* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Dissociative Disorders
Obsessive–compulsive personality disorder wikipedia , lookup
Gender dysphoria wikipedia , lookup
Anti-psychiatry wikipedia , lookup
Schizoid personality disorder wikipedia , lookup
Autism spectrum wikipedia , lookup
Rumination syndrome wikipedia , lookup
Bipolar II disorder wikipedia , lookup
Political abuse of psychiatry wikipedia , lookup
Bipolar disorder wikipedia , lookup
Factitious disorder imposed on another wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
Personality disorder wikipedia , lookup
Excoriation disorder wikipedia , lookup
Panic disorder wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Mental status examination wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Asperger syndrome wikipedia , lookup
Mental disorder wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Spectrum disorder wikipedia , lookup
Antisocial personality disorder wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Conduct disorder wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Child psychopathology wikipedia , lookup
Conversion disorder wikipedia , lookup
Abnormal psychology wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
Narcissistic personality disorder wikipedia , lookup
History of mental disorders wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
History of psychiatry wikipedia , lookup
® PSYCHIATRY BOARD REVIEW MANUAL PUBLISHING STAFF PRESIDENT, GROUP PUBLISHER Dissociative Disorders Bruce M. White EDITORIAL DIRECTOR Debra Dreger SENIOR EDITOR Becky Krumm, ELS Series Editor: Jerald Kay, MD Professor and Chair, Department of Psychiatry, Wright State University School of Medicine, Dayton, OH ASSISTANT EDITOR Jennifer M. Lehr EXECUTIVE VICE PRESIDENT Barbara T. White, MBA EXECUTIVE DIRECTOR OF OPERATIONS Jean M. Gaul PRODUCTION DIRECTOR Suzanne S. Banish Contributors: Paulette Marie Gillig, MD, PhD Professor of Psychiatry, Department of Psychiatry, Wright State University School of Medicine, Dayton, OH Brock P. Nolan, MD Psychiatry Junior Resident Instructor, Wright State University School of Medicine, Dayton, OH PRODUCTION ASSOCIATES Tish Berchtold Klus Mary Beth Cunney PRODUCTION ASSISTANT Stacey Caiazzo ADVERTISING/PROJECT MANAGER Patricia Payne Castle MARKETING MANAGER Table of Contents Deborah D. Chavis Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 NOTE FROM THE PUBLISHER: This publication has been developed without involvement of or review by the American Board of Psychiatry and Neurology. Endorsed by the Association for Hospital Medical Education The Association for Hospital Medical Education endorses HOSPITAL PHYSICIAN for the purpose of presenting the latest developments in medical education as they affect residency programs and clinical hospital practice. Diagnosis of Dissociative Disorders . . . . . . . . . . 3 Treatment of Dissociative Disorders. . . . . . . . . . 8 Board Review Questions . . . . . . . . . . . . . . . . . 10 Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Cover Illustration by Tish Berchtold Klus Copyright 2003, Turner White Communications, Inc., 125 Strafford Avenue, Suite 220, Wayne, PA 19087-3391, www.turner-white.com. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission of Turner White Communications, Inc. The editors are solely responsible for selecting content. Although the editors take great care to ensure accuracy, Turner White Communications, Inc., will not be liable for any errors of omission or inaccuracies in this publication. Opinions expressed are those of the authors and do not necessarily reflect those of Turner White Communications, Inc. Psychiatry Volume 7, Part 2 1 PSYCHIATRY BOARD REVIEW MANUAL Dissociative Disorders Paulette Marie Gillig, MD, PhD, and Brock P. Nolan, MD INTRODUCTION THE CONCEPT OF DISSOCIATION Normal thinking involves the experience that events are connected on a smooth continuum of time and place within one’s state of awareness, or one’s “consciousness.” The concept of consciousness includes apperception (ie, perception modified by one’s own emotions and thoughts, attention [the ability to focus on certain portions of an experience], and the ability to be self-directed and avoid overcompliance or uncritical acceptance to an idea or influence). Dissociation occurs when certain events, feelings, thoughts, memories, or experiences are isolated from the other mental processes with which they would normally be associated in consciousness. Dissociation involves a loss of organization of mental processes rather than loss of the contents of the mental processes themselves. Dissociation is a problem of information processing, with failure of integration of elements; it does not involve a loss of the contents of the elements, as in dementia.1 TYPES OF DISSOCIATIVE DISORDERS Dissociation can affect one or more aspects of the organization of mental processes, and each dissociative disorder represents a different mental process that can be affected (Table 1). The 5 main types of dissociative disorders are dissociative amnesia, dissociative fugue, dissociative identity disorder, depersonalization