Dissociative Disorders

Dissociative Disorders
4/29/2019 Gessessew T. 1
Dissociative Disorders
• Dissociation is defined as an unconscious defense mechanism
involving the separation of any group of mental or behavioral
processes from the rest of the person’s psychic activity.
• Disruption in one or more mental functions, such as memory,

identity, perception, consciousness, or motor behavior.
• The disturbance may be sudden or gradual, transient or chronic.
• The signs and symptoms of the disorder are often caused by

psychological trauma.
• Dissociative disorders are characterized by a disruption of and/or
discontinuity in the normal integration of consciousness, memory,
identity, emotion, perception, body representation, motor control,
and behavior.
• Dissociative symptoms can potentially disrupt every area of

psychological functioning.
• Dissociation is a disconnection between a persons psychological

functioning ( like thoughts, perception….)
Types of dissociative disorder
o Dissociative identity disorder,
o Dissociative amnesia,
o Depersonalization/derealization disorder,
o Other specified dissociative disorder, and
o Unspecified dissociative disorder.
• The dissociative disorders are frequently found in the aftermath of
trauma, and many of the symptoms, including embarrassment and
confusion about the symptoms or a desire to hide them, are
influenced by the proximity to trauma.
• In DSM-5, the dissociative disorders are placed next to, but are not
part of, the trauma- and stressor-related disorders, reflecting the
close relationship between these diagnostic classes.
• Both acute stress disorder and posttraumatic stress disorder contain

dissociative symptoms, such as amnesia, flashbacks, numbing, and
depersonalization/derealization.
• DD: chronic trauma occurs in childhood
1.Dissociative Amnesia
• The main feature 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.
• Not result from the direct physiological effects of a substance or a

neurological or other general medical condition.
• Dissociative amnesia is characterized by an inability to recall
autobiographical information that is inconsistent with normal
forgetting.
• This amnesia may be localized (i.e., an event or period of time),

selective (i.e., a specific aspect of an event), or generalized (i.e.,
identity and life history).
• It may or may not involve purposeful travel or bewildered
wandering (i.e., fugue).
• Although some individuals with amnesia promptly notice that

they have "lost time“ or that they have a gap in their memory,
• Most individuals with dissociative disorders are initially unaware

of their amnesias.
• For them, awareness of amnesia occurs only when personal
identity is lost or when circumstances make these individuals
aware that autobiographical information is missing (e.g., when they
discover evidence of events they cannot recall or when others tell
them or ask them about events they cannot recall).
• Until and unless this happens, these individuals have "amnesia for
their amnesia."
• Amnesia is experienced as an essential feature of dissociative
amnesia; individuals may experience localized or selective
amnesia most commonly, or generalized amnesia rarely.
• Dissociative fugue is rare in persons with dissociative amnesia but

common in dissociative identity disorder.
Diagnostic Criteria of Dissociative Amnesia
A. An inability to recall important autobiographical information,
usually of a traumatic or stressful nature, that is inconsistent with
ordinary forgetting.
B. The symptoms cause clinically significant distress or impairment

in social, occupational, or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a

substance or a neurological or other medical condition.
D. The disturbance is not better explained by DID, PTSD, ASD,

SSD, or neurocognitive disorder.
• Specify if :
• With dissociative fugue: Apparently purposeful travel or

bewildered wandering that is associated with amnesia for identity or
for other important autobiographical information.
Types of Dissociative Amnesia
1. Localized amnesia:
 Inability to recall events related to a circumscribed
(restricted) period of time.
 Is the most common form of dissociative amnesia.
2. Selective amnesia:
 Ability to remember some, but not all, of the events occurring
during a circumscribed period of time.
 Thus, the individual may remember part of a traumatic event
but not other parts.
 Some individuals report both localized and selective amnesias.
3. Generalized amnesia:
 Failure to recall one's entire life.
 A complete loss of memory for one's life history, is rare.
 May forget personal identity.
 Has an acute onset; the perplexity, disorientation, and

purposeless wandering
 May be more common among combat veterans, sexual assault

victims, and individuals experiencing extreme emotional stress
or conflict.
4. Continuous amnesia:
Failure to recall successive events as they occur.
an individual forgets each new event as it occurs.
5. Systematized amnesia:
The individual loses memory for a specific category of

information.
Amnesia for certain categories of memory, such as all memories

relating to one's family or to a particular person , or childhood
sexual abuse.
Epidemiology
• 2 to 6 % of the general population.
• Incidence: men : women is 1:1
• Onset is late adolescence and adulthood.
• Difficult to assess in preadolescent children because of their

more limited ability to describe subjective experience.
• The 12-month prevalence among adults in a small U.S.

