A BRIEF SEMINAR ON DISSOCIATIVE SPECTRUM DISORDER

1. DISSOCIATIVE SPECTRUM
DISORDER
DR. SUBRATA NASKAR

2. PLAN OF PRESENTATION
• INTRODUCTION
• HISTORY
• CLASSIFICATION
• ETIOLOGICAL MODELS
• EPIDEMIOLOGY
• NEUROBIOLOGY
• CLINICAL FEATURES
• COURSE AND PROGNOSIS
• MANAGEMENT
• ASSOCIATED DISORDERS
• THE INDIAN SCENE
• DISSOCIATION AND MEDIA

3. INTRODUCTION
• THE CONCEPT OF DISSOCIATIVE OR CONVERSION DISORDER HAS
BEEN DESCRIBED SINCE ANTIQUITY.
• THESE DISORDERS HAVE BEEN PREVIOUSLY CLASSIFIED AS
‘HYSTERIA’, BASED ON GREEK 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.

4. • DISSOCIATIVE DISORDERS IS A DISRUPTION IN THE USUALLY INTEGRATED
FUNCTIONS OF
• CONSCIOUSNESS
• MEMORY
• IDENTITY
• PERCEPTION OF THE ENVIRONMENT
• 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).

5. EVOLUTION OF CONCEPT
• BODY-MIND DUALISM, IS THE INTELLECTUAL
LEGACY OF RENE DESCARTES, THE
SEVENTEENTH CENTURY FRENCH
PHILOSOPHER AND MATHEMATICIAN.
• THE CARTESIAN PARADIGM HAS GENERALLY
FORCED A CLEAVING OF HUMANITY INTO
PSYCHE AND SOMA.

6. • 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.
• BY THE END OF THE EIGHTEENTH CENTURY, THE SPINAL CORD WAS SEEN AS
THE CENTRE OF BODY’S NERVOUS COMMUNICATION AND ITS IRRITATION
WAS THOUGHT TO PRODUCE SYMPTOMS ELSEWHERE IN THE BODY.
• 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.

8. • JEAN-MARTIN CHARCOT, A LEADING PARISIAN
NEUROLOGIST, CONCEPTUALIZED HYSTERIA AS
AN INHERITED DISEASE OF THE NERVOUS
SYSTEM, CAUSED BY LESIONS OF THE NERVOUS
CENTERS.
• THESE LESIONS WERE CALLED “FUNCTIONAL”
BECAUSE THEY WERE PRESUMED TO EXIST BUT
COULDN’T BE LOCALIZED BY THE TECHNIQUES
OF THAT TIME.
1825 –1893

9. CHARCOT DEMONSTRATING HYPNOSIS ON A "HYSTERICAL"
PATIENT, "BLANCHE" (BLANCHE WITTMANN), WHO IS
SUPPORTED BY DR. JOSEPH BABIŃSKI

10. • AFTER HIS DEATH, TWO OF CHARCOT’S MOST IMPORTANT
SUCCESSORS, BABINSKI AND JANET, TOOK DIVERGENT
VIEWS.
• BABINSKI TOOK THE VIEW 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

11. • FREUD’S PSYCHOANALYTIC UNDERSTANDING
DOMINATED TWENTIETH-CENTURY UNDERSTANDING OF
CONVERSION SYMPTOMS.
• 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

12. CLASSIFICATIONS
• CLASSIFICATION OF DISSOCIATIVE DISORDERS IS
SOMEWHAT DIFFERENT IN THE TWO MAJOR
CLASSIFICATORY SYSTEMS.
• DSM IV-TR INCLUDES
• DISSOCIATIVE AMNESIA
• DISSOCIATIVE FUGUE
• DISSOCIATIVE IDENTITY DISORDER
• DEPERSONALIZATION DISORDER
• DISSOCIATIVE DISORDER NOT OTHERWISE SPECIFIED (NOS)

13. • ICD-10 CLASSIFIES DISSOCIATIVE DISORDERS UNDER F44
• F44.0 DISSOCIATIVE AMNESIA
• F44.1 DISSOCIATIVE FUGUE
• F44.2 DISSOCIATIVE STUPOR
• F44.3 TRANCE AND POSSESSION DISORDERS
• F44.4 DISSOCIATIVE MOTOR DISORDERS
• F44.5 DISSOCIATIVE CONVULSIONS
• F44.6 DISSOCIATIVE ANAESTHESIA AND SENSORY LOSS
• F44.7 MIXED DISSOCIATIVE [CONVERSION] DISORDERS
• F44.8 OTHER DISSOCIATIVE [CONVERSION] DISORDERS
• .80 GANSER'S SYNDROME
• .81 MULTIPLE PERSONALITY DISORDER
• .82 TRANSIENT DISSOCIATIVE [CONVERSION] DISORDERS OCCURRING IN CHILDHOOD AND
ADOLESCENCE
• .88 OTHER SPECIFIED DISSOCIATIVE [CONVERSION] DISORDERS
• F44.9 DISSOCIATIVE [CONVERSION] DISORDER, UNSPECIFIED

14. • THE ICD10 CATEGORY OF DISSOCIATIVE DISORDERS OF MOVEMENT AND
SENSATION ARE CLASSIFIED UNDER THE RUBRIC OF SOMATOFORM
DISORDERS IN DSM IV-TR AND THESE DISORDERS ARE NAMED AS
CONVERSION DISORDERS.
• DSM IV-TR MENTIONS FOUR SUBTYPES OF CONVERSION DISORDERS
• CONVERSION DISORDER WITH MOTOR SYMPTOMS OR DEFICIT
• CONVERSION DISORDER WITH SENSORY SYMPTOMS OR DEFICIT
• CONVERSION DISORDER WITH SEIZURE OR CONVULSION
• CONVERSION DISORDER WITH MIXED PRESENTATION.
• ICD 10 CLASSIFIES DEPERSONALIZATION DEREALIZATION SYNDROME UNDER
THE HEADING OF OTHER NEUROTIC DISORDERS. F48
• DSM IV-TR INCLUDES DISSOCIATIVE TRANCE DISORDER IN THE CHAPTER OF
“CRITERIA SETS AND AXES PROVIDED FOR FURTHER STUDY” (APPENDIX B)
AND DOESN’T MENTION SEPARATE ENTITY OF DISSOCIATIVE STUPOR (WHO,
1992; APA, 2000).

15. CHANGES IN DSM V
NO CHANGE

16. SO WHAT ELSE IN THE SPECTRUM NOT INCLUDED
IN THE MAJOR CLASSIFICATIONS
• GENERAL DISSOCIATION
• PTSD
• DISSOCIATION IN EPILEPSY
• PERSONALITY DISORDERS
• EATING DISORDERS

17. EPIDEMIOLOGY
• 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%
• DISSOCIATIVE DISORDER NOS 0.2%
• IN A RANDOM SAMPLE OF 1055 ADULTS FROM CANADA.

18. • RECENTLY, JHONSON ET AL (2006), IN A COMMUNITY SAMPLE OF 658 ADULTS, FOUND THE
PREVALENCE AS
• DISSOCIATIVE AMNESIA IN 1.8%
• DISSOCIATIVE IDENTITY DISORDER IN 1.5%
• DEPERSONALIZATION DISORDER IN 0.8%
• DISSOCIATIVE DISORDER NOS IN 4.4%
• IN AN ADULT PSYCHIATRIC OUTPATIENT SAMPLE OF 82 PATIENTS, FOOTE ET AL (2006)
FOUND
• DISSOCIATIVE AMNESIA IN 10%
• DISSOCIATIVE IDENTITY DISORDER IN 6%
• DEPERSONALIZATION DISORDER IN 5%
• DISSOCIATIVE DISORDER NOS IN 9%
• INTERESTINGLY, NONE OF THE ABOVE STUDIES GOT A SINGLE CASE OF DISSOCIATIVE
FUGUE.
• 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.
• IT HAS BEEN REPORTED IN UP TO 3% OF OUTPATIENT REFERRALS INTO MENTAL HEALTH
CLINICS.
• STUDIES OF GENERAL MEDICAL/SURGICAL INPATIENTS HAVE IDENTIFIED CONVERSION
SYMPTOM RATES RANGING BETWEEN 1% AND 14%

19. ETIOLOGICAL THEORIES
• INFORMATION PROCESSING THEORIES:
• IN EARLY 1970S, HILGARD (1973) REINTEGRATED JANET’S THEORY OF
DISSOCIATION IN THE LIGHT OF EMPIRICAL STUDIES OF HYPNOTIC PHENOMENA
AND CALLED IT “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.
• THE COGNITIVE STRUCTURE AT THE TOP OF THE HIERARCHY EXERCISES
EXECUTIVE FUNCTION OF MONITORING AND CONTROL, AND IS RESPONSIBLE
FOR AWARENESS AND INTENTIONALITY.
• 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.

20. MENTAL APPARATUS
X

21. • RECENTLY, BROWN (2002) HAS DEVELOPED A MORE INTEGRATED
INFORMATION PROCESSING MODEL.
• BROWN HYPOTHESIZES THAT CONVERSION SYMPTOMS REFLECT THE
SELECTION OF INAPPROPRIATE COGNITIVE REPRESENTATION BY LOW LEVEL
ATTENTION.
• ACCORDING TO BROWN, SENSORY INFORMATION AUTOMATICALLY TRIGGERS
MULTIPLE RELATED REPRESENTATIONS IN MEMORY.
• THIS PROCESS GENERATES A NUMBER OF HYPOTHESES, EACH REPRESENTING
A POSSIBLE INTERPRETATION OF THE STIMULUS IN THE CONTEXT OF PAST
EXPERIENCE.
• ULTIMATELY, THE MOST ACTIVE HYPOTHESIS IS SELECTED AND THEN USED TO
ORGANIZE THE RELEVANT INFORMATION INTO A PRIMARY REPRESENTATION
THAT PROVIDES THE BASIS FOR ACTIONS AND CONTENTS OF CONSCIOUSNESS

22. DISCRETE BEHAVIOURAL STATE MODEL
• PUTNAM (1988) PUT FORWARD THIS MODEL IN LATE 1980S.
• PUTNAM 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”.
• 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.
• PUTNAM PROPOSES THAT WITH MATURATION, TRANSITIONS BETWEEN STATES
SMOOTH OUT, BECOMES LESS OBVIOUS, AND ARE LESS LIKELY TO SHOW
OBVIOUS PHYSIOLOGICAL CORRELATES.
Frank W. Putnam

23. • 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.
• 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.

24. 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).
• FEW RECENT STUDIES IN SUPPORT OF THIS THEORY ARE AS FOLLOWS-
• 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.