disorder, and dissociative disorder not otherwise specified (NOS). Dissociative disorders occur worldwide but may take various symptom structures depending on the culture in which they are found. When dissociation affects memory processes, dissociative amnesia occurs. In dissociative amnesia, certain memories are segregated without distortion from the rest of memory processes and are inaccessible to conscious awareness. Dissociative fugue or dissociative identity disorder (formerly multiple personality disorder) occurs with dissociation of aspects of identity. Depersonalization disorder occurs with dissociated perception. Dissociative trance disorder (a NOS cate- 2 Hospital Physician Board Review Manual gory of dissociative disorders in the DSM-IV) and acute stress disorder (classified as an anxiety disorder but with many dissociative qualities) occur when there is a dissociation of aspects of consciousness itself. Transient episodes of dissociation can occur normally when a person has experienced an acute traumatic or otherwise anxiety-producing event. Examples of these episodes in the literature include law enforcement officers involved in critical incidents,2 episodes of skydiving,3 and serious traffic accidents.4 Dissociative experiences are also common and are culturally accepted expressions of cultural activities and religious experiences in many societies. Dissociative disorders are not viewed as normal within these cultures, however.5 PATHOPHYSIOLOGY OF DISSOCIATIVE DISORDERS Dissociative disorders are almost always (but not exclusively) associated with multiple severe traumas from a trusted person or organization that take place over time and result in the experience of victimization of another’s indifference. Like other children, children who are exposed to multiple traumas develop imaginary playmates and protectors, but those with a tendency toward dissociative disorders may carry these imaginary figures in some form into adult life.6 – 8 Approximately 90% of persons diagnosed with dissociative disorders are women. Recent research has shown that children who had experienced maternal attachment disruptions were more likely to show dissociative symptoms in the classroom.9 Dissociation also has been correlated with lack of parental care10 and has been observed in the children of mothers who had suffered losses and became emotionally detached from their children.11 It is hypothesized that a continuing unresolved response to attachment-related trauma results in cognitive disorganization and that, in vulnerable individuals, this disorganization acts as a mediating variable between the effects of earlier traumatic experiences and later dissociative symptoms. Dissociation also is likely a critical mediator of risk-taking behavior (eg, suicide, self-mutilation, sexual aggression) among sexually abused children. Dissociation is used in an attempt to maintain mental control when physical control is absent. In persons Dissociative Disorders without a dissociative disorder, dissociation is state-dependent, but individuals who have dissociative disorders use the defense chronically. They tend to be easily hypnotized and more sensitive to suggestion than others and tend to passively accept the thoughts and feelings of others, almost as if they were functioning in a trance state. Persons with dissociative disorders experience some of their behavior as automatic and unwilled. They are extremely sensitive to rejection or disapproval, and they are often relatively unaware of their reactions to stress, because they slip into a dissociative defense so readily. The defense of dissociation must be differentiated from repression12 (Table 2). In persons with repression, mental processes are organized in a vertical manner, and the defense of repression results from a dynamic developmental conflict over unacceptable wishes. In repression, the contents of mental processes are disguised, and primary process thinking is evident. Psychotherapy for persons suffering from repressed conflict emphasizes transference toward the therapist. In contrast, the divisions in mental structure in dissociation are organized horizontally, not vertically, and there is a potential for simultaneous access to consciousness of a variety of memories. The concept or theory of dissociation fits with some contemporary theories of information processing (eg, neural nets—a parallel information-processing model based on the co-occurrence of patterns of activation). The theory is also consistent with the fact that episodic and implicit (ie, procedural) memories are processed and stored in different parts of the brain. DIAGNOSIS OF DISSOCIATIVE DISORDERS DISSOCIATIVE AMNESIA Vignette 1 A surgeon is preparing to enter the operating room to perform a mastectomy on an anesthetized cancer patient. Suddenly, the surgeon looks up from the scrub sink and is confused about what is happening and why he is dressed in surgical garb. He cannot remember the procedure he is about to perform or what the patient’s diagnosis might be. The surgeon is escorted to the emergency department; several hours later, he