Dissociative Disorders

Table of Contents

1. Introduction to Dissociative Disorders
2. Dissociative Amnesia (300.12)
    • DSM-IV-TR criteria
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments

3. Depersonalization Disorder (300.6)
    • DSM-IV-TR criteria
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments

4. Dissociative Fugue (300.13)
    • DSM-IV-TR criteria
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments

5. Dissociative Identity Disorder (300.14)
    • DSM-IV-TR criteria
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments
  • The video below is from the movie Sybil (1976) which is based off a true story of a girl named Sybil with DID. In this scene, you are introduced to a handful of Sybil's "identities".

6. Dissociative Disorder NOS (300.15)

2. Dissociative Amnesia (300.12)
  • DSM-IV-TR Criteria
    • A. 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.
    • B. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder, Dissociative Fugue, Posttraumatic 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., Amnestic Disorder due to head trauma).
    • C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.



3. Depersonalization Disorder (300.6)
      • DSM-IV-TR criteria
        • A. 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).
        • B. During the depersonalization experience, reality testing remains intact.
        • C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
        • D. 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)
      • Associated features
        • Associated features may include anxiety or depression. Sometimes, individuals have a hard time with sense of time and may have somatic manifestations. Comorbidity can include Obsessive-compulsive, Dysthymic, or Major Depressive disorders. Individuals with Depersonalization disorder may have personality disorders as well.
      • Child vs. adult presentation
        • The disorder is more likely to occur in late adolescence to adulthood.
      • Gender and cultural differences in presentation
        • From various studies, equal numbers of men and women are diagnosed. Individuals from individualistic societies are more likely to suffer from the disorder (see Etiology).
      • Epidemiology
        • Although much of the general population experiences a depersonalization experience (whether caused by a traumatic experience or danger, or a drug induced experience), only about 2.4% of the population has been diagnosed with depersonalization disorder.
      • Etiology
        • Similar to the other dissociative disorders, scientists link severe childhood abuse to depersonalization disorders. Brain imaging including pet scans show sensory cortex abnormalities. Positron emission tomography scans used to assess brain glucose metabolism show abnormalities in the sensory cortex including the temporal, occipital, and parietal lobes. The sensory cortex controls the senses and perception of an individual’s body in space. Lower levels of nerve cell responses in the area of the brain that controls emotion may correlate to the emotional detachment that individual’s feel during an episode of depersonalization. Western cultures where individuals live in a more individualistic society may be more likely to suffer from a depersonalization disorder. Individualism is stressed in most Western cultures and may have an effect on an individual’s sense of self.
      • Empirically supported treatments
        • There are currently no empirically supported treatments for this condition. For the most part, DPD remains resistant to traditional treatment measures. Psychotherapeutic techniques like cognitive behavioral therapy have been used to treat this disorder, but none of them have an established effectiveness. Pharmacological options continue to be researched. Some possible options that could be used to treat this condition include selective serotonin reuptake inhibitors, anticonvulsants, and opioid antagonists.