25. 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 AN EARLIER BELIEF THAT DISSOCIATION OCCURS AS A
CONTINUUM FROM NORMAL TO PATHOLOGICAL (ISAAC & CHAND, 2006; LOWEINSTEIN
& PUTNAM, 2005).
• TWO LARGE SCALE STUDIES (WALLER ET AL, 1996; ROSS & ELLASON, 2005) HAVE
SUPPORTED THIS THEORY BY SHOWING THAT PATIENTS WITH DISSOCIATIVE DISORDER
HAVE MUCH HIGHER SCORES ON VARIOUS ITEMS OF DIFFERENT SCALES FOR SCORING
DISSOCIATIVE EXPERIENCE.

26. • WALLER ET AL (1996) ALSO IDENTIFIED 8 ITEMS OF THE DISSOCIATIVE
EXPERIENCE SCALE THAT COULD ROBUSTLY DIFFERENTIATE DISSOCIATIVE
DISORDER PATIENTS FROM OTHER PSYCHIATRIC PATIENTS AND NORMAL
CONTROLS.

27. DISSOCIATIVE EXPERIENCES SCALE ITEMS COMPRISING THE DISSOCIATIVE
EXPERIENCES SCALE TAXON
• SUBJECTS ARE ASKED TO RATE THE PERCENTAGE OF TIME, FROM 0 TO 100 PERCENT, THAT THEY HAVE THE EXPERIENCE.
• SOME PEOPLE HAVE THE EXPERIENCE OF FINDING THEMSELVES IN A PLACE AND HAVING NO IDEA HOW THEY GOT THERE.
• SOME PEOPLE HAVE THE EXPERIENCE OF FINDING NEW THINGS AMONG THEIR BELONGINGS THAT THEY DO NOT REMEMBER
BUYING.
• SOME PEOPLE SOMETIMES HAVE THE EXPERIENCE OF FEELING AS THOUGH THEY ARE STANDING NEXT TO THEMSELVES OR
WATCHING THEMSELVES DO SOMETHING, AND THEY ACTUALLY SEE THEMSELVES AS IF THEY WERE LOOKING AT ANOTHER PERSON.
• SOME PEOPLE ARE TOLD THAT THEY SOMETIMES DO NOT RECOGNIZE FRIENDS OR FAMILY MEMBERS.
• SOME PEOPLE HAVE THE EXPERIENCE OF FEELING THAT OTHER PEOPLE, OBJECTS, AND THE WORLD AROUND THEM ARE NOT REAL.
• SOME PEOPLE HAVE THE EXPERIENCE OF FEELING THAT THEIR BODY DOES NOT SEEM TO BELONG TO THEM.
• SOME PEOPLE SOMETIMES FIND THAT, IN ONE SITUATION, THEY MAY ACT SO DIFFERENTLY COMPARED TO ANOTHER SITUATION THAT
THEY FEEL ALMOST AS IF THEY WERE TWO DIFFERENT PEOPLE.
• SOME PEOPLE SOMETIMES FIND THAT THEY HEAR VOICES INSIDE THEIR HEAD THAT TELL THEM TO DO THINGS OR COMMENT ON
THINGS THAT THEY ARE DOING.

28. 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.
• 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

29. 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 CINGULATE CORTEX AND
SOMATOSENSORY CORTICES).
• SOMATIC MARKER HYPOTHESIS DEFINES “FEELINGS” AS SUBJECTIVE
PERCEPTION OF BODY STATE AND FEELINGS CAN EMERGE DUE TO ACTUAL
STIMULATION OF EMOTION TRIGGERING SITES OR VIA “AS-IF BODY LOOPS”.
• THE AS-IF BODY LOOPS REFER TO THE DIRECT SIGNALING FROM EMOTION
TRIGGERING SITES WITHOUT THE ACTUAL STIMULUS.

30. • THEY MAY DEVELOP AS A RESULT OF THE REPEATED ASSOCIATION OF A
CERTAIN MENTAL IMAGE OF AN ENTITY OR EVENT AND AN EMOTIONAL
BODY STATE.
• WITH TIME, THE AS-IF BODY LOOP WOULD ALLOW FOR THE
ANTICIPATED BODY STATE TO BE MAPPED AND FOR FEELINGS TO
EMERGE IN RESPONSE TO THE ASSOCIATED IMAGE, WITHOUT THE
PROCESS OF BODY ACTIVATION BEING REQUIRED.
• IT CAN THEORETICALLY RESULT IN BODY-SENSING REGIONS RECEIVING
INFORMATION THAT DOESN’T CORRESPOND TO THE ACTUAL STATE OF
THE BODY, RESULTING IN GENERATION OF “FALSE BODY IMAGE”-IN
WHICH CASE THE INDIVIDUAL’S PERCEPTION OF BODY STATE WILL ALSO
BE FALSE.

31. NEURAL NETWORKS AND DISSOCIATION- A
LINKING THEORETICAL MODEL
• PARALLEL DISTRIBUTED PROCESSING IS A MODEL FOR THE
MICROSTRUCTURE OF COGNITION (MCCLELLAND & RUMELHART, 1986),
WHERE THE ACTIVITIES OF MANY NEURONS ARE DESCRIBED AS
CONFIGURATION OR NEURAL PATTERN AND THEIR PSYCHOLOGICAL
CORRELATES ARE CALLED MENTAL REPRESENTATIONS.
• IN THIS MODEL, SUBUNITS OR NEURAL NETS PROCESS INFORMATION
THROUGH COMPUTATION OF CO-OCCURRENCE OF INPUT STIMULI.
• THE ACTIVATION PATTERNS IN THESE NEURAL NETS ALLOW FOR
CATEGORY RECOGNITION.
• THE OUTPUT OF ONE SET OF NETS BECOMES THE INPUT TO ANOTHER,
THEREBY GRADUALLY BUILDING UP INTEGRATED AND COMPLEX PATTERNS
OF ACTIVATION AND INHIBITION.

32. • SUCH BOTTOM-UP PROCESSING MODELS HAVE THE ADVANTAGE OF
ACCOUNTING FOR THE PROCESSING OF VAST AMOUNTS OF INFORMATION
AND FOR THE HUMAN ABILITY TO RECOGNIZE PATTERNS ON THE BASIS OF
APPROXIMATE INFORMATION.
• HOWEVER, SUCH MODELS ALSO MAKE THE CLASSIFICATION AND
INTEGRATION OF INFORMATION PROBLEMATIC.
• WHEN A NET RUNS INTO DIFFICULTY IN BALANCING THE PROCESSING OF
INPUT INFORMATION (A MODEL FOR TRAUMATIC INPUT), IT IS MORE
LIKELY TO HAVE DIFFICULTY ACHIEVING A UNIFIED AND BALANCED
OUTPUT.
• SUCH NEURAL NETS TEND TO FALL INTO A “DISSOCIATED” SITUATION IN
WHICH THEY MOVE IN ONE DIRECTION OR ANOTHER BUT CANNOT REACH
AN OPTIMAL OR BALANCED SOLUTION, AND THEREFORE THEY ARE
UNABLE TO PROCESS SMOOTHLY ALL OF THE INCOMING INFORMATION

33. 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

34. ETIOLOGICAL THEORIES ON CONVERSION DISORDER
PSYCHOANALYTIC FACTORS
• ACCORDING TO PSYCHOANALYTIC THEORY, CONVERSION DISORDER IS CAUSED BY
REPRESSION OF UNCONSCIOUS INTRAPSYCHIC CONFLICT AND CONVERSION OF ANXIETY
INTO A PHYSICAL SYMPTOM.
• THE CONFLICT IS BETWEEN AN INSTINCTUAL IMPULSE (E.G., AGGRESSION OR SEXUALITY)
AND THE PROHIBITIONS AGAINST ITS EXPRESSION.
• THE SYMPTOMS ALLOW PARTIAL EXPRESSION OF THE FORBIDDEN WISH OR URGE BUT
DISGUISE IT, SO THAT PATIENTS CAN AVOID CONSCIOUSLY CONFRONTING THEIR
UNACCEPTABLE IMPULSES
• THE CONVERSION DISORDER SYMPTOM HAS A SYMBOLIC RELATION TO THE
UNCONSCIOUS CONFLICT
• EXAMPLE, VAGINISMUS PROTECTS THE PATIENT FROM EXPRESSING UNACCEPTABLE SEXUAL WISHES.
• CONVERSION DISORDER SYMPTOMS ALSO ALLOW PATIENTS TO COMMUNICATE THAT
THEY NEED SPECIAL CONSIDERATION AND SPECIAL TREATMENT.
• SUCH SYMPTOMS MAY FUNCTION AS A NONVERBAL MEANS OF CONTROLLING OR
MANIPULATING OTHERS.

35. • LEARNING THEORY
• IN TERMS OF CONDITIONED LEARNING THEORY, A CONVERSION SYMPTOM CAN BE SEEN AS A
PIECE OF CLASSICALLY CONDITIONED LEARNED BEHAVIOR. EG: SYMPTOMS OF ILLNESS,
LEARNED IN CHILDHOOD, ARE CALLED FORTH AS A MEANS OF COPING WITH AN OTHERWISE
IMPOSSIBLE SITUATION.
• BIOLOGICAL FACTORS
• PRELIMINARY BRAIN-IMAGING STUDIES HAVE FOUND HYPOMETABOLISM OF THE DOMINANT
HEMISPHERE AND HYPERMETABOLISM OF THE NONDOMINANT HEMISPHERE AND HAVE
IMPLICATED IMPAIRED HEMISPHERIC COMMUNICATION IN THE CAUSE OF CONVERSION
DISORDER.
• THE SYMPTOMS MAY BE CAUSED BY AN EXCESSIVE CORTICAL AROUSAL THAT SETS OFF
NEGATIVE FEEDBACK LOOPS BETWEEN THE CEREBRAL CORTEX AND THE BRAINSTEM
RETICULAR FORMATION.
• ELEVATED LEVELS OF CORTICOFUGAL OUTPUT, IN TURN, INHIBIT THE PATIENT'S AWARENESS OF
BODILY SENSATION, WHICH MAY EXPLAIN THE OBSERVED SENSORY DEFICITS IN SOME PATIENTS
WITH CONVERSION DISORDER.
• NEUROPSYCHOLOGICAL TESTS SOMETIMES REVEAL SUBTLE CEREBRAL IMPAIRMENTS IN
VERBAL COMMUNICATION, MEMORY, VIGILANCE, AFFECTIVE INCONGRUITY, AND ATTENTION
IN THESE PATIENTS.