suddenly recalls the surgical case while recounting his mother’s recent death from breast cancer to a medical student. Characteristics of Dissociative Amnesia Dissociative amnesia is characterized by the inability to recall periods of time within a person’s life history. Table 1. Dissociative Disorders and Affected Mental Processes Dissociative Disorder Affected Mental Process Dissociative amnesia Memory Dissociative fugue Identity Dissociative identity disorder Identity Depersonalization disorder Perception Dissociative trance disorder Aspects of consciousness Acute stress disorder Aspects of consciousness The memory gap usually concerns a traumatic or stressful event in the person’s life. The memory impairment is reversible; it sometimes resolves spontaneously, but it can also be reversed by hypnosis. The memory gap can be localized to a specific period of time, or it can be selective, whereby the person can recall some but not all of the events during the circumscribed period of time. The unavailable memory is not vaguely recalled; rather, it is densely unavailable. The memory gap can last for minutes up to years. The memory loss is retrograde, and there is no difficulty in learning new episodic memory. Quite often, the memories lost are of childhood abuse. The onset of the memory loss after the traumatic event can be sudden or gradual. Although the memory is lost to conscious awareness, there are implicit effects of the dissociated memory that can have an influence on consciousness (eg, a rape victim may behave like someone who has been traumatized while not remembering the rape). Associated depressive symptoms are common. Dissociative amnesia must be differentiated from amnestic disorder due to a general medical condition, a brain injury, or substance abuse.13,14 Diagnostic criteria for dissociative amnesia are listed in Table 3. DISSOCIATIVE FUGUE Vignette 2 A 42-year-old woman is transferred from a detention facility to a psychiatric institution for evaluation after being arrested at a local airport. The woman was apprehended at a security checkpoint for attempting to board a flight without proper identification. At the detention facility her identity was determined (via fingerprints and physical characteristics) to be that of a woman reported missing several weeks earlier from a city 1500 miles away. She denies any knowledge of this “former” identity but is unable to give details of her life beyond the 2-month period predating her arrest. She reports working at a local fast food restaurant, using her daily cash earnings to pay for her room at a boarding Psychiatry Volume 7, Part 2 3 Dissociative Disorders Table 2. Models of Mental Experience Mental Function Dissociation Repression Organization Horizontal Vertical Barriers Amnesia Dynamic conflict Etiology Trauma Developmental conflict over unacceptable wishes Nature of contents Untransformed traumatic memories Disguised, primary process, dreams, slips of the tongue Means of access Hypnosis Interpretation Treatment Psychotherapy emphasizing access, control, and working through traumatic memories Psychotherapy emphasizing interpretation, transference Adapted with permission from Spiegel D. Dissociative disorders. In: Tasman A, Kay J, Lieberman JA, editors. Psychiatry. Philadelphia: WB Saunders; 1997:1157. house. After a thorough medical and psychiatric evaluation, hypnosis is undertaken in an attempt to resolve the dissociative state. The woman is easily hypnotized; during the session she reassumes the identity of the woman reported missing weeks earlier. She readily recounts details of her life that could only be known to her. Upon further hypnosis, she gives additional information, including the details of her husband’s death in an automobile accident approximately 1 year ago. During the days following hypnosis, she is able to return to her home and family with no further complications. Characteristics of Dissociative Fugue Dissociative fugue involves motor behavior that is purposeful but automatic. It usually occurs following traumatic loss or bereavement that causes a mental conflict between a person’s model of the world and a new reality.15 The clinical signs of dissociative fugue are simultaneously subtle and dramatic. The abandonment of an entire identity (eg, relationships, occupation) with or without the assumption of a new persona makes this a fascinating condition. Not all persons who experience this disorder assume new identities; most in a fugue state have no idea who they really are. They may give approximately inaccurate answers to questions, similar to patients with Ganser syndrome. While in a state of fugue, the patient typically has no insight into the fact that a large period or periods of his or her life may not be present in the accessible memory. Fugue episodes may be single or recurrent in a given patient and may resolve spontaneously or by hypnosis. Regarding the differential diagnosis, conditions such as epilepsy, dementia, substance intoxication/withdrawal, mania, and other dissociative disorders require consideration. In situations in which primary or secondary gain is