DD

1. by-Dr Sad af Sid d iq u i
moderator -Dr Piyu s h P Singh
DISSOCIATIVE
DISORDERS

2. 1. Introduction
2. History
3. Classification
4. Epidemiology
5. Etiological theories
6. Neurobiology
7. Clinical features
8. Dissociation in other psychiatric disorder
9. Management

3. INTRODUCTION

4. • Dissociation is a common defense/reaction to stressful or
traumatic situations. Severe isolated traumas or repeated
traumas may result in a person developing a dissociative
disorder.
• A dissociative disorder impairs the normal state of awareness
and limits or alters one’s sense of identity, memory or
consciousness. Once considered rare, recent research
indicates that dissociative symptoms are as common as
anxiety and depression.

5. • The concept of dissociative or conversion disorder has been
described since antiquity.
• These disorders have been previously classified as ‘hysteria’,
based on Egyptian theory of wandering uterus.
• The term dissociation has its origin in the constituent parts of
the term: dis-association, which means disconnecting or
lowering the strength of associated connections.

6. • The common theme shared by dissociative disorders is a
partial or complete loss of normal integration between
memories of the past, awareness of identity and immediate
sensations and control of body movements.
• This group of illness also lacks the evidence of proximate
organic illness or pathophysiological disturbance, and the
symptoms correspond to the ideas of the patient about how
parts of body or mind malfunction or fail to function.
Isaac & Chand, 2006; Bob, 2003

7. EVOLUTION OF CONCEPT

8. • The ancient “wandering womb” hypothesis and also humoral
theory remained prominent until the middle of the
eighteenth century.
• “Master organ theories” emerged in the 1700s and referred to
the idea that master organs such as uterus, digestive system
or nerves influenced the brain and resulted in nervous
symptoms.

9. • During the 1800s, the spinal irritation doctrine was expanded
into reflex theory, which asserted that every organ in the body
could reflexively influence every other organ.
• Charcot conceptualized hysteria as an inherited disease of the
nervous system, caused by lesions of the nervous centers.

10. • These lesions were called “functional” because they were
presumed to exist but couldn’t be localized by the techniques
of that time.
• Two of Charcot’s most important successors, Babinski and
Janet, took divergent views.

11. • Babinski describes that hysteria was caused by suggestion and
could be removed by persuasion or counter suggestion.
• Pierre Janet established the concept of “dissociation” to
describe the disruption of normal mental synthesis between
ideas, acts and sensory and motor functions as seen in
patients with hysterical symptoms (Gordon, 1984).

12. • In his theory of dissociation, Janet referred to
mental/behavioural/affective states as “psychological
automatisms”.
• The psychological automatism was an elementary system of
the mind, a complex act tuned to external and internal
conditions, preceeded by an idea, and accompanied by an
emotion.

13. • Janet argued that psychological automatisms could be split off
from consciousness under conditions of terror or severe
stress, illness or fatigue, and function outside awareness of
voluntary control (Van der Kolk, 1989).
• Neo-dissociation theory of Hilgard -1977, theory assumes that
the mind is organized as a system of mental structures, which
monitor and control experience, thought, and action in
different domains.

14. • In principle, each of the structures can process inputs and
outputs independently of the others, although under ordinary
circumstances each structure is in communication with the
others, and several different structures might compete for a
single input or output channel.
• Freud’s psychoanalytic understanding dominated twentieth-
century understanding of conversion symptoms.

15. • During the later part of 1890s, Freud followed Janet’s
dissociation trauma hypothesis and, in his observation of
eighteen hysterical patients, proposed childhood sexual
trauma as the origin of their symptoms.
• Later, he coined the term “conversion” to describe the process
by which unacceptable mental contents were transformed
into somatic symptoms.

16. • Whereas both the classical dissociation theory of Janet (1889)
and the Neo-dissociation theory of Hilgard (1977) assume that
the normal unity of consciousness is disrupted by an amnesia-
like process, Woody and Bowers (1994) have offered an
alternative view that many mental and behavioral functions
are performed unconsciously and automatically to begin with,
by specialized cognitive modules.
• Thus, some degree of dissociation is the natural state.

17. CLASSIFICATION: ICD 10 & DSM-5

18. • Classification of Dissociative disorders is somewhat different
in the two major classificatory systems.
DSM-5
• dissociative amnesia,
• dissociative identity disorder,
• depersonalization disorder,
• other specified dissociative disorder and
• unspecified dissociative disorder.