4. Dissociative Fugue (300.13)
      • DSM-IV-TR criteria
        • A. The predominant disturbance is sudden, unexpected travel away from home or one’s customary place of work, with inability
          to recall one’s past.
        • B. Confusion about personal identity or assumption of a new identity (partial or complete).
        • C. 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).
        • D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      • Associated features
        • Dissociative Fugue was formerly known as Psychogenic Fugue. It is comorbid with Bipolar Disorder, Major Depressive Disorder, and Schizophrenia, as well as PTSD, Substance Related disorders, Panic and Anxiety Disorders, Eating Disorders, and Somatoform Disorders. Note: Dissociative Fugue is often mistaken for malingering. This happens because the disorder enables people to escape their responsibilities or undesirable or dangerous situations; therefore it is seen as if a person is taking the ‘easy-way-out’. A person in the midst of a Dissociative Fugue episode may appear only slightly confused or they may appear to have no symptoms at all and attract no attention. Eventually, however, the person will begin to show significant signs of confusion or distress as they become aware of memory loss or confusion about their identity. This amnesia is characteristic of the disorder. When the fugue ends, the person may experience depression, grief, shame, and suicidal impulses.
      • Child vs. adult presentation
        • Dissociative Fugue usually begins in adulthood. There is little information about the presentation of this disorder in children. When it does affect children, it is most commonly due to severe trauma such as sexual abuse, but even then it does not usually present until adulthood.
      • Gender and cultural differences in presentation
        • Some research revealed that this condition most often occurs in females, but the reason is unknown. One source stated that females are at a rate six to nine times higher than males, and it increases as age increases. This pattern is most likely associated with the stresses on a woman to be both mother and a family provider and caretaker, in conjunction with the societal pressures and gender prejudices. Most studies however, believed that Dissociative Fugue is equally prevalent across genders.
          There is little information on the cultural differences in presentation of Dissociative Fugue. It is important to remember that what may be considered dissociative in one culture may be seen as normal in another. Cultures prone to warfare are more likely to experience the distressing pressures of war, which is a common causal traumatic event of this disorder. Various cultures with defined “running” syndrome may have symptoms that meet diagnostic criteria for Dissociative Fugue, such as the amok in Western Pacific cultures.
      • Epidemiology
        • This is a relatively rare disorder, actually the rarest of the dissociative disorders, affecting about only 2 in 1000 people in the United States. The prevalence rate is estimated at 0.2%. It is much more common however among people who have been in wars, accidents, natural disasters, or other highly traumatic or stressful events.
      • Etiology
        • Episodes of Dissociative Fugue are usually triggered by very stressful events. Traumatic experiences such as war, natural disasters, accidents, and sexual abuse during childhood, often increase the incidence of the disorder. More personal types of stress, like the shocking death of a loved one or unbearable pressures at work or home, might also lead to the unplanned travel and amnesia that is characteristic of Dissociative Fugue.
      • Empirically supported treatments
        • Most fugues last for only hours or days, and then often disappear on their own. The goal of treatment is to assist the person to come to terms with the trauma or stress that triggered the fugue in the first place. Another goal of treatment is to help develop new coping methods to prevent further fugue episodes. As with most disorders, the particular treatment approach depends on the individual and the severity of his or her symptoms. The most likely treatment however will include a combination of psychotherapy, cognitive therapy, medication, family therapy, creative therapy, and clinical hypnosis. Psychotherapy is the main treatment for dissociative disorders such as Dissociative Fugue. Such treatments aim to increase insight into problems. Cognitive therapy focuses on changing dysfunctional thinking patterns. Medication is useful when the person also suffers from depression or anxiety. Family therapy aims to teach the family more about the disorder and learn about the symptoms of recurrence. Creative therapies, such as music therapy and art therapy, let the person express themselves in safe manners. Clinical hypnosis uses intense relaxation, concentration, and focuses attention to achieve an altered state of awareness. This is risky however because of the risk of creating false memories. The prognosis for Dissociative Fugue is often very good because the episodes do not usually last longer than a few months and people generally recover quickly. Efforts to restore the memories of what happened during the fugue are usually unsuccessful or take a long time to be recovered.
      • Illustrative case
        • A case study was reported in Psychology Today (Drawing a Blank, October 2007) and was also reported in Maclean’s Magazine (The Man Who Lost Himself, May 2007) about a man named Jeff Ingram. A short summary of this case goes as follows: Ingram, 40, is a former mill worker in Olympia, Washington. He left his home one morning headed for Alberta to visit a terminally ill friend. A few days later he woke up on a street in Denver with no idea of who he was. Ingram became confused, angry, and worried when he was being questioned by the hospital’s receptionist because he had no knowledge of his identity. Even months after being reunited with his family, Ingram still had no pre-fugue memories, including that of his three year relationship with then-fiancée. In order to prevent such confusion in the future, Ingram ordered GPS shoes and had his identity information tattooed on him. He also wears a zip disk with medical information around his neck. It is believed that the possible trigger of Ingram’s fugue episode was the stress of his friend’s battle of cancer. A more detailed article can be found in Maclean’s magazine (May 2007).


