The definitions below are from the section on dissociative disorders in the
DSM IV as found in the American Psychiatric Electronic Library CD-ROM.
The essential feature of the Dissociative Disorders is a disruption in the usually integrated
functions of consciousness, memory, identity, or perception of the environment. The
disturbance may be sudden or gradual, transient or chronic. The following disorders are
included in this section:
Dissociative Amnesia is characterized by an inability to recall important personal
information, usually of a traumatic or stressful nature, that is too extensive to be explained
by ordinary forgetfulness.
Dissociative Fugue is characterized by sudden, unexpected travel away from home or
one’s customary place of work, accompanied by an inability to recall one’s past and
confusion about personal identity or the assumption of a new identity.
Dissociative Identity Disorder (formerly Multiple Personality Disorder) is characterized
by the presence of two or more distinct identities or personality states that recurrently
take control of the individual’s behavior accompanied by an inability to recall important
personal information that is too extensive to be explained by ordinary forgetfulness.
Depersonalization Disorder is characterized by a persistent or recurrent feeling of being
detached from one’s mental processes or body that is accompanied by intact reality
testing.
Dissociative Disorder Not Otherwise Specified is included for coding disorders in
which the predominant feature is a dissociative symptom, but that do not meet the criteria
for any specific Dissociative Disorder.
Dissociative symptoms are also included in the criteria sets for Acute Stress Disorder,
Post traumatic Stress Disorder, and Somatization Disorder. An additional Dissociative
Disorder diagnosis is not given if the dissociative symptoms occur exclusively during the
course of one of these disorders. In some classifications, conversion reaction is
considered to be a dissociative phenomenon; however, in DSM-IV, Conversion Disorder is
placed in the “Somatoform Disorders” section to emphasize the importance of considering
neurological or other general medical conditions in the differential diagnosis.
A cross-cultural perspective is particularly important in the evaluation of Dissociative
Disorders because dissociative states are a common and accepted expression of cultural
activities or religious experience in many societies. Dissociation should not be considered
inherently pathological and often does not lead to significant distress, impairment, or help-
seeking behavior. However, a number of culturally defined syndromes characterized by
dissociation do cause distress and impairment and are recognized indigenously as
manifestations of pathology (see p. 727 and p. 843).
300.12 Dissociative Amnesia (formerly Psychogenic Amnesia)
Diagnostic Features
The essential feature of Dissociative Amnesia is an inability to recall important personal
information, usually of a traumatic or stressful nature, that is too extensive to be explained
by normal forgetfulness (Criterion A). This disorder involves a reversible memory
impairment in which memories of personal experience cannot be retrieved in a verbal form
(or, if temporarily retrieved, cannot be wholly retained in consciousness). The disturbance
does not occur exclusively during the course of Dissociative Identity Disorder, Dissociative
Fugue, Post traumatic Stress Disorder, Acute Stress Disorder, or Somatization Disorder
and is not due to the direct physiological effects of a substance or a neurological or other
general medical condition (Criterion B). The symptoms must cause clinically significant
distress or impairment in social, occupational, or other important areas of functioning
(Criterion C).
Dissociative Amnesia most commonly presents as a retrospectively reported gap or
series of gaps in recall for aspects of the individual’s life history. These gaps are usually
related to traumatic or extremely stressful events. Some individuals may have amnesia for
episodes of self-mutilation, violent outbursts, or suicide attempts. Less commonly,
Dissociative Amnesia presents as a florid episode with sudden onset. This acute form is
more likely to occur during wartime or in response to a natural disaster.
Several types of memory disturbances have been described in Dissociative Amnesia. In
localized amnesia, the individual fails to recall events that occurred during a circumscribed
period of time, usually the first few hours following a profoundly disturbing event (e.g., the
uninjured survivor of a car accident in which a family member has been killed may not be
able to recall anything that happened from the time of the accident until 2 days later). In
selective amnesia, the person can recall some, but not all, of the events during a
circumscribed period of time (e.g., a combat veteran can recall only some parts of a
series of violent combat experiences). Three other types of amnesia–generalized,
continuous, and systematized–are less common. In generalized amnesia, failure of recall
encompasses the person’s entire life. Individuals with this rare disorder usually present to
the police, to emergency rooms, or to general hospital consultation-liaison services.