19. But in ICD 10, dissociative disorders include
• dissociative amnesia
• dissociative fugue,
• dissociative stupor,
• trance and possession disorder,
• dissociative disorders of movement and sensation.
• mixed dissociative disorders (i.e., Ganser’s syndrome ,
multiple personality disorder, transient dissociative disorder
occurring in childhood and adolescence and other specified
dissociative disorders).

20. CHANGES IN DSM-5
• Major changes in dissociative disorders in DSM-5 include the
following:
1) de-realization is included in the name and symptom structure
of what previously was called depersonalization disorder and is
now called depersonalization/de-realization disorder.
2) dissociative fugue is now a specifier of dissociative amnesia
rather than a separate diagnosis.

21. • 3) the criteria for dissociative identity disorder have been
changed to indicate that symptoms of disruption of identity
may be reported as well as observed, and that gaps in the
recall of events may occur for everyday and not just traumatic
events.

22. • In sum, both classification systems agree that dissociation
relates to the (autobiographical) memory system,
consciousness and the domain of personal identity.
• However, the ICD-10 acknowledges that it also may involve
the sensory and motor systems, leading to symptoms which
are subsumed under the term of conversion.

23. • In contrast, the DSM-5 restricts dissociation to the level of
psychic functions and systems.
• Consequently, conversion disorders are one among the
somatoform disorders in the DSM-5, while the ICD-10 claims
that dissociative and conversion disorders represent one
category that is independent from the somatoform disorders.

24. EPIDEMIOLOGY

25. • The first systematic general population study of the
prevalence of dissociative disorder was done by Ross et al
(1990).
• They found dissociative amnesia in 6%, dissociative identity
disorder in 1.3%, depersonalization disorder in 2.8% and
dissociative disorder NOS in 0.2% in a random sample of 1055
adults from Canada.
• Reported rates of dissociative disorder of movement and
sensation (conversion disorder) have varied widely, ranging
from 11/100,000 to 500/100,000 in general population
samples.

26. • Dissociative amnesia,has been reported in approximately 1.8
to 6 percent of general population samples, with 7.3 percent
of a general population sample of Turkish women meeting
diagnostic criteria for dissociative amnesia.
• A survey of a random sample of 1,000 adults in the rural
South found a 1-year prevalence of 19 percent for
depersonalization and 14 percent for de-realization.

27. • Studies of general medical/surgical inpatients have identified
conversion symptom rates ranging between 1% and 14% (APA,
2000)
• Samples of psychiatric inpatients, outpatients, and substance
abuse patients in North America, Europe, and Asia have found
that between 5 and 30 percent of patients could be diagnosed
with a dissociative disorder when screened.

28. • Overall, the prevalence of dissociative disorders in inpatient
and outpatient psychiatric settings seems to be around 10%,
while approximately half of them (5%) has DID, the most
severe type of dissociative disorders.
(Epidemiology of Dissociative Disorders: An Overview Epidemiology Research International Volume 2011)

29. • The majority of patients were diagnosed with dissociative
motor disorder (43.3% outpatients, 37.7% inpatients),
followed by dissociative convulsions (23% outpatients, 27.8%
inpatients)
• Female preponderance was seen across all sub-types of
dissociative disorder except dissociative fugue.
Dissociative disorders in a psychiatric institute in India--a selected review and patterns over a decade

30. ETIOLOGICAL THEORIES

31. INFORMATION PROCESSING THEORIES
• In early 1970s, Hilgard -“Neodissociation theory”.
• This theory conceptualizes the mental apparatus as consisting
of a hierarchy of connected cognitive structures that monitor,
organize and control thought and action.
• According to this theory, certain conditions can disrupt the
links between structures, resulting in a reduction either of
normal voluntary control over subordinate structures or in
awareness of a body process controlled by a given structure.

32. • Brown hypothesizes that conversion symptoms reflect the
selection of inappropriate cognitive representation by low
level attention.
• This selection takes place during the creation of primary
representations that are understood to underlie both the
activation of thought and active schemata, and the subjective
experience and control of action.

33. DISCRETE BEHAVIOURAL STATE MODEL
• Putnam put forward this model in late 1980s.
• He postulates “states” to be the fundamental unit of
organization of consciousness.
• The concept of state/mental state is defined as “a
constellation of certain patterns of physiological variables
and/or patterns of behaviour which seem to repeat
themselves and which appear to be relatively stable”.