community study was 1.8% (1.0% for males; 2.6% for
females).
Etiology
• Traumatic experiences such as physical or sexual abuse can induce
the disorder.
• As a result of severe psychological trauma, the patient temporarily

and unconsciously shut down the memory of all events in life.
Differential Diagnosis
• Dissociative identity disorder:
• Individuals with dissociative identity disorder report pervasive
discontinuities in sense of self and agency, accompanied by many
other dissociative symptoms.
• The amnesias of individuals with localized, selective, and/ or
systematized dissociative amnesias are relatively stable.
• Amnesias in dissociative identity disorder include:
– amnesia for everyday events,
– finding of unexplained possessions / belongings,
– sudden fluctuations in skills and knowledge,
– major gaps in recall of life history, and
– brief amnesic gaps in interpersonal interactions.
• Posttraumatic stress disorder: Some individuals with PTSD cannot
recall part or all of a specific traumatic event (e.g., a rape victim
with depersonalization and/or derealization symptoms who cannot
recall most events for the entire day of the rape).
• When that amnesia extends beyond the immediate time of the

trauma, a comorbid diagnosis of dissociative amnesia is warranted.
• In neurocognitive disorders, memory loss for personal information
is usually surrounded in cognitive, language , affective, attentional,
and behavioral disturbances.
• In dissociative amnesia, memory deficits are primarily for

autobiographical information; intellectual and cognitive abilities
are preserved.
• Substance-related disorders: In the context of repeated
intoxication with alcohol or other substances/medications, there
may be episodes of “Black outs" or periods for which the individual
has no memory.
• To aid in distinguishing these episodes from dissociative amnesia, a
longitudinal history noting that the amnestic episodes occur only in
the context of intoxication and do not occur in other situations
would help identify the source as substance- induced.
• Seizure disorders: Individuals with seizure disorders may exhibit
complex behavior during seizures or post-ictally with subsequent
amnesia.
• Catatonic stupor:
• Mutism in catatonic stupor may suggest dissociative amnesia, but

failure of recall is absent.
• Factitious disorder and malingering.
• Normal and age-related changes in memory.
Comorbidity
• As dissociative amnesia begins to remit, a wide variety of
affective phenomena may surface: dysphoria, grief, rage, shame,
guilt, psychological conflict and turmoil, and suicidal and
homicidal ideation, impulses, and acts.
• Then they meet diagnostic criteria for persistent depressive

disorder; MDD; other specified or unspecified depressive disorder
and adjustment disorder.
• Somatic symptom disorder and conversion disorder (functional
neurological symptom disorder).
• Personality disorder, especially dependent, avoidant, and

borderline.
Suicide Risk
• Suicidal and other self-destructive behaviors are common in
individuals with dissociative amnesia.
• Suicidal behavior may be a particular risk when the amnesia

remits suddenly and overwhelms the individual with intolerable
memories.
Course and Prognosis
• Little is known about the clinical course of dissociative amnesia.
• Acute dissociative amnesia frequently spontaneously resolves once

the person is removed to safety from traumatic or overwhelming
circumstances.
• Some patients do develop chronic forms of generalized,

continuous, or severe localized amnesia and
• Profoundly disabled and require high levels of social support, such

as nursing home placement or intensive family care-taking.
Treatment of dissociative amnesia
1. Psychotherapy: Supportive psychotherapy (initial stage), Consider
CBT when the patient recovers from the amnesia and Cognitive
therapy for cognitive distortions
2. Pharmacological : sodium amobarbital or diazepam to help patient

to facilitate recall traumatic events in a semi-conscious state but
this process is rarely performed now a days.
• Medication:
– No known pharmacotherapy exists for dissociative amnesia

other than pharmacologically facilitated interviews.
– Sodium amobarbital, thiopental, oral benzodiazepines, and

amphetamines.
– Pharmacologically facilitated interviews using intravenous

amobarbital or diazepam (Valium) are used primarily in
working with acute amnesias and conversion reactions in
general hospital medical and psychiatric services.
• This procedure is also occasionally useful in refractory cases of
chronic dissociative amnesia when patients are unresponsive to
other interventions.
2. Depersonalization/Derealization Disorder
• Depersonalization/derealization disorder is characterized by
clinically significant persistent or recurrent depersonalization
(i.e., experiences of unreality or detachment from one's mind,
self, or body) and/or derealization (i.e., experiences of unreality
or detachment from one's surroundings).
• These alterations of experience are accompanied by intact reality