Continuous amnesia is defined as the inability to recall events subsequent to a specific
time up to and including the present. Systematized amnesia is loss of memory for certain
categories of information, such as all memories relating to one’s family or to a particular
person. Individuals who exhibit these latter three types of Dissociative Amnesia may
ultimately be diagnosed as having a more complex form of Dissociative Disorder (e.g.,
Dissociative Identity Disorder).
Associated Features and Disorders
Associated descriptive features and mental disorders. Some individuals with
Dissociative Amnesia report depressive symptoms, depersonalization, trance states,
analgesia, and spontaneous age regression. They may provide approximate inaccurate
answers to questions (e.g., “2 plus 2 equals 5”) as in Ganser syndrome. Other problems
that sometimes accompany this disorder include sexual dysfunction, impairment in work
and interpersonal relationships, self-mutilation, aggressive impulses, and suicidal
impulses and acts. Individuals with Dissociative Amnesia may also have symptoms that
meet criteria for Conversion Disorder, a Mood Disorder, or a Personality Disorder.
Associated laboratory findings. Individuals with Dissociative Amnesia often display high
hypnotizability as measured by standardized testing.
Specific Age Features
Dissociative Amnesia is especially difficult to assess in preadolescent children, because
it may be confused with inattention, anxiety, oppositional behavior, Learning Disorders,
psychotic disturbances, and developmentally appropriate childhood amnesia (i.e., the
decreased recall of autobiographical events that occurred before age 5). Serial observation
or evaluations by several different examiners (e.g., teacher, therapist, case worker) may
be needed to make an accurate diagnosis of Dissociative Amnesia in children.
Prevalence
In recent years in the United States, there has been an increase in reported cases of
Dissociative Amnesia that involves previously forgotten early childhood traumas. This
increase has been subject to very different interpretations. Some believe that the greater
awareness of the diagnosis among mental health professionals has resulted in the
identification of cases that were previously undiagnosed. In contrast, others believe that
the syndrome has been over diagnosed in individuals who are highly suggestible.
Course
Dissociative Amnesia can present in any age group, from young children to adults. The
main manifestation in most individuals is a retrospective gap in memory. The reported
duration of the 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. Individuals who have had one episode of Dissociative Amnesia may be
predisposed to develop amnesia for subsequent traumatic circumstances. Acute amnesia
may resolve spontaneously after the individual is removed from the traumatic
circumstances with which the amnesia was associated (e.g., a soldier with localized
amnesia after several days of intense combat may spontaneously regain memory of these
experiences after being removed from the battlefield). Some individuals with chronic
amnesia may gradually begin to recall dissociated memories. Other individuals may
develop a chronic form of amnesia.
Differential Diagnosis
Dissociative Amnesia must be distinguished from Amnesic Disorder Due to a General
Medical Condition, in which the amnesia is judged to be the direct physiological
consequence of a specific neurological or other general medical condition (e.g., head
trauma, epilepsy) (see p. 158). This determination is based on history, laboratory findings,
or physical examination. In Amnesic Disorder Due to a Brain Injury, the disturbance of
recall, though circumscribed, is often retrograde, encompassing a period of time before
the head trauma, and there is usually a history of a clear-cut physical trauma, a period of
unconsciousness, or clinical evidence of brain injury. In contrast, in Dissociative Amnesia,
the disturbance of recall is almost always anterograde (i.e., memory loss is restricted to
the period after the trauma). The rare case of Dissociative Amnesia with retrograde
amnesia can be distinguished by the diagnostic use of hypnosis; the prompt recovery of
the lost memories suggests a dissociative basis for the disturbance. In seizure
disorders, the memory impairment is sudden in onset, motor abnormalities may be
present, and repeated EEGs reveal typical abnormalities. In delirium and dementia, the
memory loss for personal information is embedded in a far more extensive set of cognitive,
linguistic, affective, attentional, perceptual, and behavioral disturbances.. In contrast, in
Dissociative Amnesia, the memory loss is primarily for autobiographical information and
cognitive abilities generally are preserved. The amnesia associated with a general medical
condition usually cannot be reversed.