34. • Discrete mental-behavioural states can be detected in new
born infants.
• When a transition of state occurs, the new state is reflected in
the quantitative and qualitative variables that define it.
• According to his model, dissociative disorders are
characterized by the individual’s consciousness being
organized into a series of discrete mental-behavioural states
characterized by specific affects, body images, modes of
cognition, perceptions, memories and behaviour.

35. • Unlike most adults, in individuals prone to dissociation, the
transitions between the individual’s states remain abrupt and
discontinuous.
• This can occur either as a result of severe childhood trauma
that has disrupted the normal developmental process of
smoothing out transitions between states, or in response to
conditions of severe stress, terror, severe illness or fatigue

36. DISSOCIATION AS A RESPONSE TO TRAUMA
• Since 1980s, research has elucidated multiple lines of
evidence linking dissociative disorder with antecedent
trauma.
• Several hundred peer-reviewed studies have found
significantly high levels of dissociation in traumatized groups
in comparison with the non-traumatized clinical and the
general population.
Van der Hart et al, 2004

37. • Sar et al (2004) found childhood physical trauma in 44.7% and
childhood sexual abuse in 26.3% in a sample of 38 patients
with conversion disorder.
• Maaranen et al (2004) reported a strong association of
childhood adverse experiences in people with somatoform
dissociation. Stone et al (2004) reported a higher incidence of
parental divorce in patients with pseudoseizures.

38. TAXON MODEL
• Taxon items represent statistically derived clusters of
symptoms experienced by those with a dissociative illness.
• It assumes that pathological dissociation such as dissociative
identity disorder represents a different type of taxon of
psychological organization.
• This is a contrast to earlier belief that dissociation occurs as a
continuum from normal to pathological (Isaac & Chand, 2006;
Loweinstein & Putnam, 2005).

39. • The taxon model implies a significantly different
developmental scenario than the continuum model, as well as
a different approach to treatment.
• In a continuum model of dissociation, a positive treatment
response would be conceptualized as moving a dissociative
individual more toward the normal dissociation segment of
the continuum.
• By contrast, a positive treatment outcome in a taxon model
implies changing an individual’s type from the dissociative to
the nondissociative category.

40. HYPNOTIC MODEL
• This model hypothesizes that a traumatized individual uses his
or her innate hypnotic capacity to induce autohypnosis as a
defense against overwhelming or repetitive traumatic
experiences.
• With continued use, the autohypnotic state is transformed
into an independent alter personality state.
• Several lines of evidence are said to support the autohypnotic
theory.

41. • The first is that dissociative, especially dissociative identity
disorder patients are highly hypnotizable.
• Second, many of the clinical phenomena associated with
pathological dissociation, such as trance states, age
regression, auditory hallucinations and amnesias, can be
produced in normal individuals with hypnosis.
• Finally, a pair of studies suggested that childhood trauma
might increase hypnotizability .
(Loweinstein & Putnam, 2005).

42. SOMATIC MARKER HYPOTHESIS
• This hypothesis was proposed by Damasio (2000).
• He developed a neurobiological model of consciousness and
proposed that conversion reactions may reflect transient but
radical changes in body maps, the neural representation of
body states.
• The spinothalamic pathway conveys afferent interoceptive
information from all tissues of the body and body state is
mapped continuously at different brain levels (i.e., brainstem
nuclei, hypothalamus, thalamus, anterior cingulated cortex
and somatosensory cortices).

43. • Somatic marker hypothesis defines “feelings” as subjective
perception of body state and feelings can emerge due to
actual stimulation of emotion triggering sites.

44. IATROGENIC AND SOCIOCOGNITIVE MODEL
• Some authorities believe that dissociative identity disorder
and dissociative amnesia are not authentic psychiatric
disorders but rather the product of suggestion on susceptible
individuals that leads them to believe that they have a
dissociative disorder and to enact the role of a person with
multiple selves or amnesia for childhood maltreatment.
• This has been called the iatrogenic or sociocognitive model.
• However, no empirical studies have been performed in clinical
population to attempt to examine the sociocognitive model or
related ideas.