testing.
• Depersonalization is Persistent or recurrent feeling of detachment

from one's self.
• There is no evidence of any distinction between individuals with
predominantly depersonalization versus derealization symptoms.
• Therefore, individuals with this disorder can have

depersonalization, derealization, or both.
• Derealization is somewhat related and refers to feelings of

unreality or of being detached from one’s environment.
• The patient may describe his or her perception of the outside

world as lacking clarity and emotional coloring, as though
dreaming or dead.
Diagnostic Criteria
A. The presence of persistent or recurrent experiences of
depersonalization, derealization, or both:
1. Depersonalization: Experiences of unreality, detachment, or being

an outside observer with respect to one’s thoughts, feelings,
sensations, body, or actions (e.g., perceptual alterations, distorted
sense of time, unreal or absent self, emotional and/ or physical
numbing).
2. Derealization: Experiences of unreality or detachment with respect

to surroundings (e.g., individuals or objects are experienced as
unreal, dreamlike, foggy, lifeless, or visually distorted).
B. During the depersonalization or derealization experiences, reality
testing remains intact.
C. The symptoms cause clinically significant distress or impairment

D. The disturbance is not attributable to the physiological effects of a

substance or another medical condition (e.g., seizures).
E. The disturbance is not better explained by another mental disorder.
Diagnosis and Clinical Features
• A number of distinct components comprise the experience of
depersonalization:
– a sense of bodily changes,
– duality of self as observer and actor,
– being cut off from others, and
– being cut off from one’s own emotions.
• Patients experiencing depersonalization often have great difficulty
expressing what they are feeling.

• Trying to express their subjective suffering with banal
phrases, such as “I feel dead,” “Nothing seems real,” or “I’m
standing outside of myself”
Epidemiology
• Transient depersonalization/derealization symptoms lasting hours
to days are common in the general population.
• Transient experiences of depersonalization and derealization are
extremely common in normal and clinical populations.
• In general, approximately one-half of all adults have experienced
at least one lifetime episode of depersonalization/derealization.
• Lifetime prevalence in U.S. and non-U.S. countries is
approximately 2% (range of 0.8% to 2.8%).
• Depersonalization is found two to four times more in women than
in men.
• The third most commonly reported psychiatric symptoms, after
depression and anxiety.
• 1-year prevalence of 19 % in the general population.
• It is common in seizure patients and migraine sufferers;
• They can also occur with use of marijuana, lysergic acid

diethylamide (LSD), and mescaline.
• Less frequently as a side effect of some medications, such as

anticholinergic agents.
• They are also common after mild to moderate head injury.

• The mean age at onset of depersonalization/derealization disorder
is 16 years.
• Although the disorder can start in early or middle childhood.
• Less than 20% of individuals experience onset after age 20 years
• Only 5% after age 25 years.
• Onset in the fourth decade of life or later is highly unusual.
• Onset can range from extremely sudden to gradual.
• Duration of the episodes can vary greatly, from brief (hours or
days) to prolonged (weeks, months, or years).
• Given the rare of disorder onset after age 40 years, in such cases
the individual should be examined more closely for underlying
medical conditions (e.g., brain lesions, seizure disorders, sleep
apnea).
• The course of the disorder is often persistent.
• Mean age of onset is thought to be in late adolescence or early

adulthood in most cases.
Risk and Prognostic Factors
• Temperamental: Harm-avoidant temperament, immature
defenses, and both disconnection and over-connection schemata.
• Immature defenses such as idealization/devaluation, projection

and acting out result in denial of reality and poor adaptation.
• Environmental: There is a clear association between the disorder
and childhood interpersonal traumas in a substantial portion of
individuals.
• Emotional abuse and emotional neglect have been most strongly

and consistently associated with the disorder.
• Other stressors: physical abuse; witnessing domestic violence;

growing up with a seriously impaired, mentally ill parent; or
unexpected death or suicide of a family member.
• The most common precipitants of the disorder are:
o Severe stress (interpersonal, financial, occupational)
o Depression
o Anxiety (particularly panic attacks)
o Illicit drug use.
• Marijuana use may precipitate new-onset panic attacks and