present, malingering must also be ruled out. Epilepsy and 4 Hospital Physician Board Review Manual substance abuse can be excluded on the basis of objective data (eg, electroencephalography, toxicology, physical examination), as can dementia, which involves prominent deficits of mental status and function. Unpredictable, distant travel could occur because of a manic state, but it would classically involve significant mood symptoms and would not be accompanied by the dissociative symptoms common among these disorders. Finally, malingering must be considered with the caveat that financial or interpersonal gain is often present in true fugue states as well as in malingered disorders. Diagnostic criteria for dissociative fugue are listed in Table 4. DEPERSONALIZATION DISORDER Vignette 3 A 22-year-old construction worker is concerned that he might be injured at work because he suffers from attacks of dizziness. He reports to his physician that, at the peak of the attacks, he cannot understand anything he sees or hears. It takes him approximately 1 minute to collect his thoughts. These dizzy attacks occur several times each day while he is at work. He recalls that 1 year ago, before the illness started, he felt tremendously fatigued and sad most of the time. Lately, before and during these dizzy spells, he has been having “strange” thoughts, like he is 2 persons at once, or as though the world is unreal and he is walking in a dream. These episodes come upon him especially when he feels stressed, and he does not seem to be able to will himself out of them. Characteristics of Depersonalization Disorder Individuals with depersonalization disorder feel detached or estranged from themselves either chronically or episodically, as if they are outside their own bodies observing what is occurring or listening to their own mental processes. They may feel as if they are living in a Dissociative Disorders Table 3. DSM-IV-TR Diagnostic Criteria for Dissociative Amnesia Table 4. DSM-IV-TR Diagnostic Criteria for Dissociative Fugue A. The predominant disturbance is 1 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. A. The predominant disturbance is sudden, unexpected travel away from home or one’s customary place of work, with inability to recall one’s past. B. 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 (eg, a drug of abuse, a medication) or a neurological or other general medical condition (eg, Amnestic Disorder Due to Head Trauma). C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Reprinted with permission from Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed., text revision. Washington (DC): American Psychiatric Association; 2000:523. dream or a movie or like they are automatons, although they are aware that this feeling is not normal. Reality testing is preserved. Derealization may also be present, in which the external world seems strange or unreal, and patients may report alleged changes in the size or shape of objects or in the passage of time. Although these symptoms also occur during panic attacks, the diagnosis of depersonalization disorder is not made if the symptoms occur in the context of such attacks or in posttraumatic stress disorder or acute stress disorder. The differential diagnosis of depersonalization disorder includes symptoms caused by the physiologic consequences of a specific general medical condition (eg, epilepsy, a substance-induced condition).16 Diagnostic criteria for depersonalization disorder are listed in Table 5. Depersonalization disorder involves both the initial symptoms and the reactive anxiety associated with them. Childhood trauma, especially emotional abuse by parents, may play a role in the pathogenesis of depersonalization disorder.17 Although the disorder is not necessarily associated with abnormal behavior, a recent study found that the experience of depersonalization at the time of delivery was present in all cases of women charged with alleged neonaticide that occurred on the day of delivery.18 DISSOCIATIVE IDENTITY DISORDER Vignette 4 A very shy, quiet woman named Mary appeared at her workplace wearing an uncharacteristically stylish, B. Confusion about personal identity or assumption of a new identity (partial or complete). C. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder and is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, temporal lobe epilepsy). D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Reprinted with permission from Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed., text revision. Washington (DC): American Psychiatric Association; 2000:526. colorful outfit and wearing a pendant with the letter “D” on it. She strode into her manager’s office and demanded to know why she was being paid less than her coworkers. When she continued to argue and would not leave his office, the manager called the police. She told the police officer that she had to come there, because “that wimp Mary would never have the guts to do it.” She said her name was Darla and that Mary “didn’t know anything about this.” Characteristics of Dissociative Identity Disorder Although dissociative identity disorder