45. NEUROBIOLOGY

46. DISORGANIZED ATTACHMENT AND THE ORBITOFRONTAL CORTEX
AS THE BASIS FOR THE DEVELOPMENT OF DISSOCIATIVE
IDENTITY DISORDER
• One particularly promising theory posits that, in addition to
traumagenic origins, infant disorganized attachment may be a
significant contributor to the development of DID.
• Neuroimaging studies have identified areas of the brain, the
orbitofrontal cortex in particular, that function differently in
DID patients, thus providing a neurobiological basis for the
disorder.

47. • One study compared rCBF of DID patients while they were in
their host personality with normal controls and observed
lower rCBF in the orbitofrontal cortex (OFC) of the DID
subjects.
• The orbitofrontal cortex is thought to be involved in decision-
making. Thus, Sar hypothesizes that the decreased
functioning of the OFC results in impulsivity and that the
switch to an alter personality may represent a drastic
expression of impulsive behavior caused by cognitive and
emotional conflicts.

48. • A more adequate description, provided by Rhawn Joseph, is
that the OFC is the “senior executive of the emotional brain.
• This system is also involved in the regulation of the body state
and reflects changes taking place in that state (Luria, 1980).
• Antonio Damasio posits in his model of consciousness that the
development of a notion of self arises from the brain’s second
order mapping of the relation between “objects” and the
organism.

49. • Within this model of consciousness, the OFC, with its
functions in both emotional processing of sensory information
as well as homeostasis and the mapping of the body, would
seem to be a critical component in the generation of a self.
• Thus, it is quite plausible that an abnormally functioning OFC
could lead to the generation of multiple selves.

50. • Attachment theory posits that an infant’s development of
attachment to its caregiver, usually its parent(s), plays a large
role in the development of its personality and later social
behaviors.
• Liotti builds upon the work of Main and Hesse by
hypothesizing that the conflicting models of self that are
developed within an infant with disorganized attachment
create the risk for the later development of DID.

51. • The conflicting attachment experiences endured by an infant
with disorganized attachment would lead to irregular
development of the OFC, which would mirror the
development of the conflicting models of self.
American Psychiatric Association, STAT!Ref, and Teton Data Systems. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 2000

52. NEUROPHYSIOLOGY STUDIES
• HRV, EEG and (functional) MRI are sensitive methods to
detect physiological changes related to dissociation and
dissociative disorders such as FNSS.
• The majority of the identified studies concerned the
physiological characteristics of hypnosis; relatively few
investigations on dissociation related FNSS were identified.
General findings were increased parasympathetic functioning
during hypnosis (as measured by HRV), and lower HRV in
patients with FNSS

53. • Flor-Henry et al (1990) documented two cases of multiple
personality disorder with bilateral frontal and left temporal
dysfunction on neuropsychological test batteries and relative
activation of the left hemisphere across all cerebral regions in
EEG analysis

54. • Allen & Movius (2000) documented four cases of multiple
personality disorder evaluated by ERP during a memory
assessment task, in which words learned by one identity were
then presented to a second identity.
• All patients, when tested as second personality, produced ERP
and behavioural evidence consistent with recognition of
material learned by the first identities.

55. NEUROCHEMICAL STUDIES
• Delahanty et al (2003) found that peritraumatic dissociation
was correlated with 15 hour urine epinephrine level in 59
motor vehicle accident patients. Such a correlation was not
found for norepinephrine.
• Simeon et al (2003) found strong negative correlation
between urinary norepinephrine and depersonalization scores
in patients with depersonalization disorder.

56. • The authors concluded that although dissociation
accompanied by anxiety was associated with heightened
noradrenergic tone, there was a marked basic norepinephrine
decline with increasing severity of dissociation.
• Chambers et al (1999) found that high doses of ketamine
produced slowed perception of time, tunnel vision,
derealization and depersonalization in trauma victims.

57. • Pretreatment with a benzodiazepine or lamotrigine reduced
but didn’t entirely eliminate the effects of ketamine.
• It suggests that NMDA glutamate receptors play a central role
in dissociative symptoms

58. NEUROIMAGING
• key findings in neuroimaging studies of dissociative disorder
are volume reduction of amygdala and hippocampus,
nondominant hemisphere lesions in dissociative seizure.
• There is increase as well as decrease in contralateral
hemisphere activity in motor conversion disorder.
• In one study, patients with depersonalization disorder had
higher activity in somatosensory association areas
Simeon et al 2000