depersonalization/derealization symptoms simultaneously.
• Psychodynamic: Traditional psychodynamic formulations have
emphasized the disintegration of the ego or have viewed
depersonalization as an affective response in defense of the ego.
• Traumatic Stress: A substantial proportion, typically 1/3-1/2 of

patients in clinical depersonalization case series report histories of
significant trauma.
Neurobiological Theories
• The association of depersonalization with migraines and
marijuana, its generally favorable response to selective serotonin
reuptake inhibitors (SSRIs).
• The increase in depersonalization symptoms seen with the

depletion of L-tryptophan, a serotonin precursor, point to
serotoninergic involvement.
DDx
• Depersonalization can result from a medical condition or
neurological condition, intoxication or withdrawal from illicit
drugs, as a side effect of medications, or can be associated with
panic attacks, phobias, PTSD, or acute stress disorder,
schizophrenia, or another dissociative disorder.
• A thorough medical and neurological evaluation is essential,

including standard laboratory studies, an EEG, and any indicated
drug screens.
Con’t…
• Drug-related depersonalization is typically transient, but persistent
depersonalization can follow an episode of intoxication with a
variety of substances, including marijuana, cocaine, and other
psychostimulants.
• Illness anxiety disorder: the diagnosis of
depersonalization/derealization disorder is characterized by the
presence of a gathering of typical depersonalization/derealization
symptoms and the absence of other manifestations of illness
anxiety disorder.
Con’t…
• Major depressive disorder: Feelings of numbness, deadness,
apathy, and being in a dream are not uncommon in major
depressive episodes.
• If the depersonalization/derealization clearly precedes the onset of

a major depressive episode or clearly continues after its resolution,
the diagnosis of depersonalization/ derealization disorder applies.
Con’t…
• Obsessive-compulsive disorder: Some individuals with
depersonalization/derealization disorder can become obsessively
preoccupied with their subjective experience or develop rituals
checking on the status of their symptoms.
• However, other symptoms of obsessive-compulsive disorder

unrelated to depersonalization/derealization are not present.
Con’t…
• Other dissociative disorders: In order to diagnose
depersonalization/derealization disorder, the symptoms should
not occur in the context of another dissociative disorder, such as
dissociative identity disorder.
Con’t…
• Anxiety disorders: Depersonalization/derealization is one of the
symptoms of panic attacks, increasingly common as panic attack
severity increases.
• Therefore, depersonalization/ derealization disorder should not be

diagnosed when the symptoms occur only during panic attacks
that are part of panic disorder, social anxiety disorder, or specific
phobia.
Con’t…
• Diagnosis of depersonalization/derealization disorder can be made
if :
1. The depersonalization/derealization component of the presentation

is very prominent from the start, clearly exceeding in duration and
intensity the occurrence of actual panic attacks; or
2. The depersonalization/derealization continues after panic disorder

has remitted or has been successfully treated
Con’t…
• Psychotic disorders: The presence of intact reality testing
specifically regarding the depersonalization/derealization
symptoms is essential to differentiating depersonalization/
derealization disorder from psychotic disorders.
Con’t…
• Substance/medication-induced disorders:
• Depersonalization/derealization associated with the physiological

effects of substances during acute intoxication or withdrawal is not
diagnosed as depersonalization/derealization disorder.
• The most common precipitating substances are the illicit drugs

marijuana, hallucinogens, ketamine, ecstasy, and salvia.
• In about 15% of all cases of depersonalization/derealization

disorder, the symptoms are precipitated by ingestion of such
substances.
• If the symptoms persist for some time in the absence of any
further substance or medication use, the diagnosis of
depersonalization/ derealization disorder applies.
• Mental disorders due to another medical condition:
• Features such as onset after age 40 years or the presence of
atypical symptoms and course in any individual suggest the
possibility of an underlying medical condition.
• In such cases, it is essential to conduct a thorough medical and
neurological evaluation, which may include standard laboratory
studies, viral titers, an electroencephalogram, vestibular testing,
visual testing, sleep studies, and/or brain imaging.
Comorbidity
• Unipolar depressive disorder and anxiety disorder
• Comorbidity with PTSD is low.
• The three most commonly co-occurring personality disorders

were avoidant, borderline, and obsessive-compulsive.
• Depersonalization after traumatic experiences or intoxication
commonly remits spontaneously after removal from the traumatic
circumstances or ending of the episode of intoxication.
• Depersonalization accompanying mood, psychotic, or other
anxiety disorders commonly remits with definitive treatment of
these conditions.
• Depersonalization disorder itself may have an episodic, relapsing
and remitting, or chronic course.
• Many patients with chronic depersonalization may have a course

