Dissociative Disorders



1. Introduction to Dissociative Disorder


-- Dissociative disorders are so-called because they are marked by dissociation from or an interruption of a person's fundamental aspects of waking consciousness (such as one's personal identity, one's personal history, etc.). Dissociative disorders come in many forms, the most famous of which is dissociative identity disorder (formerly known as multiple personality disorder). All of the dissociative disorders are thought to stem from trauma experienced by the individual with this disorder. The dissociative aspect is thought to be a coping mechanism. (American Psychiatric Association, 2000)
-- the person literally dissociates himself/herself from a situation or experience too traumatic to integrate with his conscious self. Symptoms of these disorders, or even one or more of the disorders themselves, are also seen in a number of other mental illnesses, including post-traumatic stress disorder, panic disorder, and obsessive compulsive disorder.




2. Dissociative Amnesia (300.12)


-- Dissociative Amnesia could be brought on by a Traumatic Event.
-- It used to be known as Psychogenic Amnesia. The crucial feature of this type of dissociative disorder is the failure to recall important personal information more extensive
than explained by an individual's normal forgetfulness. The nature of the information is usually traumatic or stressful. (American Psychiatric Association, 2000)

  • Mental illness
    • Patient is alert or oriented.
    • Patient is subadequately related with limited eye contact.
    • Speech is slow and logical.
    • Attention and concentration are limited.
    • Energy level is not characterized by hyperactivity or slowing.
    • Recent memory may be slightly impaired.
    • Remote memory is intact.
    • Mood is anxious or dysphoric.
    • Affect is constricted.
    • A negligible degree of conceptual disorganization is present.
    • Reasoning and judgment are limited, and insight is lacking.
    • An increased likelihood of passive suicidal ideation as well as violent ideation, sometimes even homicidal, is present, most likely due to severe frustration of the dissociation.
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  • The DSM-IV-TR criteria according to the American Psychiatric Association (2000) includes the following:
    • 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" (p. 523).
    • 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)" (p. 523).
    • C. "The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (p. 523).
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  • Associated features for dissociative amnesia according to the American Psychiatric Association (2000) are:
    • Dissociative amnesia occurs when a person blocks out certain information, usually associated with a stressful or traumatic event.
    • With this disorder, the degree of memory loss goes beyond normal forgetfulness and includes gaps in memory for long periods of time or of memories involving the traumatic event.
    • Some individuals with this disorder report trance states, spontaneous age regression, anxiety, depersonalization, analgesia, depressive symptoms, and they may provide approximate, though incorrect, answers to questions.
    • This disorder may be accompanied by sexual dysfunction, self-mutilation, suicidal impulses and acts, and impairment in social functioning, and they may meet criteria for Conversion Disorder, Mood Disorders, Substance-Related Disorders, or Personality Disorders. There is a lack of damage to the brain, but brain images do show abnormal activity. Results of FMRI's suggest that, during an amnesiac episode, patients are unable to retrieve emotional memories normally, suggesting possible changes in the limbic system.
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  • Child vs. Adult presentation
    • Dissociative Amnesia is more common among young adults than in older adults but can occur at any age past infancy. It is difficult to assess in preadolescent children, as it may be confused with inattention, anxiety, psychosis, oppositional behavior, or developmentally appropriate childhood amnesia.
  • Gender and cultural differences in presentation.
    • Dissociative Amnesia is more common among women than men.
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  • Epidemiology
    • "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." (American Psychiatric Association, 2000)
    • "Dissociative Amnesia can be present in any age group. The main symptom is a retrospective gap in memory. The reported duration of the forgotten events varies. Only a single episode may be reported, although there are commonly two or more episodes described. Individuals who have had one episode may be predisposed to develop amnesia for subsequent traumas. Acute Amnesia may resolve spontaneously after the individual is removed from the circumstances with which it is associated. Some may begin to recall distant memories, while others may develop a chronic form of amnesia." (American Psychiatric Association, 2000)
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  • Etiology
    • Dissociative amnesia has been linked to overwhelming stress, which might be the result of traumatic events—such as war, abuse, accidents or disasters—that the person has experienced or witnessed. There also might be a genetic link to the development of dissociative disorders, including dissociative amnesia, people with these disorders usually have close relatives who have had similar conditions. (American Psychiatric Association, 2000)
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  • Differential diagnosis
    • The differential diagnosis of DA are any organic metal disorders, dementia, delirium, transient global amnesia, Korsakoff's disease, post-concussion amnesia, substance abuse, other dissociative disorders, and malingering, factitious disorders.