Memory loss associated with the use of substances or medications must be
distinguished from Dissociative Amnesia. Substance-Induced Persisting Amnesic
Disorder should be diagnosed if it is judged that there is a persistent loss of memory that
is related to the direct physiological effects of a substance (e.g., a drug of abuse or a
medication) (see p. 161). Whereas the ability to lay down new memories is preserved in
Dissociative Amnesia, in Substance-Induced Persisting Amnesic Disorder, short-term
memory is impaired (i.e., events may be recalled immediately after they occur, but not
after a few minutes have passed). Memory loss associated with Substance Intoxication
(e.g., “blackouts”) can be distinguished from Dissociative Amnesia by the association of
the memory loss with heavy substance use and the fact that the amnesia usually cannot
be reversed.
The dissociative symptom of amnesia is a characteristic feature of both Dissociative
Fugue and Dissociative Identity Disorder. Therefore, if the dissociative amnesia occurs
exclusively during the course of Dissociative Fugue or Dissociative Identity Disorder,
a separate diagnosis of Dissociative Amnesia is not made. Because depersonalization is
an associated feature of Dissociative Amnesia, depersonalization that occurs only during
Dissociative Amnesia should not be diagnosed separately as Depersonalization
Disorder.
In Post traumatic Stress Disorder and Acute Stress Disorder, there can be amnesia for
the traumatic event. Similarly, dissociative symptoms such as amnesia are included in
the criteria set for Somatization Disorder. Dissociative Amnesia is not diagnosed if it
occurs exclusively during the course of these disorders.
There are no tests or set of procedures that invariably distinguish Dissociative Amnesia
from Malingering, but individuals with Dissociative Amnesia usually score high on
standard measures of hypnotizability and dissociative capacity. Malingered amnesia is
more common in individuals presenting with acute, florid symptoms in a context in which
potential secondary gain is evident–for example, financial or legal problems or the desire
to avoid combat, although true amnesia may also be associated with such stressors.
Care must be exercised in evaluating the accuracy of retrieved memories, because the
informants are often highly suggestible. There has been considerable controversy
concerning amnesia related to reported physical or sexual abuse, particularly when abuse
is alleged to have occurred during early childhood. Some clinicians believe that there has
been an under reporting of such events, especially because the victims are often children
and perpetrators are inclined to deny or distort their actions. However, other clinicians are
concerned that there may be over reporting, particularly given the unreliability of childhood
memories. There is currently no method for establishing with certainty the accuracy of
such retrieved memories in the absence of corroborative evidence.
Dissociative Amnesia must also be differentiated from memory loss related to Age-
Related Cognitive Decline and nonpathological forms of amnesia including everyday
memory loss, posthypnotic amnesia, infantile and childhood amnesia, and amnesia for
sleep and dreaming. Dissociative Amnesia can be distinguished from normal gaps in
memory by the intermittent and involuntary nature of the inability to recall and by the
presence of significant distress or impairment.
Diagnostic criteria for 300.12 Dissociative Amnesia
The predominant disturbance is one or more episodes of inability to recall important
personal information, usually of a traumatic or stressful nature, that is too extensive to be
explained by ordinary forgetfulness.
The disturbance does not occur exclusively during the course of Dissociative Identity
Disorder, Dissociative Fugue, Post traumatic Stress Disorder, Acute Stress Disorder, or
Somatization Disorder and is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a neurological or other general medical condition
(e.g., Amnesic Disorder Due to Head Trauma).
The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
300.13 Dissociative Fugue ( formerly Psychogenic Fugue)
Diagnostic Features
The essential feature of Dissociative Fugue is sudden, unexpected, travel away from home
or one’s customary place of daily activities, with inability to recall some or all of one’s past
(Criterion A). This is accompanied by confusion about personal identity or even the
assumption of a new identity (Criterion B). The disturbance does not occur exclusively
during the course of Dissociative Identity Disorder and is not due to the direct
physiological effects of a substance or a general medical condition (Criterion C). The
symptoms must cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning (Criterion D).
