
clinically significant eating disorder during their lifetime
(Wade, Keski-Rahkonen, & Hudson, 2011). Despite this
prevalence, only one in ten individuals with an eating disorder
receives treatment (Noordenbox, 2002). It is estimated that over
90% of those diagnosed with an eating disorder are young
females between the ages of 12 and 25 (SAMHSA, 2003), but
adult males suffer significantly as well (EDC, 2007).
Data from the National Comorbidity Replication Survey
(NCS-R) and the Adolescent Supplement (NCS-A) show that
adults and children with eating disorders often have coexisting
mental disorders such as depression, anxiety, and substance use;
sadly, few seek treatment specific to their eating disorder. More
distressing, this data demonstrates that eating disorders are
often associated with functional impairment and suicidality
(Hudson et al., 2007; Swanson, Crow, Le Grange, Swendsen &
Merikangas, 2011).
The first three disorders were relocated to this category
“Feeding and Eating Disorders” to highlight that although they
are most often diagnosed in children, they can occur at any age,
including adulthood. These disorders are distinguished by
problems with the process of eating and retaining food, eating
inappropriate food, or lack of interest in or avoidance of food.
Among individuals with intellectual disabilities their presence
appears to increase with the severity of the condition. Pica
Disorder is the eating of nonfood items such as paint chips,
string, hair, or newspaper. Although it may occur with other
eating and mental disorders, symptoms must be severe enough

to warrant an independent diagnosis. Rumination Disorder
involves vomiting and re-eating food. Avoidant/Restrictive
Food Intake Disorder was formerly feeding disorder of infancy
or early childhood, but it has been expanded to capture a
broader range of symptoms and age levels. This disruption in
eating and feeding behavior is marked by continuous inability to
meet appropriate sustenance and dietary needs. It is associated
with a serious decrease in body weight, failure to grow,
nutritional deterioration, reliance on enteral feeding and
impairment in psychosocial functioning (APA, 2013). For any
of these diagnoses, all three eating disorders should not develop
solely during the course of another eating disorder and cannot
be a culturally sanctioned practice or attributable to a medical
condition or another mental disorder (See DSM-5 for full
description of these disorders.)
The following three eating disorders are considered very
serious due to their chronic nature and morbidity, especially
without treatment. The first, Anorexia Nervosa, has an annual
prevalence rate of “0.4% among young females, with a 10:1
female-to-male ratio” (APA, 2013, p. 341) and is characterized
by significant weight loss resulting from excessive dieting and a
distorted body image. “Significantly low weight is defined as a
weight that is less than minimally normal or, for children and
adolescents, less than minimally expected” (APA, 2013, p. 338).
Individuals affected by this disorder have an unreasonable fear
of becoming fat regardless of their low body weight, which
interferes with weight gain. This intense focus on being thin is
often accompanied by a distorted body image; that is, the
individuals experience their weight or shape as greater than
what it actually is and often lack insight into the gravity of their
low body composition (APA, 2013).
There are two subtypes of Anorexia Nervosa: Restricting
Type and Binge/ Purging Type. Subtypes are used to identify
current symptoms over the last 3 months and often alternate
between subtypes. Individuals with the Restricting Type
severely restrict their food intake without engaging in bingeing

or purging behaviors. Individuals with the Binge/Purging Type
of anorexia maintain their weight at an abnormally low level
through food restriction but also engage in binge eating and
purging behaviors, such as self-induced vomiting or laxative or
diuretic abuse. Clinicians need to specify if individuals are in
partial (some of the criteria are met) or full (no criteria are met)
remission if the client previously met the full criteria. Also, the
current severity level of clinical symptoms and functioning
needs to be indicated from mild to extreme based on body mass
index (BMI) for adults and percentiles for children and
adolescents (APA, 2013).
Another significant eating disorder, Bulimia Nervosa (BN) is
also more prevalent in young females, “estimated at 1% to
1.5%” with female-to-male ratios similar to anorexia (APA,
2013, p. 347). Individuals suffering from bulimia generally
maintain a normal weight for their age and height. The primary
issue for the individual diagnosed with bulimia is a pattern of
binge eating that occurs at least once per week for 3 months.
This is followed by contradictory actions to avoid weight gain,
such as vomiting; laxative, diuretic, or enema abuse; fasting; or
excessive exercise. Additionally, bulimia is accompanied by
both a loss of control and excessive concern related to body
shape/weight. A binge consists of eating a larger amount of
food than normal under similar circumstances in a relatively
short period of time (usually less than 2 hours). To meet
diagnostic criteria, the bulimic behavior must not occur entirely
during episodes of anorexia nervosa. Clinicians need to specify
whether in partial or full remission as well as severity level
based on frequency of episodes of inappropriate compensatory
behaviors, from mild to extreme (APA, 2013).
Binge Eating Disorder (BED) became a diagnostic category in
the DSM-5 and is defined as repeating episodes of excessive
eating accompanied by feeling a loss of restraint and marked
distress. To meet diagnostic criteria, 3 out of 5 of the following
features must be present: eating more quickly than is typical;
eating without the physical sensation of hunger; eating until