characterized by severe impairment in occupational, social, and
personal functioning.
Treatment of depersonalization/derealization disorder
• SSRI may be helpful in frequent depersonalization disorder and

comorbid depressive disorder.
• SSRI antidepressants, such as fluoxetine (Prozac), may be helpful

to patients with depersonalization disorder.
• Two recent, double-blind, placebo-controlled studies, however,

found no efficacy for fluvoxamine (Luvox) and lamotrigine
(Lamictal), respectively, for depersonalization disorder.
• Some patients with depersonalization disorder respond at best
infrequently and partially to the usual groups of psychiatric
medications, singly or in combination: antidepressants, mood
stabilizers, typical and atypical neuroleptics, and
anticonvulsants.
• Psychotherapy: psychodynamic, cognitive, cognitive-behavioral,
and supportive.
• Stress management stratégies, distraction techniques, réduction of
sensory stimulation, relaxation training, and physical exercise may
be some what helpful in some patients.
Dissociative Fugue
• Dissociative fugue was deleted as a major diagnostic category in
DSM-5.
• Is now diagnosed on a subtype (specifier) of dissociative amnesia.
• Can be seen in patients with both dissociative amnesia and

dissociative identity disorder.
• Dissociative fugue is described as 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.
• This is accompanied by confusion about personal identity or even
the assumption of a new identity.
• It is not due to the direct physiological effects of a substance or a

general medical condition.
• It must cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.
Etiology
• Traumatic circumstances (i.e., combat, rape, recurrent childhood
sexual abuse, massive social dislocations, natural disasters),
leading to an altered state of consciousness dominated by a wish to
flee (run away) are the underlying cause of most fugue episodes.
Epidemiology
• The disorder is thought to be more common during natural
disasters, wartime, or times of major social dislocation and
violence.
• No adequate data exist to demonstrate a gender bias to this disorder;

however, most cases describe men, primarily in the military.
• Dissociative fugue is usually described in adults.
• Dissociative fugues have been described to last from minutes to

months.
• Some patients report multiple fugues.
• Children or adolescents may be more limited than adults in their

ability to travel.
• Fugues in this population may be brief and involve only short

distances.
• After the termination of a fugue, the patient may experience
perplexity, confusion, trance-like behaviors, depersonalization,
derealization, and conversion symptoms, in addition to amnesia.
• Some patients may terminate a fugue with an episode of

generalized dissociative amnesia.
• As the patient with dissociative fugue begins to become less

dissociated, he or she may display mood disorder symptoms,
intense suicidal ideation, and PTSD or anxiety disorder symptoms.
• Most fugues are relatively brief, lasting from hours to days.
• Most individuals appear to recover,
• Refractory dissociative amnesia may persist in rare cases.
• Recurrent fugues in most individuals presenting with an episode

of dissociative fugue.
Treatment
• Psychodynamically oriented psychotherapy that focuses on
helping the patient recover memory for identity and recent
experience.
• Hypnotherapy and pharmacologically facilitated interviews are
frequently necessary adjunctive techniques to assist with memory
recovery.
• Patients may need medical treatment for injuries sustained during
the fugue as well as food and sleep.
• Psychiatric hospitalization may be indicated if the patient is an
outpatient.
3. Dissociative identity disorder
• Dissociative identity disorder, previously called multiple
personality disorder, a persons personality spilt b/n one or more
alternative personality.
• The most extensively researched of all the dissociative disorders.
• It is characterized by the presence of two or more distinct identities

or personality states.
• The identities or personality states, sometimes called alters, self-
states, alter identities, or parts, among other terms, differ from one
another in that each presents as having its own pattern of
perceiving, relating to, and thinking about the environment and
self, in short, its own personality.
• It is the classic dissociative psychopathology in that the symptoms

of all the other dissociative disorders are commonly found in
patients with dissociative identity disorder: amnesia, fugue,
depersonalization, derealization, and similar symptoms.
• The presence of two or more independent identities that
recurrently take control of the individual's behavior with only one
evident at a time.
• Tone of voice, mannerisms, and other personality

characteristics change.(at least 2, range 5-10)
• Inability to recall important personal information, amnestic about

the other states.
• Stress often produces transient exacerbation of dissociative

symptoms that makes them more evident.
Epidemiology
• Few systematic epidemiological data exist for dissociative identity
disorder.
• Clinical studies report female to male ratios between 5 to 1 and 9

to 1 for diagnosed cases.
• The 12-month prevalence of dissociative identity disorder among

adults in a small U.S. community study was 1.5%.
• The prevalence across genders in that study was 1.6% for males
and 1.4% for females.
• Onset from childhood to adolescence