was previously called multiple personality disorder, patients with this disorder do not really have multiple personalities. Instead, the personality structure is dissociated into 2-dimensional personality states that are fragments of what, if integrated, would be an overall personality structure. Clinically, patients with dissociative identity disorder frequently have periods of time that they cannot account for, or find themselves somewhere and cannot recall how they got there. They may find strange things among their possessions and have no recollection of buying them, or they may meet people who seem to know them well but whom they do not recognize. They can be observed in therapy to switch to alternate personality states. They may report that they feel that several persons are within the body and that these persons sometimes take over. Patients with dissociative identity disorder switch personality states in stressful situations. They usually manifest these symptoms for 6 to 7 years before the diagnosis is made and are often first diagnosed with borderline Psychiatry Volume 7, Part 2 5 Dissociative Disorders Table 5. DSM-IV-TR Diagnostic Criteria for Depersonalization Disorder Table 6. DSM-IV-TR Diagnostic Criteria for Dissociative Identity Disorder A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body (eg, feeling like one is in a dream). A. The presence of 2 or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self). B. During the depersonalization experience, reality testing remains intact. C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. 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 (eg, a drug of abuse, a medication) or a general medical condition (eg, temporal lobe epilepsy). Reprinted with permission from Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed., text revision. Washington (DC): American Psychiatric Association; 2000:532. personality disorder or schizophrenia. The disorder emerges between adolescence and the thirties, and the symptoms are chronic and recurrent. Patients are not fully aware of the extent of their dissociative symptoms. The majority of patients with dissociative identity disorder have a history of severe sexual and physical abuse (including ritualistic abuse) by a loved one or a trusted organization.13,17,19,20 In order to make sense of the world, the otherwise helpless child incorporates the negative objects of the world into the psyche in order to control them. The child not only escapes the current situation by dissociation, but he or she also divides the distress into alternate personality states who share part of the pain and who lend support through fantasy relationships. The number of personality states (termed alters) varies, but 10 is the mode.13,19,20 Switching between states is sudden and often dramatic; when it occurs, the personality state may view itself to be in a different environmental context than the previous state was in, because the personality states often represent a part of the person that “split off” at a certain age. Because this splitting off occurs at times of great stress, usually one or more of the alters experiences depression.6,7,15 The given personality state sees the world in the way that a child of that age would experience it and often believes that no time has passed since this personality state split off. Switching between personality states may occur not only when a personality state is distressed but also when a certain task needs to be done by a more competent alter (eg, an occupational role). The switching also can be dangerous if a hostile alter disrupts and punishes 6 Hospital Physician Board Review Manual B. At least 2 of these identities or personality states recurrently take control of the person’s behavior. C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. D. The disturbance is not due to the direct physiological effects of a substance (eg, blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (eg, complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play. Reprinted with permission from Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed., text revision. Washington (DC): American Psychiatric Association; 2000:529. a functionally successful alter. The hostile alter may try to kill one or more of the others, thinking it will not be hurt.13,19,20 Many of the alters are unaware of the existence of the others, but one alter is usually identified as the original personality and may know about the others. Diagnostic criteria for dissociative identity disorder are listed in Table 6. Diagnoses that are associated with dissociative identity disorder include depression, substance abuse, and personality disorders. Posttraumatic stress disorder may be present, but to make this additional diagnosis, hypervigilance must also be present. Different alters may manifest traits of different personality disorders. On personality inventories and even on tests of cognitive function, one alter may respond differently than another, and switching between personality states may take place during the testing period. Although some persons with dissociative