Travel may range from brief trips over relatively short periods of time (i.e., hours or days) to
complex, usually unobtrusive wandering over long time periods (e.g., weeks or months),
with some individuals reportedly crossing numerous national borders and traveling
thousands of miles. During a fugue, individuals generally appear to be without
psychopathology and do not attract attention. At some point, the individual is brought to
clinical attention, usually because of amnesia for recent events or a lack of awareness of
personal identity. Once the individual returns to the prefugue state, there may be no
memory for the events that occurred during the fugue.
Most fugues do not involve the formation of a new identity. If a new identity is assumed
during a fugue, it is usually characterized by more gregarious and uninhibited traits than
characterized the former identity. The person may assume a new name, take up a new
residence, and engage in complex social activities that are well integrated and that do not
suggest the presence of a mental disorder.
Associated Features and Disorders
Associated descriptive features and mental disorders. After return to the prefugue
state, amnesia for traumatic events in the person’s past may be noted (e.g., after
termination of a long fugue, a soldier remains amnesic for wartime events that occurred
several years previously in which the soldier’s closest friend was killed). Depression,
dysphoria, grief, shame, guilt, psychological stress, conflict, and suicidal and aggressive
impulses may be present. The person may provide approximate inaccurate answers to
questions (e.g., “2 plus 2 equals 5”) as in Ganser syndrome. The extent and duration of
the fugue may determine the degree of other problems, such as loss of employment or
severe disruption of personal or family relationships. Individuals with Dissociative Fugue
may have a Mood Disorder, Post traumatic Stress Disorder, or a Substance-Related
Disorder.
Specific Culture Features
Individuals with various culturally defined “running” syndromes (e.g., pibloktoq among
native peoples of the Arctic, grisi siknis among the Miskito of Honduras and Nicaragua,
Navajo “frenzy” witchcraft, and some forms of amok in Western Pacific cultures) may
have symptoms that meet diagnostic criteria for Dissociative Fugue. These are conditions
characterized by a sudden onset of a high level of activity, a trancelike state, potentially
dangerous behavior in the form of running or fleeing, and ensuing exhaustion, sleep, and
amnesia for the episode. (See also Dissociative Trance Disorder in Appendix B, p. 727.)
Prevalence
A prevalence rate of 0.2% for Dissociative Fugue has been reported in the general
population. The prevalence may increase during times of extremely stressful events such
as wartime or natural disaster.
Course
The onset of Dissociative Fugue is usually related to traumatic, stressful, or overwhelming
life events. Most cases are described in adults. Single episodes are most commonly
reported and may last from hours to months. Recovery is usually rapid, but refractory
Dissociative Amnesia may persist in some cases.
Differential Diagnosis
Dissociative Fugue must be distinguished from symptoms that are judged to be the direct
physiological consequence of a specific general medical condition (e.g., head
injury) (see p. 165). This determination is based on history, laboratory findings, or physical
examination. Individuals with complex partial seizures have been noted to exhibit
wandering or semipurposeful behavior during seizures or during postictal states for which
there is subsequent amnesia. However, an epileptic fugue can usually be recognized
because the individual may have an aura, motor abnormalities, stereotyped behavior,
perceptual alterations, a postictal state, and abnormal findings on serial EEGs.
Dissociative symptoms that are judged to be the direct physiological consequence of a
general medical condition should be diagnosed as Mental Disorder Not Otherwise
Specified Due to a General Medical Condition. Dissociative Fugue must also be
distinguished from symptoms caused by the direct physiological effects of a
substance (see p. 192).
If the fugue symptoms only occur during the course of Dissociative Identity Disorder,
Dissociative Fugue should not be diagnosed separately. Dissociative Amnesia and
Depersonalization Disorder should not be diagnosed separately if the amnesia or
depersonalization symptoms occur only during the course of a Dissociative Fugue.
Wandering and purposeful travel that occur during a Manic Episode must be
distinguished from Dissociative Fugue. As in Dissociative Fugue, individuals in a Manic
Episode may report amnesia for some period of their life, particularly for behavior that
occurs during euthymic or depressed states. However, in a Manic Episode, the travel is
associated with grandiose ideas and other manic symptoms and such individuals often
call attention to themselves by inappropriate behavior. Assumption of an alternate identity
does not occur.