59. • In another study, functional MRI was used to examine brain
activation in PTSD patients in a dissociative state while
reexperiencing traumatic memories; greater activation was
found in the temporal, inferior, and medial frontal regions and
in occipital, parietal, anterior cingulate, and medial prefrontal
cortical regions.
Lanius RA, Brain activation during script-driven imagery induced dissociative responses in PTSD: a
functional magnetic resonance imaging investigation. Biol Psychiatry. 2002

60. • Administration of ketamine, an antagonist of N-methyl-D-
aspartic acid (NMDA) receptors, which are highly
concentrated in the hippocampus, resulted in dissociative
symptoms in healthy subjects, including feelings of being out
of body and of time standing still, perceptions of body
distortions, and amnesia.
• On the basis of these findings, it was hypothesized that stress,
acting through NMDA receptors in the hippocampus, may
mediate symptoms of dissociation.
Glutamate and post-traumatic stress disorder: toward a psychobiology of dissociation. Semin Clin
Neuropsychiatry. 1999

61. DISSOCIATION SCALES AND DIAGNOSTIC INTERVIEWS
Symptom screening measures
• Dissociative experience scale (DES) is one of the best known
among general dissociation screening scales.
• Developed by Bernstein & Putnam (1986), Dissociative
Experiences Scale (DES) is a 28-item self-report instrument.
• It is a visual analog scale where the respondent has to slash a
line to indicate a score anywhere from 0 to 100 for each item.

62. • Another good screening measure is the 20-item Somatoform
Dissociative Questionnaire (SDQ-20) developed by Nijenhuis
et al (1996).
• The scale taps many of the somatosensory and dissociative
symptoms including motor inhibitions, loss of function,
anaesthesia and analgesia, pain and problems with vision,
hearing and smell.
• The scale has good reliability and validity for discriminating
dissociative disorder patients.

63. Diagnostic interviews
• Two DSM-based structured interviews have been developed
for the formal diagnosis of dissociative disorders-
1. The Structured Clinical Interview for DSM-IV Dissociative
Disorders, Revised ( SCID-D-R; Steinberg et al, 1994)
2. The Dissociative Disorder Interview Schedule (DDIS; Ross et
al, 1989).

64. • The SCID-D-R is a semi-structured clinician administered
interview that assesses the presence and severity of amnesia,
identity confusion and alteration, depersonalization and
derealization.
• The DDIS is a clinical diagnostic instrument which inquires
about a wide range of phenomena in addition to dissociative
symptoms, including child abuse history, major depression,
somatic complaints, substance abuse and paranoid
experiences

65. CLINICAL FEATURES

66. DISSOCIATIVE AMNESIA
• There are two major clinical presentations of dissociative
amnesia-
• The classic presentation is an overt, florid dramatic clinical
disturbance in which an individual is found without memory
for identity or life history.
• Less extreme forms of amnesia, such as acute amnesia for
recent traumatic circumstances, such as combat or rape, also
fall into this category.

67. • In the non-classical presentation, chronic, recurrent or
persistent dissociative amnesia, or a combination of these, is
most likely.
• Commonly, patients with nonclassic presentation of amnesia
do not reveal the presence of dissociative symptoms unless
directly asked about those.

68. subtypes
• Localized -inability to recall events related to a circumscribed period
of time.
• Selective -ability to remember some, but not all, of the events
during a circumscribed period of time.
• Continuous-failure to recall successive events as they occur
• Generalized-failure to recall whole life of the patient.
• Systematized-amnesia for certain categories of memory such as all
memories relating to one’s family or a particular person.

69. • It is important to distinguish dissociative amnesia from
organic amnesia.
• Though there is no single test or examination that can
differentiate these two, in organic amnesia, the memory loss
for personal information is embedded in a far more extensive
set of cognitive, language, attentional, behavioural and
memory problems.
• Loss of memory for personal identity is usually not found in
organic amnesia without evidence of a marked disturbance in
many domains of cognitive function.

70. DISSOCIATIVE FUGUE
• Classically, three types of fugue have been described:
(1) fugue with awareness of loss of personal identity
(2) fugue with change of personal identity
(3) fugue with retrograde amnesia.
• During a fugue, patients often appear without psychopathology
and do not attract attention.
• After the termination of a fugue, the patient may experience
perplexity, trance-like behaviour, depersonalization, derealization,
and conversion symptoms, in addition to amnesia.