identity disorder are misdiagnosed as having schizophrenia, differentiation between these two disorders is not difficult; although patients with dissociative identity disorder may appear distrustful and cautious, their cognitive processes do not reveal the thought disorder characteristic of schizophrenia, and the voices they experience are within themselves. There is a higher incidence of dissociative identity disorder in first-degree relatives who have this disorder than in the general population.19–21 Associated Medical Conditions On physical examination, persons with dissociative identity disorder may have scars from self-inflicted Dissociative Disorders injuries or from abuse by others. It has been reported that the alter personality states may have differing degrees of visual acuity, pain tolerance, symptoms of asthma, sensitivity to allergens, or response of blood glucose to insulin; however, these findings are difficult to replicate and cannot be confirmed. Seizure disorders have relatively high rates of comorbidity with dissociative identity disorder and depersonalization disorder. DISSOCIATIVE DISORDER NOS Vignette 5 A 35-year-old man is referred to an attending psychiatrist by a physician in the emergency department at a military hospital. The patient was about to be debriefed after recently being released from a several month period of captivity as a political prisoner. He was serving in a diplomatic capacity for an international embassy when he was detained while on a sightseeing tour. Throughout his captivity, his captors were frequently abusive, both physically and emotionally, and long periods of sleep deprivation, interrogation, and food withholding were routine. He and other captives were kept isolated and were told often that their country had abandoned them and that they would be forced to into service for their “new government.” While in captivity and continuing after his release, the patient experienced what he describes as “weird trances” multiple times weekly. The patient describes these trances as periods in which he feels “out-of-body.” Once, while driving, he became aware that he was several miles from his intended destination and could not clearly recall the route he had taken to get there. He states that otherwise, his memory is no worse than in the past, and despite his experiences, he has begun to reintegrate with his family and friends appropriately. He denies any difficulties with sleep, and reports that the trances do not cause him undue anxiety. He is baffled by them, however, and wonders if he may have been poisoned or otherwise medically harmed while in captivity. The psychiatrist makes appropriate consultations with medical and neurologic consult services. The results of their evaluations, including toxicologic studies, are unremarkable. The patient is medically cleared and referred back to the psychiatrist. Characteristics of Dissociative Disorder NOS Dissociative disorder NOS includes disorders in which dissociation is the predominant feature of the disorder, but the disorder does not meet the criteria for any specific dissociative disorder. Dissociative trance disorder can be included in this category, as it is currently under study. Other episodes of loss of consciousness not Table 7. DSM-IV-TR Research Criteria for Dissociative Trance Disorder A. Either (1) or (2): (1) Trance, (ie, temporary marked alteration in the state of consciousness or loss of customary sense of personal identity without replacement by an alternate identity), associated with at least 1 of the following: (a) Narrowing of awareness of immediate surroundings, or unusually narrow and selective focusing on environmental stimuli (b) Stereotyped behaviors or movements that are experienced as being beyond one’s control (2) Possession trance, a single or episodic alteration in the state of consciousness characterized by the replacement of customary sense of personal identity by a new identity. This is attributed to the influence of a spirit, power, deity, or other person, as evidenced by one (or more) of the following: (a) Stereotyped and culturally determined behaviors or movements that are experienced as being controlled by the possessing agent (b) Full or partial amnesia for the event B. The trance or possession trance state is not accepted as a normal part of a collective cultural or religious practice. C. The trance or possession trance state causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The trance or possession trance state does not occur exclusively during the course of a Psychotic Disorder (including Mood Disorder With Psychotic Features and Brief Psychotic Disorder) or Dissociative Identity Disorder and is not due to the direct physiological effects of a substance or a general medical condition. Reprinted with permission from Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed., text revision. Washington (DC): American Psychiatric Association; 2000:785. caused by a medical condition could be classified in this category, as well as Ganser syndrome (the giving of approximate answers to questions) when not associated with dissociative