excruciatingly full; eating alone out of shame over amount
consumed; and, feeling hopeless, remorse, and depressed
afterward. For diagnosis, frequency of bingeing episodes must
be at least once per week for 3 months and cannot arise only
during the course of anorexia or bulimia. Diagnosis must
specify the current severity of binge episodes (from mild to
extreme) as well as remission status (partial/full) if applicable
(APA, 2013).
Although BED is the most common eating disorder there is
limited knowledge about its development. Annual prevalence
“among U.S. adult (age 18 or older) females and males is 1.6%
and .08%, respectively” (APA, 2013 p. 351) to lifetime
prevalence rates of 3.5% in women and 2.0% in men (Hudson et
al., 2007). Gender differences are closest in BED than in either
anorexia or bulimia, with development still more prevalent in
women. However, for subthreshold BED, this gender ratio
reverses with males 3 times higher than females (Hudson et al.,
2007). BED has been shown to occur across the developmental
lifespan with age of onset generally reported as adolescence but
occurrence in adulthood is not uncommon (APA, 2013).
Eating Disorders Not Otherwise Specified (EDNOS) has been
replaced with two categories. The first, Other Specified Feeding
or Eating Disorder, applies to demonstrations that do not meet
the full criteria for any of the eating disorders in this section. It
is used when the “clinician chooses to communicate the specific
reason that the presentation does not meet the criteria for any
specific feeding and eating disorder” (APA, 2013, p. 353),
which must be included in diagnosis (for examples see DSM-5).
The other category, Unspecified Feeding or Eating Disorder, is
used to signal that there is inadequate information available for
the clinician to make a more specific diagnosis, such as in an
emergency room setting (APA, 2013).
Assessment
In assessing a client with a potential eating disorder, it is
important to conduct a thorough psychosocial evaluation,
including demographic information, reason for visit (which may

be different from the principal diagnosis), support systems,
family information, medical history, and any other history of
mental health intervention (see Chapter 1).
Clients who present with eating-disordered symptomatology
may not initially feel comfortable discussing behaviors
associated with the disorder due to the stigma, shame, and fear
of being discovered. Often, the behaviors have been held secret
for a significant period of time. The clients may be afraid of
family and friends pressuring them to change the behavior
before they are ready to make any changes.
Even when the eating-disordered person appears confident,
accomplished, fearless, and intelligent, the internal experience
is painful (e.g., terror of “getting caught,” pervasive feelings of
confusion or turmoil, concern about “going crazy”). Although it
may be obvious that the client has an eating disorder, several
sessions may be required before the client is willing to
acknowledge the problem. Family members may even maintain
or support such denial because eating-disordered behaviors
(e.g., dieting, overeating, abstaining from eating,
overexercising) are learned from the previous generation.
Although a client may be able to talk about the eating
disorder, the client or his or her family may question the
validity of such a diagnosis. For example, the parents of an
anorectic girl might suggest that their daughter just wants to
look like all the models in the magazines. In order for the
practitioner to address this defensive stance, it is crucial to join
with the family and establish good rapport and communication;
a nonjudgmental and empathic attitude; and a calm, neutral,
matter-of-fact tone concerning the eating-disordered symptoms.
If the clinician infuses the assessment interview with too much
emotion, the client and family may intensify their guardedness
and withdraw from treatment.
Adolescents with eating disorders are often pressured into
therapy by their parents, school counselors, friends, or relatives.
Their resistance to therapy may require the practitioner to focus
on other nonfood- or weight-related issues for a considerable