5. Dissociative Identity Disorder (300.14)
      • DSM-IV-TR criteria
        • A. 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).
        • B. At least two of these identities or personality states recurrently take control of the person’s behavior.
        • C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
        • D. 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.
      • Associated features
        • Several symptoms are characteristic:
          • Fluctuating symptom pictures
          • Fluctuating levels of function from highly effective to disabled
          • Severe headaches or other pains
          • Time distortions, time lapses, and amnesia
          • Depersonalization and Derealization - Depersonalization occurs when a person feels unattached to him or herself. During this phenomenon, it is almost as if you can see yourself from another view point. Derealization is when you experience surroundings or people as if they are new, eccentric, or dreamlike when they are clearly not.
          • Patients can lose time; they can end up in places and not know how they arrived there or why. They also may find objects that they do not identify or handwriting that they do not think they wrote.
          • Individuals with Dissociative Identity Disorder frequently report having experienced severe physical and sexual abuse, especially during childhood. However, children's minds can produce distorted images or memories, so it is hard to tell how accurate they are. Some past experiences can be cleared up through objective evidence. Some individuals may have posttraumatic symptoms such as nightmares, flashbacks, and startle responses.
          • Certain identities can control their pain levels or other physical symptoms, which some individuals will self-mutilate and have suicidal thoughts. They may also experience relationships that contain both sexual and physical abuse. The identities or personality states persistently take control over the person’s behavior. These alternate identities are frequently diverse from the individual’s personality. Also, it could be of a different name, age, gender, or even race.
      • Child vs. adult presentation
        • There are no reliable figures on the diagnosis of children. However, it has increased during the 1990s. A child acting like someone else is perfectly normal. They are trying to get a sense of self. Of course, if some trauma happens in a child’s life, the result may go beyond simply mimicking another person. It may go as far as to creating alter personality states so they can create a fantasy world in order to escape real life. The average age is in early childhood, generally by the age of four. The average time period for the first symptom to occur to diagnosis is 6-7 years. The disorder may go dormant after 40 years of age but may reappear during episodes of stress or trauma or with substance abuse.
      • Gender and cultural differences in presentation
        • Dissociative Identity Disorder has been found in individuals from a several different cultures all around the world. It is diagnosed 3 to 9 times more often in adult females than in adult males; in childhood, the female-to-male ratio may be even more, but the data is limited. Males tend to have fewer identities than females. Males have approximately 8 identities. Females tend to have around 15 or more.
        • Some researchers report that dissociative symptoms were more common among minorities, but when socioeconomic statues was controlled, that difference disappeared.
      • Epidemiology
        • The studies do not give an exact estimate, however the numbers have increased drastically. A reason for this is because it could have been misdiagnosed as schizophrenia or bipolar disorders. Also, people have become more aware of child sexual abuse, which is a leading cause of DID. DID may be present in about 1% of the general population. India, Switzerland, China, and Germany’s prevalence rates range from 0.015% to 0.9%. The Netherlands is 2%. The U.S. ranges from 6 to 10% and Turkey at the highest with 14%.
        • However, scientists claim that a person having multiple personalities is bizarre, and the support for it is not credible. Some therapists maintain that using hypnosis and frequent prompting of alters bring about the indwelling identities. Even though, some patients do not show symptoms before the treatment has occurred. There is substantial support for the claim that therapists and the media are creating alters rather than discovering them.
      • Etiology
        • The causes are not yet confirmed, but there are some theoretical predictions of what causes DID. They are overwhelming stress, inadequate childhood nurturing, and the disability to separate recollections with what actually happens. The most common reason is childhood abuse; most of the cases reported deal with abuse. Some children tend to make up “happy places” that they can disappear to, to get away from the violence. If it happens often enough, the children may not be able to tell the difference between that and reality.
      • Empirically supported treatments
        • Treatment is done to try to reconnect the different personalities to one functional identity. Sometime if that does not work, a clinician may try to do something to help with the symptoms. Some of the things are psychotherapy and medications for comorbid disorders or doing some kind of behavioral therapy. Some may face a longer, slower process which may only help with symptom relief. However, the ones that are still attached to the abusers may have the most difficult time.