36. NEUROBIOLOGY
• AN ACCOUNT OF VARIOUS NEUROBIOLOGICAL APPROACHES IS GIVEN BELOW WHICH HAVE BEEN
TRIED OVER YEARS TO EXPLAIN THE BIOLOGICAL BASIS OF DISSOCIATIVE DISORDER
• NEUROIMAGING STUDIES
YEAR RESEARCHER STUDY POPULATION INVESTIGATION FINDINGS
1985 MATHEW ET AL MULTIPLE PERSONALITY
DISORDER (1 PATIENT)
RCBF RT TEMPORAL
HYPERPERFUSION
1997 MARSHALL ET
ALL
CONVERSION DISORDER ( 1
PATIENT WITH LEFT SIDED
PARALYSIS )
PET LOSS OF ACTIVATION OF
RIGHT PRIMARY MOTOR
CORTEX. ACTIVATION OF
RIGHT OFC AND ANT.
CINGULATE CORTEX ON
ATTEMPTED MOVEMENT OF
AFFECTED LEG

37. 2000 SPENCE ET AL CONVERSION DISORDER (2
PATIENTS WITH LEFT ARM
PARESIS)
PET DECREASED BLOOD FLOW TO LEFT DLPFC
2000 SIMEON ET AL DEPERSONALIZATION
DISORDER
PET HIGHER ACTIVITY IN SOMATO- SENSORY
ASSOCIATION AREAS
2001 DEVINSKY ET AL NONEPILEPTIC SEIZURE (N=60)
AND EPILEPTIC CONTROL (
N=102)
CT
MRI
PREPONDERANCE OF NON-DOMINANT
HEMISPHERE LESION IN NONEPILEPTIC
SEIZURE PATIENTS. LESIONS INCLUDED
STROKE, CORTICAL DYSPLASIA,
ENCEPHALO DYSPLASIA,
ENCEPHALOMALACIA, SEVERE HEAD
INJURY, ANEURYSM, AVM AND TUMOR
2001 VUILLEUMIER ET AL CONVERSION DISORDER (7
PATIENTS WITH UNI-LATERAL
SENSORIMOTOR LOSS
DECREASED PERFUSION TO THE
THALAMUS AND BASAL GANGLIA ON THE
SIDE CONTRALATERAL TO THE PERCEIVED
DEFICIT
2003 REINDERS ET AL 11 PATIENTS OF DISSOCIATIVE
IDENTITY DISORDER
DIFFERENT PATTERNS OF CEREBRAL
BLOOD FLOW IN DIFFERENT SENSES OF
SELF

38. 2003 WARD ET AL 12 HEALTHY MALE
VOLUNTEERS WHO HAD
HYPNOTICALLY INDUCED
PARALYSIS
FMRI INCREASED ACTIVITY IN PUTAMEN ( BILAT.),
THALAMUS, SUPPLEMENTARY MOTOR AREA AND
CEREBELLUM (LT.), POSTEROMEDIAL OFC (RT.) WITH
ATTEMPTED MOVEMENTS IN HYPNOTICALLY
INDUCED PARALYZED CONDITION
2006 VERMETTEN
ET AL
DISSOCIATIVE IDENTITY
DISORDER(N=15) AND
HEALTHY CONTROL (N=23)
MRI MEAN OF RT. & LT. HIPO-CAMPAL VOLUMES OF
PATIENTS 19.2% SMALLER AND MEAN OF RT. & LT.
AMYGDALAR VOLUMES OF PATIENTS 31.2%
SMALLER THAN CONTROLS
2006 ATMACA ET AL 12 PATIENTS WITH
UNIATERAL MOTOR
CONVERSION DISORDER
MRI SMALLER MEAN VOLUME OF CAUDATE NUCLEUS
AND LENTIFORM NUCLEUS BILATERALLY, COMPARED
TO CONTROLS
2006 BURGMER ET
AL
4 PATIENTS WITH
DISSOCIATIVE HAND
PARALYSIS
FMRI DECREASED ACTVATION OF CORTICAL HAND AREAS
DURING ATTEMPTED MOVEMENT OF AFFECTED
HAND

39. •IN SUMMARY, KEY FINDINGS IN NEUROIMAGING STUDIES
OF DISSOCIATIVE DISORDER ARE
VOLUME REDUCTION OF AMYGDALA AND HIPPOCAMPUS
NONDOMINANT HEMISPHERE LESIONS IN DISSOCIATIVE
SEIZURE
INCREASE AS WELL AS DECREASE IN CONTRALATERAL
HEMISPHERE ACTIVITY IN MOTOR CONVERSION DISORDER.

40. NEUROPHYSIOLOGY STUDIES
• 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.
• ALLEN & MOVIUS (2000) DOCUMENTED FOUR CASES OF MULTIPLE
PERSONALITY DISORDER EVALUATED BY ERP (Event-related potential) 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.

41. • FUKUZAKO ET AL (1999), IN 6 PATIENTS OF PROBABLE DISSOCIATIVE
AMNESIA, AND KIRINO ET AL (2006), IN 12 PATIENTS OF DISSOCIATIVE
DISORDER, FOUND ATTENUATION OF P300 AMPLITUDE DURING THE
ACTIVE PHASE OF DISSOCIATION COMPARED TO NORMAL CONTROLS.

42. 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.

43. • 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.
• 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

44. CLINICAL FEATURES
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.
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

45. • DISSOCIATIVE AMNESIA MAY BE
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) OR SYSTEMATIZED (AMNESIA FOR CERTAIN
CATEGORIES OF MEMORY SUCH AS ALL MEMORIES RELATING
TO ONE’S FAMILY OR A PARTICULAR PERSON).

46. • 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 (I.E., DUE TO HEAD INJURY, KORSAKOFF’S PSYCHOSIS,
CVA ETC.), 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.
CONFABULATION MAY BE PRESENT IN ORGANIC AMNESIA TO A VARIABLE
DEGREE AND IS USUALLY IMPLAUSIBLE OR BIZARRE

47. AMNESIA FOLLOWING CONCUSSION OR
SERIOUS HEAD INJURY IS USUALLY
RETROGRADE, ALTHOUGH IN SEVERE CASES IT
MAY BE ANTEROGRADE ALSO
DISSOCIATIVE AMNESIA IS USUALLY
PREDOMINANTLY RETROGRADE
ONLY DISSOCIATIVE AMNESIA CAN BE MODIFIED
BY HYPNOSIS OR ABREACTION.

48. DISSOCIATIVE FUGUE
• CLASSICALLY, THREE TYPES OF FUGUE HAVE BEEN DESCRIBED:
• FUGUE WITH AWARENESS OF LOSS OF PERSONAL IDENTITY
• FUGUE WITH CHANGE OF PERSONAL IDENTITY
• FUGUE WITH RETROGRADE AMNESIA
• DURING A FUGUE, PATIENTS OFTEN APPEAR WITHOUT PSYCHOPATHOLOGY
AND DO NOT ATTRACT ATTENTION.
• ON THE OTHER HAND, SOME INDIVIDUALS MAY DISPLAY OVERTLY BIZARRE,
DISORGANIZED OR DANGEROUS BEHAVIOUR.
• AFTER THE TERMINATION OF A FUGUE, THE PATIENT MAY EXPERIENCE
PERPLEXITY, TRANCE-LIKE BEHAVIOUR, DEPERSONALIZATION, DEREALIZATION,
AND CONVERSION SYMPTOMS, IN ADDITION TO AMNESIA.
• DISSOCIATIVE FUGUE HAS BEEN DESCRIBED TO LAST FROM MINUTES TO
MONTHS

49. 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
• AT THE TIME OF DIAGNOSIS, APPROXIMATELY TWO TO FOUR PERSONALITIES
ARE IN EVIDENCE.
• IN THE COURSE OF TREATMENT, AN AVERAGE OF 13 TO 15 IS ENCOUNTERED.
• THE PERSONALITIES’ OVERT DIFFERENCES AND DISPARATE SELF-CONCEPTS
MAY BE STRIKING.

50. • DIRECTIONALITY OF KNOWLEDGE IS ALMOST ALWAYS FOUND AMONG SOME
ALTERS, SUCH AS ALTER A KNOWS ABOUT THE DOING OF ALTER B, BUT B IS
UNAWARE OF THE ACTIVITIES OF A.
• 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
• SUFFERS BOTH PSYCHOPHYSIOLOGICAL SYMPTOMS
• TIME LOSS OR TIME DISTORTION

51. 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
ON THE OTHER HAND, DEREALIZATION (DEALT WITH DEPERSONALIZATION
IN ICD-10), IS THE SENSE THAT THE WORLD APPEARS STRANGE, FOREIGN,
OR DREAM-LIKE.

52. • 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.
• SOUNDS COME FROM A DISTANCE, MUFFLED OR DISTORTED.
• 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

53. DEREALIZATION
• DEREALIZATION IS AN ALTERATION IN THE PERCEPTION OR
EXPERIENCE OF THE EXTERNAL WORLD SO THAT IT SEEMS UNREAL.
• OTHER SYMPTOMS INCLUDE FEELING AS THOUGH ONE'S
ENVIRONMENT IS LACKING IN SPONTANEITY, EMOTIONAL COLORING
AND DEPTH.

54. 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
• URINARY RETENTION.
• SENSORY SYMPTOMS OR DEFICITS INCLUDE
• LOSS OF TOUCH OR PAIN SENSATION
• HYPERESTHESIA AND PARESTHESIA
• DOUBLE VISION
• BLINDNESS
• DEAFNESS
• HALLUCINATION.

55. • DISSOCIATIVE SEIZURE (OR NONEPILEPTIC ATTACK DISORDER OR PSYCHOGENIC
SEIZURE OR PSEUDOSEIZURE) 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
• NORMAL SERUM PROLACTIN LEVEL AFTER SEIZURE

56. SOME ASSOCIATED CONCEPTS ABOUT CONVERSION DISORDER
• PRIMARY GAIN
• PATIENTS ACHIEVE PRIMARY GAIN BY KEEPING INTERNAL CONFLICTS OUTSIDE
THEIR AWARENESS.
• SYMPTOMS HAVE SYMBOLIC VALUE; THEY REPRESENT AN UNCONSCIOUS
PSYCHOLOGICAL CONFLICT.
• SECONDARY GAIN
• PATIENTS ACCRUE TANGIBLE ADVANTAGES AND BENEFITS AS A RESULT OF
BEING SICK
• FOR EXAMPLE, BEING EXCUSED FROM OBLIGATIONS AND DIFFICULT LIFE
SITUATIONS, RECEIVING SUPPORT AND ASSISTANCE THAT MIGHT NOT
OTHERWISE BE FORTHCOMING, AND CONTROLLING OTHER PERSONS'
BEHAVIOR.