length of time before the adolescents develop enough trust to
confide in the therapist. Adults with eating disorders may be
motivated to come into therapy for a variety of reasons other
than wanting to recover from the eating disorder. Such reasons
may include wanting to assuage the family's or friends' worries;
fear of a particular medical manifestation, such as bleeding,
tachycardia, or incontinence; or problems with interpersonal
relationships.
Assessment of an individual who the practitioner suspects
might have an eating disorder involves exploring several
specific areas that pertain to eating behaviors and attitudes.
First, the practitioner should obtain a history of dieting or
compulsive eating habits. Second, the client should be assessed
for present symptoms of specific eating-disordered patterns
(e.g., restricting food intake, vomiting, abusing laxatives,
hiding food, hoarding food, having strict lists of “safe” foods,
being obsessed with recipes and cooking, and engaging in
excessive exercise routines).
Often these behaviors are accompanied by symptoms of
depression, low self-esteem, distorted body image,
hopelessness, anxiety, and, in more severe cases, suicidal
tendencies. Due to the possibility of comorbidity, specific
assessments can be conducted to rule out concurrent mental
disorders such as substance abuse, major depression, body
dysmorphic disorder, and obsessive-compulsive disorder. In
addition, personality disorders such as borderline personality
disorder, dependent personality disorder, histrionic personality
disorder, and avoidant personality disorder should be
considered.
People with eating disorders tend to have very rigid, fixed
thought patterns. This may affect their social relationships,
interpersonal skills, and ability to maintain intimate connections
with other people (e.g., close friends, partners, close work
relationships, family ties). If the client is under 18 years old,
the family situation should be thoroughly assessed. Family
factors that have been found to contribute to anorectic behavior

in adolescence include enmeshed family systems, blurred
boundaries between parents and children, and lack of separation
and individuation. Family factors that may influence bulimic
and compulsive overeating behaviors include chaotic family
dynamics, power imbalances, lack of flexibility, and a lack of
clear family structure. In all types of eating disorders, factors
that characterize families could potentially include a history of
sexual abuse or traumatic events, squelching of emotional
expression, and power and control issues.
Finally, it is essential that the eating-disordered client's case
be followed by a medical doctor while the client is in therapy
for the eating disorder. Clients with anorexia who fall below a
minimum weight are often hospitalized because of the life-
threatening risks that emaciation poses. Bulimic clients can
develop electrolyte imbalances and other physical problems that
can lead to medical complications. It is often necessary to have
a written contract with eating-disordered clients stating that if
they fall below a certain minimum weight, they understand that
they will be hospitalized. In addition, the practitioner must
obtain written consent from clients to exchange information
with the physician.
Assessment Instruments
The Eating Disorder Examination (EDE; Cooper & Fairburn,
1987; Fairburn & Cooper, 1993) is a well-validated and widely
used instrument to diagnose eating disorders (Cooper, Cooper,
& Fairburn, 1989; Grilo et al., 2010; Rizvi, Peterson, Crow, &
Agras, 2000. Peterson, Crow, & Agras, 2000). This
semistructured interview in its 16th edition, takes
approximately 1 hour to administer and assesses anorexia
nervosa, bulimia nervosa and binge eating disorder based on
responses to 33 open-ended questions (both Likert and
dichotomous). Training in both the technique of the interview as
well as the instrument is required.
The EDE is composed of 4 subscales related to the cognitive
symptomatology of eating disorders that measure dietary
restraint as well as eating, weight, and shape concern. Also,

