Which of the following is common characteristics of all dissociative disorders?

Physical Findings & Clinical Presentation

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Dissociative amnesia (DA): Loss of autobiographic memory for previous experiences or before a certain point in time. Types of DA include:

Localized amnesia: Inability to recall a specific (traumatic) period of time.

Selective amnesia: Inability to recall parts, but not all, of a specific period of time.

Systematized amnesia: Inability to recall categorical autobiographical memories, but not memory loss in chronologic order such as with localized amnesia.

Continuous amnesia: Anterograde loss of memory, or inability to remember successive events as they occurred.

Generalized (global) amnesia: Inability to recall one’s whole life, including personal details.

Thematic amnesia (as seen in DID and dissociative disorders not otherwise specified [DDNOS]): As identity states change, ability to recall specific periods of time is altered.

Dissociative fugue (DF): DF carries the same characteristics as DA, with the distinguishing feature of sudden and unplanned purposeful travel away from one’s home.

Dissociative identity disorder (DID): Formerly referred to asmultiple personality disorder (MPD), patients appear to possess two (or more) distinct identities or personality states, associated with the patient’s consciousness, perception, thoughts, and actions.

Depersonalization disorder (DPD): Also known asderealization disorder, DPD is a state in which patients believe that they have been altered in some way or that they are no longer real. Features include persistent and recurring experiences of feeling detached from one’s own body and mental processes (i.e., one observing oneself as an outsider). Reality testing remains intact.

Dissociative disorders not otherwise specified (DDNOS): Some dissociative symptoms of varying degrees but not meeting criteria for a distinct diagnosis.

Abstract

Dissociative disorders often develop after overwhelming stress, which can be generated by traumatic events or extreme inner conflicts. These disorders are related to trauma- and stressor-related disorders, which may include dissociative symptoms. A person with a dissociative disorder may completely forget a series of normal behaviors over varying periods of time, and can sense that there is a “missing” period of time. Normal integration of consciousness, memory, identity, perceptions, body representation, emotions, motor control, and behavior is disrupted. The continuity of “self” is lost. There may be intrusions into awareness with loss of continuity of experiencing, and memory loss for important personal information.

Dissociative Disorder Not Otherwise Specified

This category is reserved for presentations in which the predominant feature is dissociation without meeting criteria for any specific dissociative disorder. (Box 35-8 lists the DSM-IV4 criteria of this condition and exclusions to it.Box 35-9 lists the DSM-5 update for this disorder Other Specified/Unspecified Dissociative Disorders.) Examples of dissociative disorder NOS vary widely. Additionally, symptoms that result from torture or brainwashing may be classified in this category. Ganser's syndrome (sometimes called “prison psychosis”) is classified as a dissociative disorder NOS. It is characterized by the provision of approximate answers: that is, offering half-correct answers to simple inquiries, such as answering “Five” to the question, “What is two plus two?” The correct set of the response is given, but the answer is inaccurate. Ganser's syndrome is often reported in incarcerated populations.31–33

Finally, certain culture-bound syndromes (such asamok in Indonesia orlatah in Malaysia) are often characterized by dissociation and sometimes by violence. These syndromes have often been characterized as dissociative disorder NOS.

Introduction: Major Dissociative Disorders

Since Janet (1889) introduced the concept of dissociation, dissociative disorders have been among the most controversial diagnoses in psychology and psychiatry. It is perhaps not surprising that the dramatic and often perplexing symptoms of dissociative disorders have divided the scientific community and provided fodder for vivid and often melodramatic media depictions, as dissociative disorders are marked by a “disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (p. 291).

Indeed, in their most extreme presentation, dissociative symptoms are manifested as dissociative identity disorder (DID, formerly called multiple personality disorder). The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association (APA), 2013) describes DID as characterized by (1) identity disruption, manifested in two or more distinct personality states (‘alters’) and (2) recurrent gaps in the recall of everyday events, important personal information, and traumatic events that are not accounted for by ordinary forgetting.

The current criteria for a diagnosis of DID represent a shift from the previous diagnostic scheme (DSM-IV-TR; APA, 2000), which required that one or more ‘identities’ or ‘personality states’ take control over one's behavior. Moreover, DSM-5 explicitly states that the alterations in personality states may be self-reported or observed by others. If alternate personality states are not observed, DID can still be diagnosed when there are “sudden alterations or discontinuities in sense of self of agency… and recurrent dissociative amnesias” (p. 293). The DSM-5 represents the most significant departure from DSM-II (DSM-II; APA, 1968), which included the descriptor “multiple personalities,” a term that became indelibly associated with images of DID in the public consciousness. It is also now possible to diagnose DID when the expression of personality states arises in the cultural context of experienced possession (e.g., spirit, ghost, supernatural being, and outside person) and when the experience is recurrent, unwanted, and involuntary.

A second major dissociative disorder, dissociative amnesia, excludes the symptom of different identity states fundamental to a diagnosis of DID, and is instead associated with profound and unusual memory deficits. Amnesia may be limited to one or more specific events, or may extend to life history and identity. One poorly understood manifestation of dissociative amnesia is dissociative fugue, a reversible, often short-lived condition in which amnesia for identity or other important autobiographical information is accompanied by apparently purposeful traveling or wandering to a new location, often a new city. Although fugue was formerly a separate diagnostic entity, DSM-5 provides an option to code dissociative amnesia with or without fugue.