57. • LA BELLE INDIFFERENCE
• LA BELLE INDIFFERENCE IS A PATIENT'S INAPPROPRIATELY CAVALIER ATTITUDE
TOWARD SERIOUS SYMPTOMS; THAT IS, THE PATIENT SEEMS TO BE
UNCONCERNED ABOUT WHAT APPEARS TO BE A MAJOR IMPAIRMENT.
• THE PRESENCE OR ABSENCE OF LA BELLE INDIFFERENCE IS NOT
PATHNOGNOMONIC OF CONVERSION DISORDER, BUT IT IS OFTEN ASSOCIATED
WITH THE CONDITION.
• IDENTIFICATION
• PATIENTS WITH CONVERSION DISORDER MAY UNCONSCIOUSLY MODEL THEIR
SYMPTOMS ON THOSE OF SOMEONE IMPORTANT TO THEM.
• FOR EXAMPLE
• A PARENT OR A PERSON WHO HAS RECENTLY DIED MAY SERVE AS A MODEL FOR
CONVERSION DISORDER.
• DURING PATHOLOGICAL GRIEF REACTION, BEREAVED PERSONS COMMONLY HAVE
SYMPTOMS OF THE DECEASED.

58. HISTORY AND PHYSICAL EXAMINATION MUST BE USED TOGETHER TO DIAGNOSE
DISSOCIATIVE DISORDERS OF MOVEMENT AND SENSATION. THE FOLLOWING CHART
(GUGGEINHEIM, 2000) GIVES A LIST OF DISSOCIATIVE PHYSICAL FINDINGS IN THESE
DISORDERS
CONDITION TEST FINDINGS IN DISSOCIATIVE
DISORDER
ANAESTHESIA MAP DERMATOMES SENSORY LOSS DOESN’T CONFORM
TO RECOGNIZED PATTERN OF
DISTRIBUTION
HEMIANAESTHESIA CHECK MIDLINE STRICT HALF-BODY SPLIT
ASTASIA-ABASIA WALKING, DANCING WITH SUGGESTION, THOSE WHO
CANNOT WALK STILL BE ABLE TO
DANCE; ALTERATION OF SENSORY
AND MOTOR FINDINGS WITH
SUGGESTION

59. PARALYSIS, PARESIS DROP PARALYZED HAND ONTO FACE
HOOVER TEST
HAND FALLS NEXT TO FACE, NOT ON IT
PRESSURE NOTED IN EXAMINER’S
HAND UNDER PARALYZED LEG WHEN
ATTEMPTING STRAIGHT LEG RAISING
COMA EXAMINER ATTEMPTS TO OPEN EYES RESISTS OPENING; GAZE PREFERENCE
AWAY FROM DOCTOR
APHONIA REQUEST TO COUGH ESSENTIALLY, NORMAL COUGHING
SOUND INDICATES THAT CORDS ARE
CLOSING
INTRACTABLE SNEEZING OBSERVE SHORT NASAL GRUNTS WITH LITTLE OR
NO SNEEZING ON INSPIRATORY PHASE;
LITTLE OR NO AERO SOLIZATION OF
SECRETIONS; MINIMAL FACIAL
EXPRESSION; EYES OPEN; ABATES
WHEN ALONE
SYNCOPE HEAD-UP TILT TEST MAGNITUDE OF CHANGE IN VITAL
SIGNS AND VENOUS POOLING DOESN’T
EXPLAIN CONTINUING SYMPTOMS

60. TUNNEL VISION VISUAL FIELDS CHANGING PATTERN ON MULTIPLE
EXAMINATIONS
PROFOUND MONOOCULAR BLINDNESS SWINGING FLASH LIGHT SIGN
(MARCUS GUNN)
ABSENCE OF RELATIVE AFFERENT
PUPILLARY DEFECT
SEVERE BILATERAL “WIGGLE YOUR FINGER, I’M JUST
TESTING COORDINATION”
SUDDEN FLASH OF A BRIGHT LIGHT
“TOUCH YOUR INDEX FINGER”
PATIENT MAY BEGIN TO MIMIC NEW
MOVEMENTS BEFORE REALIZING THE
SLIP
PATIENT FLINCHES
EVEN BLIND PATIENTS CAN DO THIS BY
PROPRIOCEPTION

61. DISSOCIATIVE TRANCE DISORDER
• DISSOCIATIVE TRANCE DISORDER IS MANIFESTED BY TEMPORARY,
MARKED ALTERATION IN THE STATE OF CONSCIOUSNESS OR BY THE
LOSS OF CUSTOMARY SENSE OF PERSONAL IDENTITY WITHOUT THE
REPLACEMENT BY AN ALTERNATE SENSE OF IDENTITY.
• THERE IS OFTEN A NARROWING OF AWARENESS OF THE IMMEDIATE
SURROUNDING OR A SELECTIVE FOCUS ON STIMULI WITHIN THE
ENVIRONMENT.

62. • A VARIANT OF DISSOCIATIVE TRANCE DISORDER IS POSSESSION TRANCE.
• THE INITIAL ONSET IS OFTEN SIMILAR TO THAT OF DISSOCIATIVE TRANCE
STATE, WITH AN ACUTE TRIGGERING STRESSOR FOLLOWED SHORTLY
THEREAFTER BY CONVULSIVE OR UNCONTROLLED MOVEMENTS, TREMBLING,
FLAILING OR FAINTING.
• AFTER THAT, THE INDIVIDUAL MAY LAPSE INTO A STUPOR OR MAY APPEAR TO
BE STRUGGLING IN THE GRIP OF AN UNSEEN FORCE.
• THEN, SUDDENLY, A DISTINCTLY DIFFERENT PERSONALITY EMERGES.
• THE PERSONALITY MAY IDENTIFY ITSELF AS EXTERNAL TO AND DISTINCT
FROM THE PERSONALITY OF THE POSSESSED INDIVIDUAL.
• IT MAY CLAIM TO BE A DEITY, DEMON, SPIRIT, GHOST, DECEASED RELATIVE OR
HISTORIC INDIVIDUAL.
• THIS PERSONALITY NOW FOCUSES ATTENTION ON THE CONFLICTS OR
STRESSORS THAT TRIGGERED THE POSSESSION.
• POSSESSION EPISODES USUALLY LAST HOURS TO DAYS

63. SIMPLE DISSOCIATIVE DISORDER
• THIS IS A SUBTYPE OF DISSOCIATIVE DISORDER OUTSIDE THE DEFINITIONS OF CURRENT
CLASSIFICATORY SYSTEMS.
• THIS WAS PROPOSED BY SAXENA (1987) FOR A SUBSET OF PATIENTS WITH DISSOCIATIVE
DISORDER SEEN IN INDIAN SUBCONTINENT THAT WERE DIFFICULT TO BE PUT IN ANY
SUBTYPE OF DISSOCIATIVE DISORDER ACCORDING TO CURRENT CLASSIFICATORY
SYSTEMS.
• THIS DISORDER IS CHARACTERIZED BY
• SHORT PERIODS OF ALTERATION IN CONSCIOUSNESS MANIFESTED BY RELATIVE UNRESPONSIVENESS
TO EXTERNAL ENVIRONMENTAL AND PAINFUL STIMULI
• SUDDEN ONSET AND TERMINATION, PARTIAL OR COMPLETE AMNESIA FOR EVENTS AFTER
TERMINATION
• ASSOCIATED FEATURES LIKE MOTOR MOVEMENTS OF THE BODY THAT MAY RESEMBLE GENERALIZED
EPILEPTIC CONVULSIONS OR MAY BE BIZARRE
• CRYING, SHOUTING OR VERBALIZING THOUGHTS THAT MAY BE COMPLETELY AT VARIANCE WITH THE
USUAL CHARACTERISTICS OF THE PERSON’S PERSONALITY.
• THOUGH ORIGINALLY DESCRIBED IN INDIAN CONTEXT, THERE IS A RECENT CASE REPORT
OF SIMPLE DISSOCIATIVE DISORDER FROM CENTRAL EUROPE (BACH & SEIFRITZ, 2005)
WITH RESURGENCE OF INTEREST IN THIS PARTICULAR SUBTYPE OF DISSOCIATIVE
DISORDER.

64. • DISSOCIAIVE DISORDER NOS
• DISSOCIATIVE SYMPTOMS ARE PREDOMINANT, BUT THE CLINICAL PICTURE DOES
NOT MEET FULL CRITERIA FOR A DISSOCIATIVE DISORDER
• GANSER’S SYNDROME
• THE SYMPTOM OF PASSING OVER (vorbeigehen) THE CORRECT ANSWER FOR A
RELATED, BUT INCORRECT ONE IS THE HALLMARK OF GANSER SYNDROME.
• THE APPROXIMATE ANSWERS OFTEN JUST MISS THE MARK BUT BEAR AN
OBVIOUS RELATION TO THE QUESTION, INDICATING THAT IT HAS BEEN
UNDERSTOOD.
• WHEN ASKED HOW OLD SHE WAS, A 25-YEAR-OLD WOMAN ANSWERED, “I'M
NOT 5.”
• ANOTHER PATIENT, WHEN ASKED HOW MANY LEGS A HORSE HAD, REPLIED,
“THREE.”
• MISTAKES WHILE DOING SIMPLE CALCULATIONS (E.G., 2 + 2 = 5),
• MISTAKES WHILE IDENTIFYING SIMPLE OBJECTS (A PENCIL IS A KEY), OR TO
NAME COLORS (GREEN IS GRAY)
• THE GANSER PATIENT GIVES ERRONEOUS BUT COMPREHENSIBLE ANSWERS.

65. FACTITIOUS, IMITATIVE, AND MALINGERED DISSOCIATIVE IDENTITY DISORDER
• THERE HAVE BEEN INCREASING REPORTS OF INDIVIDUALS CLAIMING TO HAVE
DISSOCIATIVE IDENTITY DISORDER WHO DO NOT MEET DIAGNOSTIC CRITERIA FOR
DISSOCIATIVE IDENTITY DISORDER WHEN CAREFULLY ASSESSED CLINICALLY OR WITH
STRUCTURED INTERVIEWS, SUCH AS THE SCID-D-R.
• THERE MAY BE A MIXTURE OF FACTORS LEADING TO THIS PRESENTATION, INCLUDING
MISDIAGNOSIS, FACTITIOUSNESS, AND ASSUMPTION OF A SOCIAL ROLE OF AN ABUSE
VICTIM OR A DISSOCIATIVE IDENTITY DISORDER PATIENT.
• PATIENTS MAY BUILD THEIR LIVES AROUND THEIR DIAGNOSIS AND ARE COMMONLY
SUPPORTED BY CONCERNED OTHERS AND BY THEIR THERAPISTS IN SO DOING.