behavioral symptoms are assessed including frequency of binge
eating, self-induced vomiting, laxative/diuretic misuse, and
excessive exercise. Scoring for these subscales is on a 7-point
scale (0–6) with higher scores indicating greater frequency or
severity of symptoms. For most items a 28-day timeframe is
employed, except for diagnostic purposes when a longer time
period may be required. A symptom composite score can be
calculated by averaging the diagnostic items. Research indicates
good internal consistency (Cooper et al., 1989) and inter-rater
reliability and test–retest reliability (Reas, Grilo & Masheb,
2004) over 2 to 7days for all the EDE subscales and high inter-
rater reliability (Rizvi et al., 2000). Good inter-rater reliability
and test–retest reliability for the EDE (6 to 14 days) was shown
in adult patients with BED (Reas et al., 2004). Research by
Berg, Peterson, Frazier, and Crow (2012) demonstrates that the
EDE scores correlate with measures of similar constructs and
support the use of this instrument to distinguish between eating
disorder cases and controls; however, they point out that no
studies to date have assessed the inter-rater reliability of scores
on items that assess laxative/diuretic misuse or excessive
exercise. There is a child's version (ChEDE) of this scale
designed specifically for use with children ages 8 to 14 (Bryant-
Waugh, Cooper, Taylor, & Lask, 1996) as well as a self-report
questionnaire (EDE-Q) that have been shown to correlate with
the EDE.
The Eating Disorder Inventory-3 (EDI-3; Garner, 2004) is a
self-report questionnaire used to assess the symptoms and
presence of eating disorders in individuals aged 13 and above.
This is the third version of one of the most popular self-report
scales (EDI; Garner, Olmsted, & Polivy, 1983 & EDI-2, Garner,
1991), and it consists of 91 items (same as EDI-2) that are rated
on a 6-point scale from “always” to “never.” It is organized into
12 scales (e.g., drive for thinness, bulimia, body dissatisfaction)
and yields 6 composite scores, including eating disorder risk
and 5 common psychological constructs. Higher scores indicate
a greater likelihood of an eating disorder. Furthermore, this

version included individuals with an EDNOS diagnosis, which
covers binge eating. The EDI-3 demonstrates good
discriminative validity and good to adequate internal
consistency (Garner, 2004; Cumella, 2006) with recent studies
of women demonstrating results that were even better than the
original (Clausen, Rosenvinge, Friborg, & Rokkedal, 2011).
The Eating Disorder Diagnostic Scale (EDDS; Stice, Telch, &
Rizvi, 2000) is a brief, 22-item, self-report screening measure
of anorexia nervosa (AN), bulimia nervosa (BN), and binge
eating (BE) disorders. The items can be standardized for
consistency and averaged (with the exception of 2 items) to
provide a symptom composite score, and the scale can be
administered in less than 10 minutes. Psychometric studies
provided criterion, convergent, and predictive validity of the
EDDS with samples containing adolescents and adults, as well
as nonclinical and clinical populations. The eating disorder
symptom composite demonstrated internal consistency (.89) and
convergent validity with similar scales assessing eating
pathology (EDE and SCID-I). The 1-week test–retest
coefficients were .95 (AN), .71 (BN), and .75 (BED) (Stice et
al., 2000; Stice, Fisher, & Martinez, 2004). Krabbenborg et al.
(2011); established an overall symptom composite cutoff score
of 16.5, which accurately distinguished those with a disorder
from controls and may be useful in identifying subthreshold
patients as well as detecting possible protective intervention
effects. Later factor analysis found good internal consistency
related to four factors of the scale: body dissatisfaction,
bingeing behaviors, bingeing frequency, and compensatory
behaviors (Lee et al., 2007).
The Eating Attitudes Test (EAT-26; Garner, Olmsted, Bohr, &
Garfinkel, 1982) is a brief, self-report screening measure of
eating disorder symptoms and is not intended to make a
diagnosis. Many studies have been conducted using the EAT-26
as a screening tool, including the 1998 National Eating Disorder
Screening Program (NEDSP). This 26-item questionnaire
contains 3 subscales: dieting (13 items), bulimia and food