    • Memory loss in organic metal disorders is typically gradual and incomplete. Clinicians may encounter difficulty in differentiating between substance abuse and DA because many patients minimize their abuse and also misattribute their amnesia to alcohol or drugs because of their of a diagnosis of dissociation. Obtaining a careful history from multiple informants is often necessary to clarify the situation. However, unlike DA, memory loss due to substance abuse is seldom reversible.
    • Korsakoff disease may also be confused with DA. This disease, also known as alcohol amnestic disorder, is associated with heavy and prolonged alcohol abuse and is not associated with psychological stress. However, unlike DA, patients with Korsakoff disease are not able to learn new information and they often experience significant deterioration in personal functioning.
    • Amnesia from brain injury or head trauma can be differentiated from DA based on a history of trauma; patients usually have retrograde amnesia before the trauma, unlike patients with DA, who have anterograde amnesia. In addition, patients with brain injury do not show the susceptibility or response to hypnosis so frequently observed in patients with dissociative disorders. Because dissociative disorders are associated with some evidence of biology causality, not every case of trauma results in symptoms that produce the disorder, nor does every person with the disorder have a history of childhood or adult trauma. (American Psychiatric Association, 2000)
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  • Indications for hospitalization
    • In most instances in which patients present a clear and present danger to themselves or others, when medication effects must be evaluated, and in instances in which a diagnosis has not been determined, hospitalization is often necessary. Hospitalization allows patients to separate themselves from the environmental stimuli, sexual and physical abuses, and stresses that may be contributing to their reactions and episodes of amnesia, compulsive behaviors, and recklessness. It also protects them during a perplexing period of their lives when they honestly d not know who they are. Other indications are suicidal behavior or gesturing. Patients may experience problems with concentration and feelings of rejection, re-occurrence of preexisting psychiatric conditions, intrusive re-experiencing of trauma or negative thinking, feelings of emotional overwhelm, paranoia or general distrust, and episodes of schizophrenia and fear.
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  • Empirically supported treatments
    • Like most other disorders, Dissociative amnesia uses a combination of psychotherapy, cognitive therapy, medicine, family and creative therapy and a new approach- clinical hypnosis.
      • Psychotherapy
        • In psychotherapy, the first phase of the treatment is to provide support to the patient. This involves creating a comfortable and supportive atmosphere in the treatment room. Generally the therapist will be there helping the patient to regain their memory, but one study reports that patients regain their memories while at home or surrounded by close friends and family. The patients denied that their memory was regained due to the therapist, but that the therapy did help.
        • The second phase of treatment occurs once the patient has recovered enough of their memories and has had a strong sense of self. The second phase involves helping the patient cope with the traumatic effects as well as the aftereffects.
      • Cognitive Therapy
        • Therapy that focuses on changing the thinking pattern and the resulting behaviors.
      • Family Therapy
        • Therapy for the family to help teach them about the causes of the disorder. This therapy can also help the family recognize the recurrence of symptoms.
      • Creative Therapy
        • Forms of therapy that helps the patient express and explore their thoughts and feelings in a creative and safe manner.
      • Medications
        • There is no medicinal cure for amnesia. However, patients may be given antidepressants to help with the anxiety, depression, insomnia, or other symptoms that are associated with dissociative amnesia.
      • Clinical Hypnosis
        • Clinical hypnosis is a new approach to amnesia that is used if memories do not return spontaneously. In this treatment, hypnosis or the drug sodium amytal, which puts the patient in a hypnotic state, is used to try to make the memories emerge. Use of intense relaxation and concentrations. This approach allows the patient to explore feelings, thoughts, and memories that may be hidden from their conscious minds.
        • "More controversy surrounds the use of hypnotically facilitated techniques to explore areas of amnesia, or to further explore fragmentary images or recollections. Some authorities who support hypnosis for these indications point to the recovery of material that has been confirmed at a later date or to the therapeutic progress often achieved irrespective of the veracity of what is found. Others believe that use of these methods carries the risk that hypnotically facilitated memory processing will increase the patient's chances of mislabeling fantasy as real memory. They believe that these are strong disincentives to this use of hypnotic exploration." (Chu, 2005)
        • Dissociative amnesia

  • Proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)

    • A. Inability to recall important personal information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
    • Note: There are two primary forms of Dissociative Amnesia: (1) localized amnesia for a specific event or events, and (2) Dissociative Fugue: generalized amnesia for identity and life history. Fugue may be accompanied by either purposeful travel or bewildered wandering.

    • B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

    • C. The memory loss 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).