71. DISSOCIATIVE IDENTITY DISORDER
• Dissociative identity disorder is characterized by two or more
distinctive identities or personalities; at least two of these
identity states recurrently taking control of the person’s
behaviour and inability to recall important personal
information that is too extensive to be explained by ordinary
forgetfulness (APA, 1994).
• The different identities, referred to as alters, may exhibit
differences in speech, mannerisms, attitudes, thoughts, and
gender orientation

72. • Most patients have personalities that are named, but there
may be those who are nameless or whose appellations are
not proper names.
• The classic host personality, which usually (over 50% of the
time) presents for treatment, nearly always bear the legal
name and is depressed, anxious, somewhat neurasthenic,
compulsively good, masochistic, conscience-striken,
constricted hedonically and suffers both psychophysiological
symptoms and time loss or time distortion.

73. DEPERSONALIZATION DISORDER
• Patients experiencing depersonalization often have great
difficulty expressing what they are feeling.
• There are a number of distinct components to the experience
of depersonalization.
• These include a sense of bodily changes, a sense of being cut
off from others, and a sense of being cut off from one’s own
emotions. Despite the outward appearance of lack of distress,
depersonalization disorder patients are enduring an intensely
unpleasant, and often disabling, subjective experience.

74. Serotonergic involvement
• Association of depersonalization with migraines and
marijauna , response to selective serotonin reuptake
inhibitors drugs,increased depersonalization symptom seen
with depletion of tryptophan.
• Neurochemical findings have suggested possible involvement
of serotonergic, endogenous opioid and glutamatergic NMDA
pathways.
Depersonalisation disorder: a contemporary overview,Simeon D

75. • On the other hand, de-realization , is the sense that the world
appears strange, foreign, or dream-like.
• It is conceptualized as a dissociative alteration in the
perception of the environment.
• Objects may appear as if viewed from a great distance and as
if they are two dimensional, without depth or substance.

76. • Objects feel strange to the touch,Colours deem and lose their
vitality.
• The faces of others change, becoming unfamiliar or
frightening.
• The world and all action and behaviour lose meaning and
purpose.

77. SEVERAL MODELS HAVE BEEN PROPOSED TO EXPLAIN
DEPERSONALIZATION DISORDER.
A SCHEMATIC INTEGRATION OF THESE MODEL

78. DISSOCIATIVE DISORDER OF MOVEMENT AND
SENSATION (CONVERSION DISORDER)
• In these disorders, motor symptoms or deficits usually include
impaired coordination, tremor or flaccidity, difficulty
swallowing or a sensation of lump in the throat, aphonia and
urinary retention.
• Sensory symptoms or deficits include loss of touch or pain
sensation, hyperesthesia and paresthesia, double vision,
blindness, deafness and hallucination.

79. • Dissociative seizure can be distinguished from true seizure by
its occurrence in almost always awake condition, longer
duration, lack of stereotyped movements, variable and bizarre
motor activity, partial preservation of awareness, pelvic
thrusting movements, side to side head movement, emotional
display, closed eyes with resistance to passive opening,
responsiveness to painful stimuli, absence of postictal
confusion, normal postictal EEG and normal serum prolactin
level after seizure.
Bowman & Markand, 2005

80. OTHER SPECIFIED DISSOCIATIVE DISORDER
• This category is included for disorders in which the
predominant feature is a dissociative symptom (i.e., a
disruption in the usually integrated functions of
consciousness, memory, identity, or perception of the
environment) that does not meet the criteria for any specific
dissociative disorder.
• It includes –
1.Chronic and recurrent syndromes of mixed dissociative
symptoms

81. 2.Identity disturbance due to prolonged and intense coercive
persuasion.
3.Acute dissociative reactions to stressful events
4.Dissociative trance-manifest by temporary marked alteration
in the state of consciousness or by a loss of customary sense of
personal identity but without the replacement by an alternate
sense of identity.

82. REFERENCES
• Kaplan & sadock’s comprehensive textbook of psychiatry,ninth edition
• Kaplan & sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry,
10th edition
• Glutamate and post-traumatic stress disorder: toward a psychobiology of
dissociation. semin clin neuropsychiatry. 1999
• Lanius ra, brain activation during script-driven imagery induced dissociative
responses in ptsd: a functional magnetic resonance imaging investigation. biol
psychiatry. 2002
• Epidemiology of dissociative disorders: an overview,epidemiology research
international volume 2011)

83. THANK YOU