Etiology
• It is strongly linked to severe experiences of early childhood
trauma, usually maltreatment.
• The rates of reported severe childhood trauma for child and

adult patients with dissociative identity disorder range from 85 to
97 % of cases.
• Physical and sexual abuse are the most frequently reported

sources of childhood trauma.
• Maltreatment (Abuse) and severe childhood trauma are

predisposing factors.
• The key feature in diagnosing this disorder is the presence of two
or more distinct personality states.
• There are many other signs and symptoms, this make the
diagnosis difficult.
• Many other associated symptoms commonly found in patients

with dissociative personality disorder.
• A careful and detailed mental status is essential in making the

diagnosis.
• It is easy to mistake patients with this disorder as suffering from
schizophrenia, borderline personality disorder, or malingering.
Diagnostic Criteria of dissociative identity disorder
A. Disruption of identity characterized by two or more distinct

personality states.
o The disruption in identity involves marked discontinuity in sense

of self and sense of agency, accompanied by related alterations in
affect, behavior, consciousness, memory, perception, cognition,
and/or sensory-motor functioning.
o These signs and symptoms may be observed by others or reported

by the individual.
B. Recurrent gaps in the recall of everyday events, important personal
information, and/ or traumatic events that are inconsistent with
ordinary forgetting. (Recurrent amnesia)
C. The symptoms cause clinically significant distress or impairment

D. The disturbance is not a normal part of a broadly accepted cultural
or religious practice.
• Note: In children, the symptoms are not better explained by

imaginary playmates or other fantasy play.
E. The symptoms are not attributable to the physiological effects of a

substance or another medical condition.
Differential Diagnosis
• Other specified dissociative disorder: May be distinguished
from dissociative identity disorder by the presence of chronic or
recurrent mixed dissociative symptoms that do not meet Criterion
A for dissociative identity disorder or are not accompanied by
recurrent amnesia.
• Major depressive disorder: Individuals with dissociative identity
disorder are often depressed, and their symptoms may appear to
meet the criteria for a major depressive episode.
• Rigorous assessment indicates that this depression in some cases

does not meet full criteria for major depressive disorder.
• Bipolar disorders: Individuals with dissociative identity disorder
are often misdiagnosed with a bipolar disorder, most often bipolar
II disorder.
• The relatively rapid shifts in mood in individuals with this

disorder—typically within minutes or hours, in contrast to the
slower mood changes typically seen in individuals with bipolar
disorders.
• Posttraumatic stress disorder: Some traumatized individuals have
both posttraumatic stress disorder (PTSD) and dissociative identity
disorder.
• Accordingly, it is crucial to distinguish between individuals with
PTSD only and individuals who have both PTSD and dissociative
identity disorder.
• Some individuals with PTSD manifest dissociative symptoms that
also occur in dissociative identity disorder:
1. Amnesia for some aspects of trauma,
2. Dissociative flashbacks (i.e., reliving of the trauma, with reduced
awareness of one's current orientation), and
3. Symptoms of intrusion and avoidance, negative alterations in
cognition and mood, and hyperarousal that are focused around the
traumatic event.
• Individuals with dissociative identity disorder manifest
dissociative symptoms that are not a manifestation of PTSD:
1. Amnesias for many everyday (i.e., non-traumatic) events,
2. Dissociative flashbacks that may be followed by amnesia for
the content of the flashback,
3. Disruptive intrusions (unrelated to traumatic material) by
dissociated identity states into the individual's sense of self and
agency
4. Infrequent, complete changes among different identity states.
• Psychotic disorders: Dissociative identity disorder may be
confused with schizophrenia or other psychotic disorders.
• The personified, internally communicative inner voices of

dissociative identity disorder, especially of a child (e.g., "I hear a
little girl crying in a closet and an angry man crying at her"), may
be mistaken for psychotic hallucinations.
• Patients with DID have intact reality testing
• Dissociative experiences of identity fragmentation or possession,
and of perceived loss of control over thoughts, feelings, impulses,
and acts, may be confused with signs of formal thought disorder,
such as thought insertion or withdrawal.
• Individuals with dissociative identity disorder may also report