66.  HOOVER'S TEST
 THIS TEST IS PERFORMED ON A SUPINE
PATIENT. HOLD THE PATIENT'S HEELS
OFF THE TABLE, AND ASK HIM OR HER
TO RAISE ONE LEG. IF THE LEG IS RAISED
EASILY, THE TEST IS NEGATIVE
 HOWEVER, IF THIS MOVEMENT IS
DIFFICULT DUE TO ORGANIC LBP, THE
PATIENT WILL PUSH THE
CONTRALATERAL LEG TOWARD THE
TABLE FOR ASSISTANCE IN RAISING THE
LEG
 THEREFORE, LACK OF DOWNWARD
PRESSURE FROM THE CONTRALATERAL
LEG IS A POSITIVE SIGN OF
MALINGERING

67. GENERAL DISSOCIATION
• IN THE DISSOCIATION LITERATURE, DAYDREAMING, FANTASY, AND
ABSORPTION IN EVERYDAY EXPERIENCES, FALL UNDER THE RUBRIC
OF NONPATHOLOGICAL DISSOCIATION.
• NONPATHOLOGICAL DISSOCIATION IMPLIES A CHANGE IN THE STATE
OF CONSCIOUSNESS THAT IS NOT INDUCED BY ANY ORGANIC
CONDITION, DOESN’T OCCUR AS A PART OF A PSYCHIATRIC
DISORDER, AND INVOLVES THE TEMPORARY ALTERATION OR
SEPARATION OF WHAT ARE NORMALLY EXPERIENCED AS INTEGRATED
MENTAL PROCESSES.

68. 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)
• (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.
• THE OVERALL DES SCORE IS THEN OBTAINED BY ADDING UP THE 28 ITEM SCORES
AND DIVIDING BY 28
• THIS YIELDS AN OVERALL SCORE RANGING FROM 0 TO 100.
• STUDIES USUALLY TAKE AN OVERALL CUT OFF SCORE OF 30 ON THIS SCALE.
• THE DES HAS VERY GOOD VALIDITY AND RELIABILITY, AND GOOD OVERALL
PSYCHOMETRIC PROPERTIES.

69. • 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

70. 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).
• 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.
• IT INCLUDES 267 QUESTIONS AND RATE THE SEVERITY OF EACH SYMPTOM ON A
FOUR-POINT SCALE.
• 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.

71. COURSE AND PROGNOSIS
DISSOCIATIVE AMNESIA
• DISSOCIATIVE AMNESIA CAN PRESENT IN ANY AGE GROUP.
• THE REPORTED DURATION OF EVENTS FOR WHICH THERE IS
AMNESIA MAY BE MINUTES TO YEARS.
• ONLY A SINGLE EPISODE OF AMNESIA MAY BE REPORTED,
ALTHOUGH TWO OR MORE EPISODES ARE ALSO COMMONLY
DESCRIBED.
• ACUTE AMNESIA MAY RESOLVE SPONTANEOUSLY AFTER THE
INDIVIDUAL IS REMOVED FROM THE TRAUMATIC
CIRCUMSTANCES WITH WHICH THE AMNESIA WAS
ASSOCIATED.
• SOME INDIVIDUALS WITH CHRONIC AMNESIA MAY
GRADUALLY BEGIN TO RECALL DISSOCIATED MEMORIES.
• OTHER INDIVIDUALS MAY DEVELOP A CHRONIC FORM OF
AMNESIA

72. DISSOCIATIVE FUGUE
• MOST FUGUES ARE RELATIVELY BRIEF, LASTING FROM HOURS TO DAYS.
• MOST INDIVIDUALS APPEAR TO RECOVER, ALTHOUGH REFRACTORY
DISSOCIATIVE AMNESIA MAY PERSIST IN RARE CASES.
• SOME STUDIES HAVE DESCRIBED RECURRENT FUGUES IN THE MAJORITY OF
INDIVIDUALS PRESENTING WITH AN EPISODE OF DISSOCIATIVE FUGUE.
• HOWEVER, NO SYSTEMIC MODERN DATA EXIST THAT ATTEMPT TO
DIFFERENTIATE DISSOCIATIVE FUGUE FROM DISSOCIATIVE IDENTITY
DISORDER WITH RECURRENT FUGUE.

73. DISSOCIATIVE IDENTITY DISORDER
• DISSOCIATIVE IDENTITY DISORDER APPEARS TO HAVE A FLUCTUATING
CLINICAL COURSE THAT TENDS TO BE CHRONIC AND RECURRENT.
• THE AVERAGE TIME PERIOD FROM FIRST SYMPTOM PRESENTATION TO
DIAGNOSIS IS 6-7 YEARS.
• EPISODIC AND CONTINUOUS COURSES HAVE BOTH BEEN DESCRIBED.
• THE DISORDER MAY BECOME LESS MANIFEST AS INDIVIDUALS AGE BEYOND
THEIR LATE 40S, BUT MAY REEMERGE DURING EPISODES OF STRESS OR
TRAUMA OR WITH SUBSTANCE ABUSE

74. DEPERSONALIZATION DISORDER
• INDIVIDUALS WITH DEPERSONALIZATION DISORDER USUALLY PRESENT FOR
TREATMENT IN ADOLESCENCE OR EARLY ADULTHOOD, ALTHOUGH THE DISORDER
MAY HAVE AN UNDETECTED ONSET IN CHILDHOOD.
• THE MEAN AGE AT ONSET HAS BEEN REPORTED TO BE AROUND AGE 16.
• BECAUSE DEPERSONALIZATION IS RARELY THE PRESENTING COMPLAINT,
INDIVIDUALS WITH RECURRENT DEPERSONALIZATION OFTEN PRESENT WITH
ANOTHER SYMPTOM SUCH AS ANXIETY, PANIC OR DEPRESSION.
• DURATION OF EPISODES OF DEPERSONALIZATION MAY VARY FROM VERY BRIEF
(SECONDS) TO PERSISTENT (YEARS).
• DEPERSONALIZATION SUBSEQUENT TO LIFE-THREATENING SITUATIONS DEVELOPS
SUDDENLY ON EXPOSURE TO THE TRAUMA, AND TRAUMA HISTORIES ARE OFTEN
ASSOCIATED WITH THIS DISORDER.
• THE COURSE IS USUALLY CHRONIC AND MAY WAX AND WANE IN INTENSITY BUT IS
ALSO SOMETIMES EPISODIC.
• MOST OFTEN THE EXACERBATIONS OCCUR IN ASSOCIATION WITH ACTUAL OR
PERCEIVED STRESSFUL EVENT

75. DISSOCIATIVE DISORDER OF MOVEMENT AND
SENSATION (CONVERSION DISORDER)
• THE ONSET OF CONVERSION DISORDER IS GENERALLY FROM LATE CHILDHOOD
TO EARLY ADULTHOOD.
• THE ONSET IS GENERALLY ACUTE, BUT GRADUALLY INCREASING
SYMPTOMATOLOGY MAY ALSO APPEAR.
• TYPICALLY, INDIVIDUAL CONVERSION SYMPTOMS ARE OF SHORT DURATION.
• IN INDIVIDUALS HOSPITALIZED WITH CONVERSION SYMPTOMS, SYMPTOMS
REMIT WITHIN 2 WEEKS IN MOST CASES.
• RECURRENCE IS COMMON, OCCURRING IN FROM ONE-FIFTH TO ONE-
QUARTER OF INDIVIDUALS WITHIN 1 YEAR, WITH A SINGLE RECURRENCE
PREDICTING FUTURE EPISODES.

76. • FACTORS THAT ARE ASSOCIATED WITH GOOD PROGNOSIS INCLUDE
• ACUTE ONSET
• PRESENCE OF CLEARLY IDENTIFIABLE STRESS AT THE TIME OF ONSET
• A SHORT INTERVAL BETWEEN ONSET AND INITIATION OF TREATMENT
• ABOVE-AVERAGE INTELLIGENCE.
• SYMPTOMS ASSOCIATED WITH A GOOD PROGNOSIS
• PARALYSIS
• APHONIA
• BLINDNESS
• SYMPTOMS ASSOCIATED WITH BAD PROGNOSIS
• TREMORS
• SEIZURES

77. MANAGEMENT
PSYCHOTHERAPY
PSYCHOTHERAPY REMAINS THE MAINSTAY FOR MANAGEMENT OF DISSOCIATIVE DISORDER. FOLLOWING ARE THE
GENERAL TECHNIQUES OF PSYCHOTHERAPY FOR DISSOCIATIVE DISORDERS.
PSYCHOEDUCATION
• EDUCATION IS AN INVALUABLE TOOL FOR TREATING DISSOCIATIVE DISORDER.
• IT HELPS TO UNDO THE STIGMATIZATION AND SHAME ASSOCIATED WITH BEING ILL.
• EDUCATION APPEALS TO INTELLECTUAL STRENGTHS AND THE PRACTICE OF COPING SKILLS IMPROVE FUNCTION
AND RESILIENCE.
• PSYCHOEDUCATION CAN BE ACCOMPLISHED IN FOCUSED SKILL-BUILDING GROUPS, WHICH ALSO HAVE THE
ADVANTAGE OF INCREASING INTERPERSONAL CONNECTION.

78. PACING AND CONTAINMENT
PACING AND CONTAINMENT ARE CRITICAL IN BUILDING A FOUNDATION AND
FRAMEWORK FOR THERAPY. ONE OF THE ESSENTIAL GOALS OF THERAPY IS TO
MAINTAIN FUNCTION WHILE DOING THE WORK.
PACING IS A TASK SHARED BY THE THERAPIST AND PATIENT.
THE THERAPY MUST BE PLANNED AND PACED AS MUCH AS POSSIBLE.
THE FIRST STAGE OF THERAPY IS THE ESTABLISHMENT OF SAFETY AND
STABILIZATION AND THE BUILDING OF THE THERAPEUTIC ALLIANCE.
THE SECOND IS OF TRAUMA PROCESSING; THE INTEGRATION OF TRAUMATIC
RECOLLECTION AND INTENSE AFFECT.
THE THIRD IS POSTINTEGRATION OF SELF AND RELATIONAL DEVELOPMENT.