    • D. The memory loss is not restricted to the symptoms of another mental disorder (e.g., inability to remember an important aspect of the traumatic event in Posttraumatic Stress Disorder or Acute Stress Disorder, or amnesia occuring as a symptom of Dissociative Identity Disorder or Somatization Disorder).



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3. Depersonalization Disorder (300.6)

-- Derealization or depersonalization is characterized by feelings that the objects of the external environment are changing shape and size, or that people are automated and inhuman, and each of them features detachment as a major defense. Depersonalization disorder usually begins in adolescence; typically, patients have continuous symptoms. Onset can be sudden or gradual. There is an estimated 2.4% of the general population that meets the diagnostic criteria for this disorder. However, the prevalence rate is questioned by many clinicians may be lower. This disorder is frequently coexists with mood, anxiety, and psychotic disorders. (American Psychiatric Association, 2000)

  • Mental Status
    • Patients present alert and disoriented in some spheres.
    • Both relatedness and eye contact are limited.
    • Patient may appear preoccupied and irritable.
    • A distressed facial expression with constricted affect is characteristic.
    • Reasoning, judgment, and insight are fair to limited.
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  • The DSM-IV-TR criteria according to the American Psychiatric Association (2000) includes the following:
    • 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)" (p. 532).
    • B. "During the depersonalization experience, reality testing remains intact" (p. 532).
    • C. "The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning" (p. 532).
    • 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)" (p. 532).
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  • 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. Individuals with Depersonalization Disorder often have difficulty describing their symptoms and may fear that they will be seen as "crazy." They may also experience derealization in the sense that the external world is unreal, and they may perceive an alteration in the size or shape of objects. People may seem unfamiliar or mechanical. Other features could include obsessive rumination, somatic concerns, a disturbance in the sense of time, and Hypochondriasis. (American Psychiatric Association, 2000)
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  • 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). Some cultures make use of meditative and trance practices which result in experiences of depersonalization and derealization.
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  • 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. Onset is typical during the teenage years and early 20s, though some report earlier or later onset (the mean age is around 16 years). There can be an acute or insidious onset. When acute, some individuals will remember the time and place of their first depersonalization experience. Insidious onset may reach as far back as one remembers, or it may begin with smaller episodes that increase in severity over time. Duration of episodes may be very brief or persistent. Depersonalization following a life-threatening situation usually develops suddenly upon exposure to teh trauma. The course is usually chronic and may fluctuate in intensity, but it is sometimes episodic. Actual or perceived stressful events most often exacerbate the symptoms." (American Psychiatric Association, 2000)
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  • 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. (American Psychiatric Association, 2000)
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  • Empirically supported treatments
    • "Treatment recommendations and guidelines for depersonalisation disorder have not been established. There are few studies assessing the use of pharmacotherapy in this disorder. Medication options that have been reported include clomipramine, fluoxetine, lamotrigine and opioid antagonists. However, it does not appear that any of these agents have a potent anti-dissociative effect. A variety of psychotherapeutic techniques has been used to treat depersonalisation disorder (including trauma-focused therapy and cognitive-behavioural techniques), although again none of these have established efficacy to date. Overall, novel therapeutic approaches are clearly needed to help individuals experiencing this refractory disorder." (Simeon, 2004)
    • Treatment for this disorder is more about treating the symptoms of the disorder or stresses associated disorder, more than the disorder itself. Treatments for the stresses include Psychotherapy, Cognitive Therapy, medications, Family therapy, Creative Therapies, and Clinical hypnosis.
      • Psychotherapy
        • A type of counseling and is the primary treatment for dissociative disorders.
      • Cognitive Therapy
        • Therapy that focuses on changing the thinking pattern and the resulting behaviors.
      • Family Therapy
        • Therapy for the family to help teach them about the causes of the disorder. This therapy can also help the family recognize and recurrence of symptoms.
      • Creative Therapy
        • Forms of therapy that helps the patient express and explore their thoughts and feelings in a creative and safe manner.
      • Medications
        • Antidepressants and anti-anxiety medications are used for the depression and the anxiety often felt by people with this disorder.

A film based on a person suffering from depersonalization disorder.

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4. Dissociative Fugue (300.13)

-- Dissociative Fugue is characterized by sudden, unplanned trips from the home or workplace without the ability to remember some or all of the individual's past. Some of these patients take on new characteristics or aspects not related to their original identity. They tend to be running away from something of which they are unaware. After a fugue episode resolves, patients are unable to remember the events of the state. Although moving occurs in other disorders, in fugue it is purposeful and it is not enacted in a confused or dazed state. In a typical case, the fugue is brief, with purposeful travel, and limited contact with others. About 0.2% of the general population is afflicted with this type of dissociative disorder. (American Psychiatric Association, 2000).