visual, tactile, olfactory, gustatory, and somatic hallucinations,
which are usually related to posttraumatic and dissociative factors,
such as partial flashbacks.
• Individuals with dissociative identity disorder experience these
symptoms as caused by alternate identities, do not have delusional
explanations for the phenomena, and often describe the symptoms
in a personified way (e.g., "I feel like someone else wants to cry
with my eyes").
• Substance/medication-induced disorders: Symptoms associated
with the physiological effects of a substance can be distinguished
from dissociative identity disorder if the substance in question is
judged to be etiologically related to the disturbance.
• Personality disorders: In DID, the individual's longitudinal
variability in personality style (due to inconsistency among
identities) differs from the pervasive and persistent dysfunction in
affect management and interpersonal relationships typical of those
with personality disorders.
• Conversion disorder (functional neurological symptom disorder):
• This disorder may be distinguished from dissociative identity

disorder by the absence of an identity disruption characterized by
two or more distinct personality states or an experience of
possession.
• Dissociative amnesia in conversion disorder is more limited (e.g.,

amnesia for a non-epileptic seizure).
• Factitious disorder and malingering
Comorbidity
• Trauma- and stressor-related disorders(PTSD)
• Depressive disorders,
• Personality disorders (especially avoidant and borderline
personality disorders),
• Conversion disorder (functional neurological symptom disorder),
• Somatic symptom disorder,
• Eating disorders,
• Substance-related disorders,
• Obsessive-compulsive disorder, and
• Sleep disorders.
Suicide Risk
• Over 70% of outpatients with dissociative identity disorder have
attempted suicide;
• Multiple attempts are common,
• Other self-injurious behavior is frequent.
• Assessment of suicide risk may be complicated when there is:
o amnesia for past suicidal behavior or
o when the presenting identity does not feel suicidal and
o is unaware that other dissociated identities do.
• Untreated dissociative identity disorder are thought to continue
involvement in abusive relationships or violent subcultures, or
both, that may result in the traumatization of their children, with
the potential for additional family transmission of the disorder.
• Undiagnosed or untreated DID die by suicide or as a result of their

risk-taking behaviors.
• Prognosis is poorer in patients with comorbid organic mental

disorders, psychotic disorders and severe medical illnesses.
• Other factors that usually indicate a poorer prognosis include:
 significant antisocial personality features
 current criminal activity
 ongoing crime of abuse
 current victimization.
 Refractory substance abuse
 eating disorders
TREATMENT
A. Psychotherapy: include psychoanalytic psychotherapy, cognitive
therapy, behavioral therapy, hypnotherapy, and a familiarity with
the psychotherapy and psychopharmacological management of
the traumatized patient.
B. Psychopharmacological:
 Antidepressant medications are often important in the reduction

of depression and stabilization of mood.
 A variety of PTSD symptoms, especially intrusive and

hyperarousal symptoms, are partially medication responsive.
 Clinicians report some success with antidepressants, β-

blockers, clonidine (Catapres), anticonvulsants, and
benzodiazepines in reducing intrusive symptoms, hyperarousal,
and anxiety in patients with dissociative identity disorder.
• Recent research suggests that the α1-adrenergic antagonist
prazosin (Minipress) may be helpful for PTSD nightmares.
• Case reports suggest that aggression may respond to

Carbamazepine in some individuals if EEG abnormalities are
present.
• Patients with obsessive–compulsive symptoms may respond to

antidepressants .
• Open-label studies suggest that naltrexone (ReVia) may be helpful

for amelioration of recurrent self-injurious behaviors in a subset of
traumatized patients.
• Atypical neuroleptics, such as risperidone, quetiapine, ziprasidone,
and olanzapine may be more effective and better tolerated than
typical neuroleptics for overwhelming anxiety and intrusive PTSD
symptoms in patients with dissociative identity disorder.
• Occasionally, an extremely disorganized, overwhelmed,

chronically ill patient with dissociative identity disorder, who has
not responded to trials of other neuroleptics, responds favorably to
a trial of clozapine (Clozaril).
4/29/2019 Gessessew T. 100