79. CONTAINMENT SKILLS CAN BE TAUGHT THROUGH PSYCHOEDUCATION AND
IMAGERY.
THERAPISTS MUST START BY NORMALIZING FEELINGS AS AN INTEGRAL PART
OF HUMAN BEING.
AFFECT MODULATION INVOLVES THE IDENTIFICATION OF FEELINGS,
FOLLOWED BY THE CONTEXTUAL RELATIONSHIP, AND THEN MODULATION.
LEARNING TO IDENTIFY A SPECIFIC FEELING AND GIVING IT CONTEXT IS THE
BEGINNING OF CONTROL AND UNDERSTANDING.
MODULATION ALSO INVOLVES TEACHING SELF-SOOTHING, MINDFULNESS, OR
DISTRACTING STRATEGIES.
THE THERAPIST AND PATIENT CAN COLLABORATIVELY CREATE A LIST OF
STRATEGIES TO KEEP AT HAND FOR DIFFICULT MOMENTS OR DAYS

80. GROUNDING SKILLS
• A BASIC AND CENTRAL SKILL SET FOR THE ALLEVIATION OF SYMPTOMS OF
DISSOCIATIVE DISORDER IS GROUNDING.
• GROUNDING IS THE PROCESS OF BEING PSYCHOLOGICALLY PRESENT
• PARTICULARLY EFFECTIVE IN DEALING WITH DEPERSONALIZATION
EXPERIENCES.
• GROUNDING SKILLS CAN BE DIVIDED INTO TWO AREAS
• 1. SENSORY AWARENESS 2. COGNITIVE AWARENESS.
• SENSORY AWARENESS GROUNDING SKILLS ENCOURAGE PATIENTS FOCUS IN THE
PRESENT BY USING ALL FIVE SENSES IN AWARENESS OF THEIR BODY POSITION; E.G.,
PATIENTS OFTEN FIND IT HELPFUL TO HOLD A BALL, SMALL STONE OR OTHER PALM-
SIZED OBJECTS TO ENHANCE THEIR SENSE OF TOUCH.
• SIMILARLY, SENSORY CUES ARE USED FOR OTHER SENSATIONS LIKE VISION, HEARING,
SMELL AND TASTE.
• COGNITIVE AWARENESS GROUNDING SKILLS INVOLVE ORIENTING THE PATIENT TO DAY,
DATE, AGE AND LOCATION

81. TRAUMATIC REENACTMENT
• INTENSIVE, DETAILED PSYCHOTHERAPEUTIC WORK WITH TRAUMATIC
MEMORIES SHOULD ONLY BE INITIATED AFTER THE PATIENT HAS
DEMONSTRATED THE ABILITY TO USE SYMPTOM MANAGEMENT SKILLS
INDEPENDENTLY.
• THE PATIENT SHOULD BE ABLE TO GIVE INFORMAL CONSENT AND SHOULD
HAVE A REALISTIC UNDERSTANDING OF THE POTENTIAL RISKS AND BENEFITS
OF INTENSIVE FOCUS ON TRAUMATIC MATERIAL.
• FURTHERMORE, PATIENT SHOULDN’T BE IN THE MIDST OF AN ACUTE LIFE
CRISIS OR MAJOR LIFE CHANGE
• COMORBID MEDICAL AND PSYCHIATRIC DISORDERS SHOULD BE STABILIZED
• THE PATIENT MUST HAVE EGO-STRENGTH AND PSYCHOLOGICAL RESOURCES
TO WITHSTAND THE RIGORS OF THE PROCESS
• THERE MUST BE ADEQUATE RESOURCES, SUCH AS SUPPORT BY SIGNIFICANT
OTHERS, TO SUPPORT THE PATIENT FOR ADDITIONAL SESSIONS

82. HEALING PLACE
• CLINICAL PRACTICE IN THE FIELD OF TRAUMA AND DISSOCIATION IS REPLETE WITH
THE CREATION OF “SAFE PLACE” IMAGERY TO MANAGE FEAR AND ANXIETY.
• THE INSTALLATION OF A HEALING PLACE IS A VALUABLE THERAPEUTIC
INTERVENTION.
• THE PATIENT’S WILLINGNESS TO USE IT IS AN INDICATION THAT THEY ARE
MOTIVATED AND COMMITTED TO THE PROCESS OF PSYCHOTHERAPY.
• THE IMAGERY ITSELF HAS MANY VARIATIONS AND MUST BE TAILORED TO THE
INDIVIDUAL PATIENT.
• AFTER INSTALLATION OF HEALING PLACE, THE THERAPIST SHOULD INVITE THE
PATIENT TO DESCRIBE AND SHARE THE EXPERIENCE FOR AFFIRMATION AND
REINFORCEMENT OR TO DISCUSS ANY PROBLEMS ENCOUNTERED.
• THE PLACE MAY NEED TO BE MODIFIED IF THERE IS INTRUSION OF RESISTANCE OR
TRAUMATIC MATERIAL

83. MANAGEMENT OF INDIVIDUAL DISORDERS

84. DISSOCIATIVE AMNESIA
PSYCHOTHERAPY
• FREE RECALL-
• PATIENTS WITH ACUTE AND CHRONIC FORMS OF AMNESIA MAY RESPOND WELL TO FREE
RECALL STRATEGIES IN WHICH THEY ALLOW MEMORY MATERIAL TO ENTER INTO
CONSCIOUSNESS.
• COGNITIVE THERAPY-
• IT MAY HAVE SPECIFIC BENEFIT FOR INDIVIDUALS WITH TRAUMA DISORDERS.
• IDENTIFYING THE SPECIFIC COGNITIVE DISTORTIONS THAT ARE BASED IN THE TRAUMA MAY
ALSO PROVIDE AN ENTRY INTO AUTOBIOGRAPHICAL MEMORY FOR WHICH THE PATIENT
EXPERIENCES AMNESIA.
• HYPNOSIS-
• HYPNOSIS HAS FREQUENTLY PLAYED AN IMPORTANT ADJUNCTIVE ROLE IN THE TREATMENT
OF INDIVIDUALS WITH DISSOCIATIVE AMNESIA.
• HYPNOSIS IS NOT TREATMENT ITSELF; RATHER, IT IS A SET OF ADJUNCTIVE TECHNIQUES THAT
FACILITATE CERTAIN PSYCHOTHERAPEUTIC GOALS.

85. PHARMACOTHERAPY
• THERE IS NO KNOWN PHARMACOTHERAPY FOR DISSOCIATIVE AMNESIA
OTHER THAN PHARMACOLOGICALLY FACILITATED INTERVIEW.
• A VARIETY OF AGENTS HAVE BEEN USED FOR THIS PURPOSE
• SODIUM AMOBARBITAL
• THIOPENTAL
• ORAL BENZODIAZEPINES
• AMPHETAMINES.
• AT PRESENT, NO ADEQUATELY CONTROLLED STUDIES HAVE BEEN
CONDUCTED THAT ASSESS THE EFFICACY OF ANY OF THESE AGENTS IN
COMPARISON WITH ONE ANOTHER OR WITH OTHER TREATMENT
METHODS.

86. DISSOCIATIVE FUGUE
• DISSOCIATIVE FUGUE IS USUALLY TREATED WITH AN ECLECTIC, PSYCHODYNAMICALLY INFORMED
PSYCHOTHERAPY THAT FOCUSES ON HELPING THE PATIENT RECOVER MEMORY FOR IDENTITY AND
RECENT EXPERIENCE.
• HYPNOTHERAPY AND PHARMACOLOGICALLY FACILITATED INTERVIEWS ARE FREQUENTLY NECESSARY
ADJUNCTIVE TECHNIQUES TO ASSIST WITH MEMORY RECOVERY.
• THERAPY SHOULD BE CAREFULLY PACED.
• THE INITIAL PHASE IS CENTERED ON ESTABLISHING CLINICAL STABILIZATION, SAFETY, AND A
THERAPEUTIC ALLIANCE USING SUPPORTIVE AND EDUCATIVE INTERVENTIONS.
• ONCE STABILIZATION IS ACHIEVED, SUBSEQUENT THERAPY IS FOCUSED ON HELPING THE PATIENT
REGAIN MEMORY FOR IDENTITY, LIFE CIRCUMSTANCES AND PERSONAL HISTORY.
• DURING THIS PROCESS, EXTREME EMOTIONS RELATED TO TRAUMA OR SEVERE PSYCHOLOGICAL
CONFLICT, OR BOTH, MAY EMERGE THAT REQUIRE WORKING THROUGH.
• IN GENERAL, THE THERAPIST SHOULD TAKE A SUPPORTIVE AND NONJUDGMENTAL STANCE, ESPECIALLY
IF THE FUGUE HAS BEEN PRECIPITATED BY INTENSE GUILT OR SHAME OVER AN INDISCRETION.
• AT THE SAME TIME, IT IS IMPORTANT FOR THE THERAPIST TO BALANCE THIS WITH BEING A
SPOKESPERSON FOR THE PATIENT, TAKING REALISTIC RESPONSIBILITY FOR MISBEHAVIOUR

87. DISSOCIATIVE IDENTITY DISORDER
PSYCHOTHERAPY
• A VAST MAJORITY OF CLINICIANS CONSIDER PSYCHOTHERAPY AS THE
PRIMARY AND MOST EFFICACIOUS TREATMENT MODALITY.
• THE INITIAL PHASE OF PSYCHOTHERAPY CONSISTS OF PSYCHOEDUCATION AND
SETTING UP TREATMENT FRAME AND BOUNDARIES, DEVELOPMENT OF SKILLS
TO MANAGE SYMPTOMS AND COGNITIVE THERAPY.
• THE SECOND PHASE DEALS WITH THE TRAUMATIC MEMORIES.
• THE THIRD PHASE CONSISTS OF FUSION, INTEGRATION, RESOLUTION AND
RECOVERY OF PERSONALITY.

88. PHARMACOTHERAPY
• PSYCHOPHARMACOLOGIC INTERVENTIONS ARE PRIMARILY ADJUNCTIVE AND
EMPIRICAL IN NATURE IN THE TREATMENT OF DISSOCIATIVE IDENTITY
DISORDER
• AFFECTIVE SYMPTOMS- AFFECTIVE SYMPTOMS IN DISSOCIATIVE IDENTITY
DISORDER ARE ONLY INFREQUENTLY RESPONSIVE TO MOOD STABILIZING
MEDICATIONS. BUT THEY OFTEN HAVE NOTEWORTHY.
• PARTIAL RESPONSE TO ANTIDEPRESSANT MEDICATIONS, USUALLY SSRIS
(SERTRALINE, FLUOXETINE) OR TCAS ( IMIPRAMINE, DESIPRAMINE).
• REFRACTORY PATIENTS MAY NEED A SERIES OF ANTIDEPRESSANT TRIALS OR
COMBINATION THERAPY WITH TWO ANTIDEPRESSANTS.