  • Mental Status
    • The mental status exam varies widely.
    • Patient may present alert and oriented only to oneself.
    • Eye contact and relatedness are limited to fair at best.
    • Psychomotor activity is characterized by normal activity.
    • Thought processes are intact, although thought content may vary widely from preoccupations to preservations to obsessive fixations to none.
    • Reasoning and judgment are lacking, and insight is poor.
    • An increased finding of violent or homocidal ideation is present, but suicidal ideation is lacking.
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  • The DSM-IV-TR criteria according to the American Psychiatric Association (2000) includes the following:
    • 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" (p. 526).
    • B. "Confusion about personal identity or assumption of a new identity (partial or complete)" (p. 526).
    • 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)" (p. 526).
    • D. "The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (p. 526).
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  • 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, guilt, dysphoria, psychological stress, conflict, and suicidal and aggressive impulses, and he may give approximate, though inaccurate, answers to questions. (American Psychiatric Association, 2000)
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  • 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.
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  • 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. (American Psychiatric Association, 2000)
    • Single episodes are most commonly reported and vary in duration. Recovery is usually rapid, but Dissociative Amnesia may sometimes be present. (American Psychiatric Association, 2000)
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  • Etiology
    • Episodes of Dissociative Fugue are usually triggered by traumatic, overwhelming, 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. (American Psychiatric Association, 2000)
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  • Differential diagnosis
    • Dissociative fugue includes other dissociative disorders, seizure disorder, amnestic disorder, schizophrenia, mania, dementia (often of the Alzheimer type), malingering, frontal lobe disorders, head trauma and injury, and factitious disorder. Fugue differs from other mental disorders in that the flight behavior is organized and purposeful. Patients with seizure disorder do not assume a new identity and usually have an altered state of conscious with abnormal findings on electroencephalogram testing. (American Psychiatric Association, 2000)
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  • Indications for hospitalization
    • In making a primary diagnosis, observing the patient in a controlled setting is often necessary. Patients reveal their level of need through interactions with others, inappropriate behavior without remorse, or by verbalizing their symptoms when they are aware of their suffering. In general, hospitalization is indicated when medical or surgical treatment is required, when the diagnosis is unclear, when no safe alternative exist for housing the patient, or as a means of stopping the ongoing abuse. Additionally, any time a patient experiences severe confusion regarding his or her identity or chronic amnesia regarding the total fugue episode, hospitalization if indicated. Hospitalization is also a tool for assessing and administering social services and medication, developing behavior, and ensuring that a patient will respond to medication under the safety and care of medical professionals. And, hospitalization provides containment. Most patients with dissociative fugue symptoms receive acute treatment in general hospital settings and psychiatric departments because they have a tendency to be brought in during an episode. In this way, the hospital provides the safety and treatment mechanism needed for a disorder that, without intervention, remains undiagnosed. Hospitalization most often occurs in order to provide emergency crisis treatment that is best provided in an acute are setting.
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  • 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). Here is a news video clip on this case.

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  • Proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)

    Dissociative Fugue subtype:
    1. Amnesia includes lack of control over how much of a person's past they can recall, confusion about their individual identity, or assumption of a new identity (partial or complete)
    2. Sudden, unplanned journey away from home or a job.

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The above video about Sybil contains content licensed by Warner Bros. Entertainment