Peripatetic behavior may also occur in Schizophrenia. Memory for events during
wandering episodes in individuals with Schizophrenia may be difficult to ascertain due to
the individual’s disorganized speech. However, individuals with Dissociative Fugue
generally do not demonstrate any of the psychopathology associated with Schizophrenia
(e.g., delusions, negative symptoms).
Individuals with Dissociative Fugue usually score high on standard measures of
hypnotizability and dissociative capacity. However, there are no tests or set of procedures
that invariably distinguish true dissociative symptoms from those that are malingered.
Malingering of fugue states may occur in individuals who are attempting to flee a
situation involving legal, financial, or personal difficulties, as well as in soldiers who are
attempting to avoid combat or unpleasant military duties (although true Dissociative Fugue
may also be associated with such stressors). Malingering of dissociative symptoms can
be maintained even during hypnotic or barbiturate-facilitated interviews. In the forensic
context, the examiner should always give careful consideration to the diagnosis of
malingering when fugue is claimed. Criminal conduct that is bizarre or with little actual
gain may be more consistent with a true dissociative disturbance.
Diagnostic criteria for 300.13 Dissociative Fugue
The predominant disturbance is sudden, unexpected travel away from home or one’s
customary place of work, with inability to recall one’s past.
Confusion about personal identity or assumption of a new identity (partial or complete).
The disturbance does not occur exclusively during the course of Dissociative Identity
Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).
The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
300.14 Dissociative Identity Disorder (formerly Multiple Personality Disorder)
Diagnostic Features
The essential feature of Dissociative Identity Disorder is the presence of two or more
distinct identities or personality states (Criterion A) that recurrently take control of
behavior (Criterion B). There is an inability to recall important personal information, the
extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The
disturbance is not due to the direct physiological effects of a substance or a general
medical condition (Criterion D). In children, the symptoms cannot be attributed to
imaginary playmates or other fantasy play.
Dissociative Identity Disorder reflects a failure to integrate various aspects of identity,
memory, and consciousness. Each personality state may be experienced as if it has a
distinct personal history, self-image, and identity, including a separate name. Usually
there is a primary identity that carries the individual’s given name and is passive,
dependent, guilty, and depressed. The alternate identities frequently have different names
and characteristics that contrast with the primary identity (e.g., are hostile, controlling,
and self-destructive). Particular identities may emerge in specific circumstances and may
differ in reported age and gender, vocabulary, general knowledge, or predominant affect.
Alternate identities are experienced as taking control in sequence, one at the expense of
the other, and may deny knowledge of one another, be critical of one another, or appear to
be in open conflict. Occasionally, one or more powerful identities allocate time to the
others. Aggressive or hostile identities may at times interrupt activities or place the others
in uncomfortable situations.
Individuals with this disorder experience frequent gaps in memory for personal history,
both remote and recent. The amnesia is frequently asymmetrical. The more passive
identities tend to have more constricted memories, whereas the more hostile, controlling,
or “protector” identities have more complete memories. An identity that is not in control
may nonetheless gain access to consciousness by producing auditory or visual
hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered
by reports from others who have witnessed behavior that is disavowed by the individual or
by the individual’s own discoveries (e.g., finding items of clothing at home that the
individual cannot remember having bought). There may be loss of memory not only for
recurrent periods of time, but also an overall loss of biographical memory for some
extended period of childhood. Transitions among identities are often triggered by
psychosocial stress. The time required to switch from one identity to another is usually a
matter of seconds, but, less frequently, may be gradual. The number of identities reported
ranges from 2 to more than 100. Half of reported cases include individuals with 10 or fewer
identities.