preoccupations (6 items), and oral control (7 items).
Respondents must rate whether each item applies on a 6-point
scale (e.g., “always,” “usually,” “often,” “sometimes,” “rarely,”
or “never”). Items are summed to produce a total score. Clients
who score above 20 are considered at risk for an eating disorder
and referred for a diagnostic interview. Additionally,
information is gathered on the individual's BMI, and five
behavioral questions ask about weight-control behaviors (e.g.,
binge, vomit, laxative/diuretic, exercise, and weight loss). The
EAT-26 is easy to administer and score and has good
psychometrics (Mintz & O'Halloran, 2000).
The EAT-26 does not yield a specific diagnosis of an eating
disorder. A disorder must have a prevalence approaching 20% in
order for the test to be efficient in detection. This instrument
was developed and validated on primarily female populations
and is most often used to assess female high school and college
students. The EAT-26 can be useful in measuring pathology in
underweight girls but also shows a high false-positive rate in
distinguishing eating disorders from disturbed eating behaviors
in college women.
The EAT-26 has a children's version (ChEAT-26; Maloney,
McGuire, & Daniels, 1988) for use with children aged 8–13
years with psychometric properties similar to the adult version
(alpha = .88 with low item 19 deleted) and a suggestion that this
measure be further modified if used with younger children since
alphas increased with each grade level. The standard cutoff
score of 20, which is used with adults, was recommended
(Smolak & Levine, 1994; Sancho, Asorey, Arija, & Canals,
2005). Lack of honesty or accuracy in self-reporting can limit
the usefulness of the EAT-26, particularly with anorexia.
However, the EAT-26 has been shown to be useful in detecting
cases of anorexia nervosa, and the assessor can then combine
information gained from this assessment and other assessment
procedures to make a diagnosis (Maloney et al., 1988).
Emergency Considerations
Eating disorders are among the most lethal psychiatric illnesses

in the DSM-5 (APA, 2013). Meta-analysis conducted by
Arcelus, Mitchell, Wales, and Nielsen (2011), found that
mortality rates are substantial among individuals with eating
disorders, especially in those with anorexia nervosa. The
weighted annual mortality rates were 5 per 1000 person-years
for anorexia nervosa (AN), 1.7 per 1000 person-years for
bulimia nervosa (BN), and 3 per 1000 person-years for EDNOS.
More striking, one in 5 individuals with AN who died had
committed suicide. Additionally, age at assessment was found to
be a significant predictor of mortality for individuals with
anorexia. Utilizing data from the National Comorbidity Survey
Replication Adolescent Supplement, Swanson et al. (2011)
found that most adolescents who had a diagnosis of AN, BN,
and BED in the past 12 months reported significant role
impairment (97%, 78%, and 63%, respectively) especially in
their social and family relationships. Moreover, suicide risk was
demonstrated for all eating disorders. Bulimia and subclinical
anorexia were correlated with suicide plans, and BN and BED
were linked with suicide attempts.
Due to the physical complications that can develop from
starvation, laxative abuse, diuretic abuse, and vomiting
behaviors, clients with eating disorders can develop life-
threatening medical conditions that require emergency medical
procedures. Therefore, the practitioner who is working with
eating-disordered clients must develop a “team” approach to
treatment and include a physician or nurse practitioner, a
dentist, a nutritionist, and other medical professionals on the
treatment team to effectively treat the client.
Clients with eating disorders also often suffer from severe
depressive episodes that may lead to feelings of hopelessness
and, ultimately, suicidal behaviors. If the practitioner assesses
the client to have depressive symptoms, the severity of the
depression along with suicidal ideation should be considered.
Crisis intervention strategies should be utilized and a
psychiatric evaluation conducted if necessary to stabilize the
client and keep him or her safe.

Cultural Considerations
Culture beliefs and attitudes are factors that influence the
development of eating disorders (Miller & Pumariega, 2001). It
is important to recognize that in the developed Western
European and North American countries, food is taken for
granted, and only in countries in which there is an abundance of
food do eating disorders flourish. Poor and underdeveloped
countries in which food is scarce have far fewer eating-
disordered individuals among their populations. Cultural values,
therefore, are an important aspect of this illness. Culture shapes
both attitudes and behaviors related to body image and eating,
especially when values about physical aesthetics are involved.
For example, some cultural risk factors for anorexia include
social pressure to be thin (e.g., media attention/peer pressure)
and the focus on body image (Polivy & Herman, 2002; Striegel-
Moore & Bulik, 2007). Western culture's emphasis on thin
idealization can contribute to eating disorders, but it is not
solely culpable. Although the underlying causes of eating
disorders are not entirely clear, a multifactorial relationship that
includes biological, psychological, and sociocultural factors is
most accepted.
There is a growing controversy over why the number of
minorities with eating disorders is relatively low. Many feel
that the research on eating disorders in women of color suffers
from both underreporting and researcher bias (NEDA, 2012),
both of which can result in minorities going undiagnosed. Some
studies show that the experiences of African-American and
Caucasian female adolescents are extremely different, with
African-American girls being proud of their bodies regardless
of the cultural pressure to be thin (Woodrow Wilson
International Center for Scholars, 2000). A cultural identity that
embraces larger body types than does the dominant culture may
account for why some African-American women are at a lower
risk than White American females for developing eating
disorders that focus on thinness. This suggests that a protective
effect may exist in terms of ethnicity and culture for black