89. • PSEUDOPSYCHOTIC SYMPTOMS-
• IN PATIENTS WITH DISSOCIATIVE IDENTITY DISORDER, PSEUDOPSYCHOTIC SYMPTOMS
RARELY ARE AMELIORATED BY ANTIPSYCHOTIC MEDICATIONS, EVEN IN HIGHER DOSES.
• LOW DOSES OF ATYPICAL NEUROLEPTICS (RISPERIDONE, QUETIAPINE, ZIPRASIDONE,
OLANZEPINE) MAY AMELIORATE THESE SYMPTOMS.
• OCCASIONALLY, AN EXTREMELY DISORGANIZED, OVERWHELMED, CHRONICALLY ILL
DISSOCIATIVE IDENTITY DISORDER PATIENT, WHO HAS NOT RESPONDED TO TRIALS OF
OTHER NEUROLEPTICS, RESPONDS FAVOURABLY TO A TRIAL OF CLOZAPINE.
• ANXIETY SYMPTOMS-
• MANY PATIENTS WITH DISSOCIATIVE IDENTITY DISORDER MAY REQUIRE LONG-TERM
TREATMENT WITH BENZODIAZEPINES FOR PERSISTENT ANXIETY SYMPTOMS.
• TOLERANCE, PHYSICAL DEPENDENCE AND ADDICTION MUST BE CAREFULLY MONITORED
IN THESE PATIENTS.
• OBSESSIVE-COMPULSIVE SYMPTOMS IN DISSOCIATIVE IDENTITY DISORDER
PREFERENTIALLY RESPOND TO ANTI-OBSESSIVE MEDICATION LIKE FLUVOXAMINE AND
CLOMIPRAMINE.

90. • PTSD SYMPTOMS-
• A VARIETY OF UNCONTROLLED STUDIES HAVE SHOWN EFFICACY OF MOOD STABILIZERS
(CARBAMAZEPINE, VALPROATE , LAMOTRIGINE) FOR PTSD SYMPTOMS IN DISSOCIATIVE
IDENTITY DISORDER.
• LITHIUM IS RARELY EFFECTIVE FOR THIS INDICATION IN THIS POPULATION.
• A SUBGROUP OF PATIENTS OF DISSOCIATIVE IDENTITY DISORDER WITH PTSD
SYMPTOMS RESPONDS TO BETA-BLOCKERS FOR SEVERE HYPERAROUSAL SYMPTOMS,
SUCH AS PRONOUNCED STARTLE RESPONSE.
• LONG-ACTING FORMS OF PROPRANOLOL ARE USED MOST FREQUENTLY FOR THIS
INDICATION.
• SIMILARLY, THE Α-AGONIST CLONIDINE MAY BE EFFECTIVE IN A FEW PATIENTS FOR THE
SAME INDICATION
• ELECTROCONVULSIVE THERAPY:
• A CLINICAL PICTURE OF MAJOR DEPRESSION WITH PERSISTENT, REFRACTORY
MELANCHOLIC FEATURES ACROSS ALL ALTERS MAY PREDICT A POSITIVE RESPONSE TO
ECT. HOWEVER, THIS RESPONSE IS USUALLY ONLY PARTIAL

91. DEPERSONALIZATION DISORDER
• PHARMACOTHERAPY:
• PATIENTS WITH DEPERSONALIZATION DISORDER ARE USUALLY CLINICALLY REFRACTORY
GROUP.
• OVER THE PAST DECADE THERE HAVE BEEN ANECDOTAL REPORTS OF IMPROVEMENT IN
THIS CONDITION WITH SSRIS (E.G., FLUOXETINE) OR CLOMIPRAMINE.
• BUT A RECENT DOUBLE-BLIND PLACEBO-CONTROLLED STUDY COMPARING 25 PATIENTS
RECEIVING FLUOXETINE WITH 25 PATIENTS RECEIVING PLACEBO FOR 10 WEEKS FOUND
THAT FLUOXETINE WAS NO BETTER THAN PLACEBO FOR THIS CONDITION (SIMEON ET AL,
2004).
• SIMILARLY, SIERRA ET AL (2003), IN ANOTHER DOUBLE-BLIND PLACEBO-CONTROLLED
STUDY, FOUND LAMOTRIGINE NO BETTER THAN PLACEBO FOR DEPERSONALIZATION
DISORDER.
• MANY PATIENTS WHO RESPOND TO SSRIS OR MOOD STABILIZERS HAVE COMORBID
PSYCHIATRIC CONDITIONS LIKE DEPRESSION OR ANXIETY AND THAT MIGHT THE REASON
FOR IMPROVEMENT.
• NEVERTHELESS, SSRIS REMAIN THE MOST FREQUENTLY PRESCRIBED MEDICATION FOR
THIS CONDITION.

92. PSYCHOTHERAPY
• MANY DIFFERENT TYPES OF PSYCHOTHERAPY HAVE BEEN USED WITH
DEPERSONALIZATION DISORDER PATIENTS INCLUDING
• PSYCHODYNAMIC
• COGNITIVE
• COGNITIVE-BEHAVIOURAL
• HYPNOTHERAPEUTIC
• SUPPORTIVE.
• NO SYSTEMIC DATA EXIST THAT COMPARE THESE MODALITIES. STRESS
MANAGEMENT STRATEGIES, DISTRACTION TECHNIQUES, REDUCTION OF
SENSORY STIMULATION, RELAXATION TRAINING AND PHYSICAL EXERCISE
MAY BE SOMEWHAT HELPFUL IN SOME PATIENTS

93. DISSOCIATIVE DISORDER OF MOVEMENT AND SENSATION
CONVERSION DISORDER WITH MOTOR AND SENSORY SYMPTOMS
• IN ACUTE CASES WITHOUT A PRIOR HISTORY OF CONVERSION, ACCURATE
REASSURANCE COUPLED WITH REASONABLE REHABILITATION TO FIT THE SYMPTOMS IS
REQUIRED.
• CONFRONTATION OF THE PATIENT ABOUT THE SO-CALLED FALSE NATURE OF THE
SYMPTOMS IS CONTRAINDICATED.
• CHRONIC CASES ARE MORE DIFFICULT TO TREAT.
• COMORBID PSYCHIATRIC ILLNESS NEED TO BE TREATED AGGRESSIVELY.
• TREATMENT THEN NEEDS TO BEGIN WITH ANOTHER THOROUGH AND RATIONAL
EVALUATION, OPEN EXPLANATION TO THE PATIENT ABOUT THE FINDINGS, AND
EDUCATION AIMED AT HELPING THE PATIENT UNDERSTAND THAT, ALTHOUGH THE
SYMPTOMS ARE REAL AND CAUSING IMPAIRMENT, THERE IS A HOPE FOR FULL
RECOVERY.

94. • THREE SPECIFIC TREATMENTS MUST THEN BE CONSIDERED.
• FIRST, PSYCHOMOTOR AND SENSORY REHABILITATION IS USEFUL WHEN AGGRESSIVELY
PURSUED BY AN EXPERIENCED MULTIDISCIPLINARY TEAM CONSISTING OF PHYSICIANS,
PSYCHIATRISTS AND PHYSICAL AND OCCUPATIONAL THERAPISTS.
• SECOND, PHARMACOTHERAPY MAY BE USEFUL.
• ANXIOLYTIC AND ANTIDEPRESSANT MEDICATION MAY DECREASE SOME OF THE
SYMPTOMS TO ALLOW THE PATIENT TO ENGAGE IN PHYSICAL REHABILITATION OR
PSYCHOTHERAPY.
• AMOBARBITAL INTERVIEW MAY BE USEFUL TO GAIN INFORMATION ABOUT EARLY OR
HIDDEN CONFLICTS AND MAY FACILITATE INTEGRATION OF THIS INFORMATION BY THE
PATIENT UNDER SKILLED THERAPEUTIC SUPERVISION.
• FINALLY, PSYCHOTHERAPY MAY BE USEFUL BUT ALSO MAY BE CONTRAINDICATED IN A
PATIENT WHO REMAINS HIGHLY RESISTANT TO IT OR WHO GETS WORSE WHEN IT IS
INITIATED.
• THERAPY IS DIRECTED AT INCREASING FUNCTION AND HAVING THE PATIENT
DEMONSTRATE TO HIMSELF OR HERSELF THAT THE SYMPTOM OR DEFICIT IS
ALTERABLE AND THAT IT IS RELATED TO PSYCHOLOGICAL OR SOCIAL
PHENOMENA

95. CONVERSION SEIZURE (PSEUDOSEIZURE)
• EXPLAINING CONVERSION AND PSEUDOSEIZURE
• IT IS IMPORTANT TO EXPLAIN THE DIAGNOSIS IN A WAY THAT EDUCATES THE PATIENT,
PROVIDES A COGNITIVE FRAMEWORK OF UNDERSTANDING, REDUCES SHAME AND
MOTIVATES WILLINGNESS TO UNDERTAKE TREATMENT.
• INCLUDING THE FAMILY IN THE DISCUSSION IS RECOMMENDED.
• CONVERSION SYMPTOMS ARE GENERATED UNCONSCIOUSLY AND EXPRESS
UNCONSCIOUS EMOTIONS AND CONFLICTS.
• SIMPLE METAPHORS ARE HELPFUL IN EXPLAINING THESE ABSTRACT CONCEPTS TO THE
PATIENT.