Associated Features and Disorders
Associated descriptive features and mental disorders. Individuals with Dissociative
Identity Disorder frequently report having experienced severe physical and sexual abuse,
especially during childhood. Controversy surrounds the accuracy of such reports, because
childhood memories may be subject to distortion and individuals with this disorder tend to
be highly hypnotizable and especially vulnerable to suggestive influences. On the other
hand, those responsible for acts of physical and sexual abuse may be prone to deny or
distort their behavior. Individuals with Dissociative Identity Disorder may manifest
post traumatic symptoms (e.g., nightmares, flashbacks, and startle responses) or
Post traumatic Stress Disorder. Self-mutilation and suicidal and aggressive behavior may
occur. Some individuals may have a repetitive pattern of relationships involving physical
and sexual abuse. Certain identities may experience conversion symptoms (e.g.,
pseudoseizures) or have unusual abilities to control pain or other physical symptoms.
Individuals with this disorder may also have symptoms that meet criteria for Mood,
Substance-Related, Sexual, Eating, or Sleep Disorders. Self-mutilative behavior,
impulsivity, and sudden and intense changes in relationships may warrant a concurrent
diagnosis of Borderline Personality Disorder.
Associated laboratory findings. Individuals with Dissociative Identity Disorder score
toward the upper end of the distribution on measures of hypnotizability and dissociative
capacity. There are reports of variation in physiological function across identity states
(e.g., differences in visual acuity, pain tolerance, symptoms of asthma, sensitivity to
allergens, and response of blood glucose to insulin).
Associated physical examination findings and general medical conditions. There
may be scars from self-inflicted injuries or physical abuse. Individuals with this disorder
may have migraine and other types of headaches, irritable bowel syndrome, and asthma.
Specific Culture, Age, and Gender Features
It has been suggested that the recent relatively high rates of the disorder reported in the
United States might indicate that this is a culture-specific syndrome. In preadolescent
children, particular care is needed in making the diagnosis because the manifestations
may be less distinctive than in adolescents and adults. Dissociative Identity Disorder is
diagnosed three to nine times more frequently in adult females than in adult males; in
childhood, the female-to-male ratio may be more even, but data are limited. Females tend
to have more identities than do males, averaging 15 or more, whereas males average
approximately 8 identities.
Prevalence
The sharp rise in reported cases of Dissociative Identity Disorder in the United States in
recent years has been subject to very different interpretations. Some believe that the
greater awareness of the diagnosis among mental health professionals has resulted in the
identification of cases that were previously undiagnosed. In contrast, others believe that
the syndrome has been over diagnosed in individuals who are highly suggestible.
Course
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.
Familial Pattern
Several studies suggest that Dissociative Identity Disorder is more common among the
first-degree biological relatives of persons with the disorder than in the general population.
Differential Diagnosis
Dissociative Identity Disorder must be distinguished from symptoms that are caused by
the direct physiological effects of a general medical condition (e.g., seizure
disorder) (see p. 165). This determination is based on history, laboratory findings, or
physical examination. Dissociative Identity Disorder should be distinguished from
dissociative symptoms due to complex partial seizures, although the two disorders
may co-occur. Seizure episodes are generally brief (30 seconds to 5 minutes) and do not
involve the complex and enduring structures of identity and behavior typically found in
Dissociative Identity Disorder. Also, a history of physical and sexual abuse is less
common in individuals with complex partial seizures. EEG studies, especially sleep
deprived and with nasopharyngeal leads, may help clarify the differential diagnosis.
Symptoms caused by the direct physiological effects of a substance can be
distinguished from Dissociative Identity Disorder by the fact that a substance (e.g., a drug
of abuse or a medication) is judged to be etiologically related to the disturbance (see p.
192).
The diagnosis of Dissociative Identity Disorder takes precedence over Dissociative
Amnesia, Dissociative Fugue, and Depersonalization Disorder. Individuals with
Dissociative Identity Disorder can be distinguished from those with trance and possession
trance symptoms that would be diagnosed as Dissociative Disorder Not Otherwise
Specified by the fact that those with trance and possession trance symptoms typically
describe external spirits or entities that have entered their bodies and taken control.