5. Dissociative Identity Disorder (300.14)

-- DID, formerly refer to as multiple personality disorder, is characterized by the existence of two or more identities or personality traits within a single individual. Patient with this disorders demonstrate transfer of behavioral control among alter identities either by state transitions or by interference and overlap of alters who manifest themselves simultaneously. It is observed in 1-3% of the general population. (American Psychiatric Association, 2000)
  • Mental Status
    • Patient is alert and oriented in all spheres.
    • Affect may be labile or irritable.
    • Mood is euthymic or anxious.
    • Relatedness is very limited, and eye contact is very frequently minimal.
    • Thought content may be characterized significant hypervigilance, preoccupations, or hallucinations.
    • Patient appears fixed on extraneous or internal stimuli.
    • Reasoning and judgment are diminished and insight is poor.
    • An overall increase incidence of both suicidal and homocidal ideation in these patients is present.
    • Orientation is frequently off.
    • Long-term memory is poor.
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  • The DSM-IV-TR criteria according to the American Psychiatric Association (2000) includes the following:
    • 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)" (p. 529).
    • B. "At least two of these identities or personality states recurrently take control of the person’s behavior" (p. 529).
    • C. "Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness" (p. 529).
    • 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" (p. 529).
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  • 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 or derealization occurs when a person feels unattached to him or herself. During this phenomenon, it is almost as if one can see themselves from another view point. Derealization is when one experiences 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, each child's mind 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 post traumatic symptoms such as nightmares, flashbacks, and startle responses.
    • Certain identities can control their pain levels or other physical symptoms, while 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.
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  • 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 alternate personality states so they can create a fantasy world in order to escape real life. The average age of onset is in early childhood, generally by the age of four. The average time period for the first symptom to occur to diagnose is 6-7 years. The disorder may go dormant after 40 years of age but may reappear during episodes of stress,trauma or with substance abuse.
  • Gender and cultural differences in presentation
    • Dissociative Identity Disorder has been found in individuals from 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.
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  • 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. About 7% of the population may have undiagnosed dissociative disorder. 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%." (American Psychiatric Association, 2000)
    • 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. (American Psychiatric Association, 2000)
    • Dissociative Identity Disorder has a course that is chronic and recurrent. On average, the time between the appearance of the first symptoms and diagnosis is six to seven years. There have been reports of episodic and continuous courses. The disorder becomes less noticeable beyond age 40, but it may reemerge during episodes of stress or trauma or with Substance Abuse. (American Psychiatric Association, 2000)
    • Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries.
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  • 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 inability 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 the "happy place" and reality. (American Psychiatric Association, 2000)
    • Research also shows that a mixture of environmental and biological factors may cause DID. (American Psychiatric Association, 2000)
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  • Etiology Different Diagnosis
    • It is indicated when diagnosing DID, clinicians should consider other disorders such as dissociative disorder, mood disorder, personality disorder, schizophrenia, seizure disorder, eating disorder, malingering, and factitious disorders. A critical important difference between DID and Schizophrenia is that in schizophrenic people they hear voices within their heads, not from the outside. In addition, clinicians must be must be careful relying on historical references to recognize chronic amnesia, symptoms of PTST, a history of maltreatment, and the presence of alter identities that may allow them to make a diagnosis of DID even if other comorbid disorders are observed. (American Psychiatric Association, 2000)
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  • Indications for hospitalization
    • The treatment of dissociative disorders is difficult and time-consuming and is mostly enacted via behavioral modifications through outpatient therapy. However, in extreme cases or when physical or emotional harm is imminent, hospitalization may be a required intervention. Some of the indications for inpatient assessment or hospitalization include severe depression over a long period, anxiety and delusion disorders that lead to compulsive acting out of behaviors, cognitive reactions (eg, nightmares, flashbacks), physical reactions, fatigue, and interpersonal reactions (eg, conflict, problems with mood regulation, antisocial behavior, physical aggressiveness, suicidal behavior, traumatic and schizophrenic episodes). The ultimate goal for hospitalization of a patient is to ensure immediacy in restoring safey and stability. The patient remains at risk as long as no change in behavior or in approach for generating behavior modifications to improve response to stress and quality of life occurs.
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  • Empirically supported treatments
    • Treatment is done to try to reconnect the different personalities to one functional identity. Sometimes, if that does not work, a clinician may try other treatments to help with the symptoms. Some of the possible treatments are psychotherapy or medications for comorbid disorders such as anxiety and depression. They may benefit from medication that is prescribed for the comorbid disorders such as antidepressants or anti-anxiety medication. They may also do 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.
    People with DID may also form mutual self-help support groups within larger communities and online communities.
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The show, The United States of Tara on Showtime is a show that depicts a woman that deals with Dissociative Identity Disorder.



Tony, in this video, has 53 personalities.


In this video, a therapist talks about a client whose symptoms often caused others to misdiagnose her.
  • Each of the videos contains a person with more than one personality, but all of them including Sybil have a personality that knows about all the others and what is going on.

Dissociative Disorders


6. Dissociative Disorder NOS (300.15)


  • Associated Features
    • Dissociative Disorder NOS includes dissociative symptoms, such as disruption of the usually integrated functions of consciousness, memory, identity, or perception of the environment, but does not meet the criteria for a specific dissociative disorder.


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7. References


American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric
Association, 2000.
Chu, J. (2005). Guidelines for Treating Dissociative Identity Disorder in Adults (2005). Journal of Trauma & Dissociation, 6(4), 69-149.
Simeon, D. (2004). Depersonalisation Disorder: A Contemporary Overview. CNS Drugs, 18(6), 343-354.