A third major dissociative disorder, depersonalization/derealization (DP/DR) disorder, combines into one disorder what were listed as two distinct conditions in DSM-IV-TR (APA, 2000): DP (e.g., feelings of unreality or detachment related to the self, observing the self as an outsider, absent self, distorted time sense, and emotional/physical numbing) and DR (e.g., feelings of unreality or detachment with respect to surroundings; dreamlike, foggy, lifeless, or distorted experiences of objects of people; American Psychiatric Association, 2013, p. 302). The decision to meld DP and DR was spurred by research showing that individuals with prominent DP and DR symptoms are generally comparable in terms of important characteristics regarding the course and severity of their condition, the comorbidity of symptoms with other conditions, and demographic characteristics (Simeon, 2009). Episodes of DP/DR must be persistent or recurrent to warrant a diagnosis, as transient symptoms may be experienced by as many as 74% of individuals in the general population over the course of a lifetime (Hunter et al., 2004).

As in all DSM-5 disorders, to qualify for a diagnosis, the symptoms must cause significant distress or impairment in functioning and not be attributable to substance use or another medical condition. Some dissociative symptoms produce considerable distress or impairment, yet do not necessarily meet full criteria for any of the major dissociative disorders. DSM-5 includes a category called ‘other specified dissociative disorder’ to acknowledge this possibility and requires that clinicians specify the reasons why symptoms fail to cross the diagnostic threshold. Cases that might fall into this category include dissociative symptoms following prolonged and intense coercive persuasion (e.g., torture and imprisonment); acute, typically short-term dissociative reactions to stressful events; discontinuities in sense of self and agency not sufficiently pronounced to meet criteria for DID; and ‘dissociative trance’ (i.e., loss of awareness or narrowing of immediate awareness of surroundings and accompanying unresponsiveness to stimuli). Finally, in cases such as in emergency room settings in which there is inadequate information to make a specific dissociative disorder diagnosis, or in which the clinician does not wish to designate the reason that criteria are not met for a specific disorder, there is a residual diagnostic category called ‘unspecified dissociative disorder.’

Non-epileptic attack disorder (‘dissociative attacks’)

The difficulty with nomenclature is discussed on page 1097. Patients may present with attacks that resemble epileptic seizures but are caused by psychological phenomena and have no abnormal EEG discharges. Such attacks may be very prolonged, sometimes mimicking status epilepticus. Epileptic and non-epileptic attacks may coexist and time and effort are needed to clarify the relative contribution of each, allowing more accurate and comprehensive treatment.

Non-epileptic attack disorder (NEAD) may be accompanied by dramatic flailing of the limbs and arching of the back, with side-to-side head movements and vocalising. Cyanosis and severe biting of the tongue are rare but incontinence can occur. Distress and crying are common following non-epileptic attacks. The distinction between epileptic attacks originating in the frontal lobes and non-epileptic attacks may be especially difficult, and may require videotelemetry with prolonged EEG recordings. Non-epileptic attacks are three times more common in women than in men and have been linked with a history of past or ongoing life trauma. They are not necessarily associated with formal psychiatric illness. Patients and carers may need reassurance that hospital admission is not required for every attack. Prevention requires psychotherapeutic interventions rather than drug therapy (p. 1202).

Definition

Sleep-related dissociative disorders are parasomnias that can emerge from any stage of sleep, either at transition from wakefulness or within several minutes after awakening from non-rapid eye movement (NREM) sleep or rapid eye movement (REM) sleep.1

Sleep-related dissociative disorders are also known as nocturnal (psychogenic) dissociative disorders, hysterical somnambulistic trance, and dissociative pseudoparasomnia. Dissociative identity disorder, dissociative fugue and dissociative disorder NOS (not otherwise specified) have been identified with sleep-related dissociative disorders.1,4,5

Management

Dissociative disorder must always be a positive diagnosis, based upon a history that provides some reasonable psychological explanation of how and why the problem developed. The patient may deny recent stressful events and problems or disturbed relationships, so it is important to seek information from others. Great care must be taken to exclude organic pathology and it should be remembered that follow-up studies of people diagnosed with dissociative disorders have found that many turned out to have an underlying physical condition. Catatonic schizophrenia and severe depressive episodes should be considered in cases of stupor. Two further differential diagnoses are factitious disorder, also known as Munchausen's syndrome, and malingering, the major features of which are shown in Figure 2.

Treatment for dissociative disorder is psychological and social. Stressful events and problems should be gently explored and discussed. Practical sources of distress and interpersonal problems should be addressed. Sources of secondary gain should be reduced as much as possible.

Dissociative disorders usually remit within a few weeks, particularly if their onset was associated with a traumatic event. Chronic forms are less common and tend to be associated with insoluble problems and interpersonal difficulties.

PSYCHIATRIC CONDITIONS

Psychiatric Conditions