Controversy exists concerning the differential diagnosis between Dissociative Identity
Disorder and a variety of other mental disorders, including Schizophrenia and other
Psychotic Disorders, Bipolar Disorder, With Rapid Cycling, Anxiety Disorders,
Somatization Disorders, and Personality Disorders. Some clinicians believe that
Dissociative Identity Disorder has been under diagnosed (e.g., the presence of more than
one dissociated personality state may be mistaken for a delusion or the communication
from one identity to another may be mistaken for an auditory hallucination, leading to
confusion with the Psychotic Disorders; shifts between identity states may be confused
with cyclical mood fluctuations leading to confusion with Bipolar Disorder). In contrast,
others are concerned that Dissociative Identity Disorder may be over diagnosed relative to
other mental disorders based on the media interest in the disorder and the suggestible
nature of the individuals. Factors that may support a diagnosis of Dissociative Identity
Disorder are the presence of clear-cut dissociative symptomatology with sudden shifts in
identity states, reversible amnesia, and high scores on measures of dissociation and
hypnotizability in individuals who do not have the characteristic presentations of another
mental disorder.
Dissociative Identity Disorder must be distinguished from Malingering in situations in
which there may be financial or forensic gain and from Factitious Disorder in which there
may be a pattern of help-seeking behavior.
Diagnostic criteria for 300.14 Dissociative Identity Disorder
The presence of two or more distinct identities or personality states (each with its own
relatively enduring pattern of perceiving, relating to, and thinking about the environment
and self).
At least two of these identities or personality states recurrently take control of the
person’s behavior.
Inability to recall important personal information that is too extensive to be explained by
ordinary forgetfulness.
The disturbance is not due to the direct physiological effects of a substance (e.g.,
blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition
(e.g., complex partial seizures). Note: In children, the symptoms are not attributable to
imaginary playmates or other fantasy play.
300.6 Depersonalization Disorder
Diagnostic Features
The essential features of Depersonalization Disorder are persistent or recurrent episodes
of depersonalization characterized by a feeling of detachment or estrangement from one’s
self (Criterion A). The individual may feel like an automaton or as if he or she is living in a
dream or a movie. There may be a sensation of being an outside observer of one’s mental
processes, one’s body, or parts of one’s body. Various types of sensory anesthesia, lack
of affective response, and a sensation of lacking control of one’s actions, including
speech, are often present. The individual with Depersonalization Disorder maintains intact
reality testing (e.g., awareness that it is only a feeling and that he or she is not really an
automaton) (Criterion B). Depersonalization is a common experience, and this diagnosis
should be made only if the symptoms are sufficiently severe to cause marked distress or
impairment in functioning (Criterion C). Because depersonalization is a common
associated feature of many other mental disorders, a separate diagnosis of
Depersonalization Disorder is not made if the experience occurs exclusively during the
course of another mental disorder (e.g., Schizophrenia, Panic Disorder, Acute Stress
Disorder, or another Dissociative Disorder). In addition, the disturbance is not due to the
direct physiological effects of a substance or a general medical condition (Criterion D).
Associated Features and Disorders
Associated descriptive features and mental disorders. Often individuals with
Depersonalization Disorder may have difficulty describing their symptoms and may fear
that these experiences signify that they are “crazy.” Derealization may also be present
and is experienced as the sense that the external world is strange or unreal. The individual
may perceive an uncanny alteration in the size or shape of objects (macropsia or
micropsia), and people may seem unfamiliar or mechanical. Other common associated
features include anxiety symptoms, depressive symptoms, obsessive rumination, somatic
concerns, and a disturbance in one’s sense of time. In some cases, the loss of feeling
that is characteristic of depersonalization may mimic Major Depressive Disorder and, in
other cases, may coexist with it. Hypochondriasis and Substance-Related Disorders may
also coexist with Depersonalization Disorder. Depersonalization and derealization are very
frequent symptoms of Panic Attacks. A separate diagnosis of Depersonalization Disorder
should not be made when the depersonalization and derealization occur exclusively during
such attacks.
Associated laboratory findings. Individuals with Depersonalization Disorder may display
high hypnotizability and high dissociative capacity as measured by standardized testing.
Specific Culture Features
Voluntarily induced experiences of depersonalization or derealization form part of
meditative and trance practices that are prevalent in many religions and cultures and
should not be confused with Depersonalization Disorder.