American females against the development of some eating
related psychopathology. However, Asian women reported equal
to higher levels of eating dysfunction as white American women
(Wildes, Emery, & Simons, 2001). In contrast, research on
Latinas showed that they are more inclined to exhibit binge
eating rather than restricting behaviors (Smolak & Striegel-
Moore, 2001). Significant ethnic differences emerged for
bulimia, with Hispanic adolescents reporting the highest
prevalence; there was a trend toward ethnic minorities reporting
more binge eating, while non-Hispanic White adolescents
tended to report more anorexia (Swanson et al., 2011).
However, for binge eating, other studies showed that risk
factors did not include ethnicity but rather childhood obesity
and familial eating problems in studies comparing Black and
White women (Striegel-Moore et al., 2005). The variability that
exists across studies is noteworthy and warrants further study.
Contrary to earlier beliefs, a growing number of studies
suggest that U.S. ethnic minority groups are trending toward
higher levels of eating disorders and that the relationship
between ethnicity and disordered eating may vary by disorder
(Striegel-Moore, 2000; Striegel-Moore & Smolak,
2000; Cachelin, Striegel-Moore, & Regan, 2006). One study, for
example, conducted in Minnesota among over 81,000
adolescents, found that the highest prevalence for disordered
eating was among Hispanic and Native American teens of both
genders (Croll, Neumark-Sztainer, Story, & Ireland, 2002).
Quite often this trend is attributed to acculturation (i.e., how
much they have adopted the values and behaviors of the
prevailing culture). As minorities accept the dominant culture's
values, they are subjected to the same kinds of pressures to be
thin as their Caucasian counterparts. Findings by Davis and
Katzman (1999) showed that in Chinese university students
increased acculturation was associated with greater reports of
bulimia and drive for thinness in females and greater
perfectionism in males, both factors in distorted eating.
Measuring the prevalence of eating disorders in minority

populations is further complicated by the fact that they are
underrepresented in most studies, and the likelihood that they
will seek help/ treatment or be asked about eating disorder
symptoms is poor (Stein, 2000). The role that ethnicity plays in
the development of distorted eating needs to be further studied
(Boisvert & Harrell, 2012; White & Grilo, 2005; Striegel-Moore
et al., 2005).
Eating disorders (ED) occur more frequently in women;
however, men are less likely to be diagnosed as they are often
stereotyped as female disorders (SAMHSA, 2011). Adolescent
studies regarding lifetime prevalence estimates found no sex
differences in the prevalence of anorexia or subclinical binge
eating disorders, while for bulimia, binge eating disorder and
subclinical anorexia prevalence was higher in girls (Swanson et
al., 2011). Just as was observed in minorities, eating disorders
are increasing among males as they are finding themselves
subjected to the same cultural ideals in regards to body image
and social pressures that women face (Boisvert & Harrell,
2012). For example, 10% to 15% of individuals with anorexia
and bulimia are male, and among gay men, the numbers …
Title
ABC/123 Version X
1
Feeding and Eating and Sleep–Wake Disorders Worksheet
CCMH/548 Version 5
1
University of Phoenix Material
Feeding and Eating and Sleep–Wake Disorders Worksheet
Choose three feeding and eating disorders, and three sleep–
wake disorders.

Complete the following table.
Disorder
Diagnostic criteria
Etiology
Therapeutic interventions and treatment strategies
Copyright © XXXX by University of Phoenix. All rights
reserved.
Copyright © 2017, 2016, 2015 by University of Phoenix. All
rights reserved.

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