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What Are Dissociative Disorders?


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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