C. Electroconvulsive Therapy:
 For some patients, ECT is helpful in ameliorating refractory mood
disorders and does not worsen dissociative memory problems.
 Clinical experience in tertiary care settings for severely ill patients

with dissociative identity disorder suggests that a clinical picture
of major depression with persistent, refractory melancholic
features across all alter states may predict a positive response to
ECT.
 This response is usually only partial, however, as is typical for

most successful somatic treatments in the dissociative identity
disorder population.
4/29/2019 Gessessew T. 101
4. Other Specified Dissociative Disorder
• This category applies to presentations in which symptoms

characteristic of a dissociative disorder that cause clinically
significant distress or impairment in social, occupational, or other
important areas of functioning predominate.
• But do not meet the full criteria for any of the disorders in the
dissociative disorders diagnostic class.
4/29/2019 Gessessew T. 102

Examples of Other Specified Dissociative Disorder
 Chronic and recurrent syndromes of mixed dissociative

symptoms
 Identity disturbance due to prolonged and intense coercive

persuasion:
 Acute dissociative reactions to stressful events:
 Dissociative trance
 Ganser syndrome
 Brainwashing
 Recovered Memory Syndrome

4/29/2019 Gessessew T. 103
5. Unspecified Dissociative Disorder
• Cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning predominate
but do not meet the full criteria for any of the disorders in the
dissociative disorders diagnostic class.
• Is used in situations in which the clinician chooses not to specify

the reason that the criteria are not met for a specific dissociative
disorder, and includes presentations for which there is insufficient
information to make a more specific diagnosis (e.g., in emergency
room settings).
4/29/2019 Gessessew T. 104
Thank you !!!!
4/29/2019 Gessessew T. 105

Dissociative Disorders

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Dissociative Disorders

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Dissociative Disorders

• Disruption in one or more mental functions, such as memory,

• The disturbance may be sudden or gradual, transient or chronic.

• The signs and symptoms of the disorder are often caused by

• Dissociative symptoms can potentially disrupt every area of

• Dissociation is a disconnection between a persons psychological

o Other specified dissociative disorder, and

o Unspecified dissociative disorder.

• Both acute stress disorder and posttraumatic stress disorder contain

• DD: chronic trauma occurs in childhood

• Not result from the direct physiological effects of a substance or a

• This amnesia may be localized (i.e., an event or period of time),

• Although some individuals with amnesia promptly notice that

• Most individuals with dissociative disorders are initially unaware

• Dissociative fugue is rare in persons with dissociative amnesia but

B. The symptoms cause clinically significant distress or impairment

C. The disturbance is not attributable to the physiological effects of a

D. The disturbance is not better explained by DID, PTSD, ASD,

• With dissociative fugue: Apparently purposeful travel or

 A complete loss of memory for one's life history, is rare.

 May forget personal identity.

 Has an acute onset; the perplexity, disorientation, and

 May be more common among combat veterans, sexual assault

an individual forgets each new event as it occurs.

The individual loses memory for a specific category of

Amnesia for certain categories of memory, such as all memories

• Incidence: men : women is 1:1

• Onset is late adolescence and adulthood.

• Difficult to assess in preadolescent children because of their

• The 12-month prevalence among adults in a small U.S.

• As a result of severe psychological trauma, the patient temporarily

• Individuals with dissociative identity disorder report pervasive

discontinuities in sense of self and agency, accompanied by many

other dissociative symptoms.

• The amnesias of individuals with localized, selective, and/ or

systematized dissociative amnesias are relatively stable.

– amnesia for everyday events,

– finding of unexplained possessions / belongings,

– sudden fluctuations in skills and knowledge,

– major gaps in recall of life history, and

– brief amnesic gaps in interpersonal interactions.

• When that amnesia extends beyond the immediate time of the

• In dissociative amnesia, memory deficits are primarily for

intoxication with alcohol or other substances/medications, there

may be episodes of “Black outs" or periods for which the individual

• To aid in distinguishing these episodes from dissociative amnesia, a

longitudinal history noting that the amnestic episodes occur only in

the context of intoxication and do not occur in other situations

would help identify the source as substance- induced.

• Mutism in catatonic stupor may suggest dissociative amnesia, but

• Factitious disorder and malingering.

• Normal and age-related changes in memory.

• Then they meet diagnostic criteria for persistent depressive

and adjustment disorder.

• Personality disorder, especially dependent, avoidant, and

• Suicidal behavior may be a particular risk when the amnesia

• Acute dissociative amnesia frequently spontaneously resolves once

• Some patients do develop chronic forms of generalized,

• Profoundly disabled and require high levels of social support, such

2. Pharmacological : sodium amobarbital or diazepam to help patient

– No known pharmacotherapy exists for dissociative amnesia

– Sodium amobarbital, thiopental, oral benzodiazepines, and

– Pharmacologically facilitated interviews using intravenous