96. EXPLORING THE CAUSES
• THE SECOND STEP IS EXPLORATION OF THE CAUSES OF CONVERSION IN AN
INDIVIDUAL PATIENT.
• THE FOUR COMMON LIFE-EVENT PATTERNS WHICH MAY GIVE RISE TO
CONVERSION SEIZURE ARE
• OLD TRAUMA WITH RECENT REMINDER
• ENRAGING FAMILIES OR SITUATIONS
• GRIEF WITH MULTIPLE LOSSES
• DOUBLE BINDS IN FAMILY.
• ADEQUATE EVALUATION OF THE CAUSES REQUIRES OPEN-ENDED,
NONLEADING QUESTIONS ABOUT TRAUMA OR ABUSE.
• TREATMENT FOCUSES ON IDENTIFYING THE EMOTIONS THAT THESE EVENTS
RAISE AND EXPLORING THE TRAUMA

97. TREATMENT PROPER
• ANTIDEPRESSANTS SHOULD BE USED IF THERE IS COMORBID PTSD, PANIC OR
MAJOR DEPRESSION.
• SOME PATIENTS WITH OVERWHELMING ANXIETY MAY REQUIRE INITIAL
TREATMENT WITH ANXIOLYTICS UNTIL THEIR ANXIETY OR TRAUMA IS
RESOLVED IN PSYCHOTHERAPY.
• THE PRIMARY PRINCIPLES OF PSYCHOTHERAPY ARE A NONJUDGMENTAL,
SUPPORTIVE AND EDUCATIVE APPROACH THAT ADDRESSES ALEXITHYMIA
AND ENCOURAGES VERBAL EXPRESSION, PROBLEM SOLVING SKILLS AND
RESOLUTION OF TRAUMA.
• PATIENTS SHOULD FOCUS ON THEIR SYMPTOMS, THEIR DISSOCIATIVE
DEFENSES, AND THE STRESS OR EMOTIONS THAT TRIGGER CONVERSION
SEIZURES.
• CLINICIANS SHOULD EMPHASIZE HOPE, THE ABILITY TO GAIN CONTROL OVER
SYMPTOMS, AND THE NEED TO IDENTIFY AND VERBALIZE EMOTIONS

98. OTHER INCLUSIONS IN THE DISSOCIATIVE SPECTRUM
EPILEPSY AND DISSOCIATION
• CONTEMPORARY LITERATURE DOESN’T SUPPORT THE CONCEPT THAT
DISSOCIATIVE DISORDER CAN BE GENERALLY EXPLAINED ON THE BASIS OF
NEUROLOGICAL DYSFUNCTION.
• NEVERTHELESS, IT SUPPORTS THE SUGGESTIVE EVIDENCE THAT TEMPORAL
LOBE SEIZURE ACTIVITIES CAN PRODUCE DISSOCIATIVE SYNDROME, WHICH
IS SIMILAR TO THAT OBSERVED IN FUNCTIONAL CASES.
• FROM THESE FINDINGS, IT MAY BE INFERRED THAT TEMPORAL LOBE
EPILEPTIC ACTIVITY IS IMPORTANT IN THE GENERATION OF THE
DISSOCIATIVE SYMPTOMS WITHOUT A NEUROLOGICAL FOCAL LESION

99. EATING DISORDERS AND DISSOCIATION
• IN A STUDY DONE BY DENITRAK ET AL (1990), FEMALE PATIENTS WITH
ANOREXIA AND BULIMIA NERVOSA SHOWED A SIGNIFICANTLY GREATER
INCIDENCE OF DISSOCIATIVE PHENOMENA THAN A GROUP OF AGE
MATCHED NORMAL FEMALE CONTROLS.
• FURTHERMORE, THE PRESENCE OF SEVERE DISSOCIATIVE EXPERIENCE
APPEARED TO BE SPECIFICALLY RELATED TO A PROPENSITY FOR SELF
MUTILATION AND SUICIDAL BEHAVIOUR.
• THE DISTORTION OF SELF AND BODY IMAGE EXPERIENCED BY PATIENTS
WITH EATING DISORDERS MIGHT BE RELATED TO THE GREATER PROPENSITY
OF THESE PATIENTS TO UNDERGO CONSIDERABLE DISSOCIATIVE
EXPERIENCES.

100. POST TRAUMATIC STRESS DISORDER (PTSD) AND
DISSOCIATION
• THE RELATION OF DISSOCIATION TO PTSD AND ACUTE STRESS DISORDER IS A
WIDELY DEBATED AREA IN RECENT TIMES.
• AMONG ROAD TRAFFIC ACCIDENT SURVIVORS, ALL MEASURES OF
DISSOCIATION, PARTICULARLY PERSISTENT DISSOCIATION 4 WEEKS AFTER
ACCIDENT, PREDICTED CHRONIC PTSD SEVERITY AT 6 MONTHS (MURRAY ET AL,
2002).
• IN ANOTHER STUDY, PERSISTENT DISSOCIATION WAS MORE STRONGLY
ASSOCIATED WITH ACUTE STRESS DISORDER SEVERITY AND INTRUSIVE
SYMPTOMS RATHER THAN PERITRAUMATIC DISSOCIATION

101. BORDERLINE PERSONALITY DISORDER AND DISSOCIATION
• MANY STUDIES (ZITTEL & WESTEN, 2005; YEE ET AL, 2005) HAVE SHOWN
THAT A SIGNIFICANT PROPORTION (AROUND 60%) OF BORDERLINE
PERSONALITY DISORDER PATIENTS HAD A DIAGNOSIS OF DISSOCIATIVE
DISORDER AS AXIS I COMORBIDITY.
• PATIENTS WITH BORDERLINE PERSONALITY DISORDER AND A DISSOCIATIVE
DISORDER HAVE HIGH LEVELS OF REPORTED CHILDHOOD TRAUMA
• BORDERLINE PERSONALITY DISORDER AND DISSOCIATION CAN BE RELATED
TO EACH OTHER IN SEVERAL DIFFERENT WAYS.
• FOR INSTANCE, IT CAN BE THAT BORDERLINE FEATURES DEVELOP IN RESPONSE TO
LIVING WITH THE CORE SYMPTOMS OF DISSOCIATION (ROSENTHAL ET AL, 2005).
• CHRONIC EFFORTS TO SUPPRESS (DISSOCIATE) UNPLEASANT THOUGHTS MAY IN SOME
CASES BE A REGULATORY STRATEGY UNDERLYING THE RELATIONSHIP BETWEEN
INTENSE NEGATIVE EMOTIONS AND SYMPTOMS OF BORDERLINE PERSONALITY
DISORDER.

102. FORENSIC ASPECTS
• THE CONCEPT OF DISSOCIATION IN GENERAL, AND SPECIFICALLY THE DIAGNOSIS
OF DISSOCIATIVE IDENTITY DISORDER (MULTIPLE PERSONALITY DISORDER), HAVE
RECEIVED INCREASING ATTENTION IN THE WORLD OF SCIENTIFIC RESEARCH AND
PSYCHIATRIC AND PSYCHOLOGICAL FORENSIC EVALUATIONS (FRANKEL &
DALENBERG, 2006).
• THERE ARE FOUR MAJOR DEFENSES PRESENTED BY PERSONS WITH DISSOCIATIVE
IDENTITY DISORDER ON TRIALS FOR CRIMES COMMITTED BY ALTER PERSONALITY
STATES.
• THEY ARE
• THE DEFENDANT HAS NO CONTROL OVER THE ACTION OF HIS OR HER SECONDARY
PERSONALITIES,
• THE DEFENDANT DOESN’T REMEMBER THE ACTS OF SECONDARY PERSONALITIES AND
THEREFORE CANNOT PARTICIPATE IN HIS OR HER OWN DEFENSES,
• BY VIRTUE OF SUFFERING FROM DISSOCIATIVE IDENTITY DISORDER, IT IS IMPOSSIBLE FOR THE
DEFENDANT TO CONFORM HIS OR HER BEHAVIOUR TO THE LAW OR TO KNOW RIGHT FROM
WRONG AND
• THE DEFENDANT WAS UNCONSCIOUS OF ALTER STATES’ BEHAVIOUR AND HENCE CANNOT BE
HELD RESPONSIBLE FOR SO

103. • IT IS ALSO NOT UNCOMMON FOR A THEORETICALLY INNOCENT ALTER
STATE OR FOR THE PRINCIPAL PERSONALITY TO DISCOVER A VIOLENT ALTER
STATE’S OFFENCE AND THEN TRY TO CONCEAL OR ESCAPE.
• THIS CONSCIOUS AVOIDANCE OF DISCOVERY MAKES IT EXTREMELY
DIFFICULT FOR A JURY TO BELIEVE THAT THE ENTIRE CRIME WAS NOT
DELIBERATE.
• IT IS STILL DOUBTFUL BUT NOW A DAYS ITS DECIDED BY MOST COUNTRIES
THAT DISSOCIATIVE IDENTITY DISORDER IS NO GROUND FOR EXCUSE FOR
CRIMINAL ACTIVITY

104. THE INDIAN SCENE
• THERE ARE FEW STUDIES IN INDIA ON DISSOCIATIVE DISORDERS AND ITS
PHENOMENOLOGY OR EVEN THE CULTURAL CONTEXT INFLUENCING THE
DIAGNOSIS OF PATIENTS WITH THIS DISORDER.
• SAXENA & PRASAD (1989) DID A CHART REVIEW TO FIND THE PREVALENCE
OF DISSOCIATIVE DISORDERS IN INDIAN POPULATION AND FOUND IT TO BE
2.3% IN A SAMPLE 2651 ADULT PSYCHIATRIC OUTPATIENTS ACCORDING TO
DSM-III CLASSIFICATORY SYSTEM.
• IN LATE 1970S AND 1980S, SIX CASES OF MULTIPLE PERSONALITY DISORDER
ACCORDING TO DSM-III-R WERE REPORTED FROM INDIA (STEVENSON &
PASRICHA ET AL, 1979; VERMA ET AL, 1981; ADITYANJEE ET AL, 1989).
• JHINGAN ET AL (2000) REPORTED A CASE OF SYMPTOM PROGRESSION FROM
CONVERSION TO DISSOCIATIVE DISORDER AND ULTIMATELY TO MULTIPLE
PERSONALITY DISORDER.

105. DISSOCIATIVE SPECTRUM DISORDERS IN THE MEDIA

106. • MOVIES
• FIGHT CLUB 1999
• PSYCHO 1960
• THE MACHINIST 2004
• WINDOW 2004
• IDENTITY 2003
• SYBIL 2007
• PRIMAL FEAR 1996
• DR. JEKYLL AND MR. HYDE 1941
• BOOKS
• SIDNEY SHELDON'S 1998 NOVEL TELL ME
YOUR DREAMS
• ROBERT A. HEINLEIN'S I WILL FEAR NO EVIL
• ROBERT SILVERBERG'S 1983 SHORT STORY
"MULTIPLES
• ROBERT LOUIS STEVENSON'S 1886 NOVEL
THE STRANGE CASE OF DR. JEKYLL AND
MR. HYDE
• MARY HIGGINS CLARK'S 1992 NOVEL ALL
AROUND THE TOWN
• STEPHEN KING'S BOOK SERIES, THE DARK
TOWER
• HERVEY CLECKLEY AND CORBETT
THIGPEN'S 1957 BOOK THE THREE FACES
OF EVE

107. BIBLIOGRAPHY
• COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, VOL 2, KAPLAN AND
SADOCK.
• SYNOPSIS OF PSYCHIATRY, 10TH EDITION - BENJAMIN J SADOCK &
VIRGINIA A SADOCK
• ESSENTIAL SOCIAL PSYCHOLOGY , RICHARD J. CRISP AND RHIANNON
N. TURNER.
• INTRODUCTION TO PSYCHOLOGY, MORGAN AND KING
• INTERNET SOURCES.

108. THANK YOU