Prevalence
The lifetime prevalence of Depersonalization Disorder in community and clinical settings is
unknown. At some time in their lives, approximately half of all adults may have
experienced a single brief episode of depersonalization, usually precipitated by severe
stress. A transient experience of depersonalization develops in nearly one-third of
individuals exposed to life-threatening danger and in close to 40% of patients hospitalized
for mental disorders.
Course
Individuals with Depersonalization Disorder usually present for treatment in adolescence or
adulthood, although the disorder may have an undetected onset in childhood. 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 can vary from very brief (seconds) to
persistent (years). Depersonalization subsequent to life-threatening situations (e.g.,
military combat, traumatic accidents, being a victim of violent crime) usually develops
suddenly on exposure to the trauma. The course may be chronic and marked by
remissions and exacerbations. Most often the exacerbations occur in association with
actual or perceived stressful events.
Differential Diagnosis
Depersonalization Disorder must be distinguished from symptoms that are due to the
physiological consequences of a specific general medical condition (e.g., epilepsy)
(see p. 165). This determination is based on history, laboratory findings, or physical
examination. Depersonalization that is caused by the direct physiological effects of
a substance is distinguished from Depersonalization Disorder by the fact that a
substance (e.g., a drug of abuse or a medication) is judged to be etiologically related to
the depersonalization (see p. 192). Acute Intoxication or Withdrawal from alcohol and
a variety of other substances can result in depersonalization. On the other hand,
substance use may intensify the symptoms of a preexisting Depersonalization Disorder.
Thus, accurate diagnosis of Depersonalization Disorder in individuals with a history of
alcohol- or substance-induced depersonalization should include a longitudinal history of
Substance Abuse and depersonalization symptoms.
Depersonalization Disorder should not be diagnosed separately when the symptoms
occur only during a Panic Attack that is part of Panic Disorder, Social or Specific
Phobia, or Post traumatic or Acute Stress Disorders. In contrast to Schizophrenia,
intact reality testing is maintained in Depersonalization Disorder. The loss of feeling
associated with depersonalization (e.g., numbness) may mimic a depression. However,
the absence of feeling in individuals with Depersonalization Disorder is associated with
other manifestations of depersonalization (e.g., a sense of detachment from one’s self)
and occurs even when the individual is not depressed.
Diagnostic criteria for 300.6 Depersonalization Disorder
Persistent or recurrent experiences of feeling detached from, and as if one is an
outside observer of, one’s mental processes or body (e.g., feeling like one is in a dream).
During the depersonalization experience, reality testing remains intact.
The depersonalization causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
The depersonalization experience does not occur exclusively during the course of
another mental disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder,
or another Dissociative Disorder, and is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g.,
temporal lobe epilepsy).
300.15 Dissociative Disorder Not Otherwise Specified
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. Examples include:
Clinical presentations similar to Dissociative Identity Disorder that fail to meet full
criteria for this disorder. Examples include presentations in which a) there are not two or
more distinct personality states, or b) amnesia for important personal information does not
occur.
Derealization unaccompanied by depersonalization in adults.
States of dissociation that occur in individuals who have been subjected to periods of
prolonged and intense coercive persuasion (e.g., brainwashing, thought reform, or
indoctrination while captive).
Dissociative trance disorder: single or episodic disturbances in the state of
consciousness, identity, or memory that are indigenous to particular locations and
cultures. Dissociative trance involves narrowing of awareness of immediate surroundings
or stereotyped behaviors or movements that are experienced as being beyond one’s
control. Possession trance involves replacement of the customary sense of personal
identity by a new identity, attributed to the influence of a spirit, power, deity, or other
person, and associated with stereotyped “involuntary” movements or amnesia. Examples
include amok (Indonesia), bebainan (Indonesia), latah (Malaysia), pibloktoq (Arctic),
ataque de nervios (Latin America), and possession (India). The dissociative or trance
disorder is not a normal part of a broadly accepted collective cultural or religious practice.
(See p. 727 for suggested research criteria.)
Loss of consciousness, stupor, or coma not attributable to a general medical condition.
Ganser syndrome: the giving of approximate answers to questions (e.g., “2 plus 2
equals 5”) when not associated with Dissociative Amnesia or Dissociative Fugue.
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Last edited: 01/02/03.