amnesia. The patient described in the vignette has experienced a period of dissociative symptoms that interfere with normal functioning but do not fully meet diagnostic criteria for any other dissociative disorders; therefore, his diagnosis is dissociative disorder NOS. Dissociative Trance Disorder Dissociative trance disorder, which is included in the appendix of DSM-IV-TR with research criteria for further study (Table 7), involves an involuntary state of trance Psychiatry Volume 7, Part 2 7 Dissociative Disorders that is not considered culturally normal. This disorder is divided into 2 subcategories: dissociative trance and possession trance. In persons with dissociative trance, the trance state involves an alteration in consciousness but no identity change, and the activities performed during the trance are simple (eg, collapse, immobilization, dizziness). After the trance state subsides, memory is not much affected. There are several cultural variants of dissociative trance. In contrast, during possession trance, the individual assumes a distinct alternative identity and may perform complex activities or express forbidden thoughts or needs. Persons who have entered a possession trance are later amnestic for the episode. This disorder is most prominent in situations in which persons are unable to express discomfort directly. Possession trance is understood as expressing distress, even in cultures that allow normal trance phenomena; persons with dissociative trance disorders are considered abnormal within their culture. A recent study performed in Singapore showed that the occurrence of possession trance in an individual is positively correlated with neuroticism on the Eysenck Personality Questionnaire and negatively correlated with extraversion scores.22 One hypothesis is that the trance may be physiologically mediated by catecholamines and opioid peptides.23 ACUTE STRESS DISORDER Vignette 6 A 37-year-old woman sees her primary care physician for evaluation; her chief concern is that she is “going through a nervous breakdown.” The clinic nurse records her vital signs, which are all within accepted normal ranges—although her pulse is 96 bpm. A review of systems is performed, which yields unremarkable results; the patient’s only significant medical history consists of the births of her 2 sons, age 6 and 9 years. On further questioning by the physician regarding her symptoms, the patient reports that 10 days ago, she was waiting in line at a local gasoline station when 2 men loudly entered the store. The men brandished firearms and forced the customers in the store to lie down on the ground. The station attendant initially refused to open the safe, and one of the burglars beat him in the face and chest. The other burglar threatened several of the patrons if the clerk did not comply. The patient recalls experiencing severe terror that she would be hurt or killed and that her children would be left without a mother. Eventually, the clerk opened the safe, and the men left without further incident. Beginning 3 days after this event, the patient developed anxiety throughout the day. She noted that her anxiety peaked around the late afternoon, correspond- 8 Hospital Physician Board Review Manual ing to the time that the incident occurred. The patient reports that at other times during the day, she feels a strange “distance from herself” during which she “feels nothing.” She elaborates that at times she feels she is watching the entire experience played out “on a movie screen,” yet she is unable to recall the faces or physiques of the burglars. She relates frequent episodes in which she awakens from sleep feeling she is back on the floor of the gas station and has experienced nightmares of the ordeal on several occasions. Despite the station being directly on her normal route to work, she has been unable to go near the site and, instead, takes another route to work that requires her to travel several miles further each day. At times, she finds herself at work staring off into space, trying to “relive” the event to a different outcome. Her work performance has suffered over the past 10 days, prompting her supervisor to recommend that she take a few days off to “get her act together.” Characteristics of Acute Stress Disorder Acute stress disorder is classified among the anxiety disorders in DSM-IV-TR, but many of the symptoms are dissociative in nature. These symptoms include a subjective sense of numbing, detachment, absence of emotional responsiveness, reduction in awareness of surroundings, derealization, depersonalization, or inability to recall an important aspect of a severe trauma. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event. Diagnostic criteria for acute stress disorder are listed in Table 8. TREATMENT OF DISSOCIATIVE DISORDERS Some cases of dissociative amnesia, depersonalization disorder, and dissociative fugue resolve spontaneously; however, dissociative identity disorder is usually chronic. Psychotherapy is the treatment of choice for patients with dissociative disorders. These patients usually are hypnotizable, and hypnotic techniques such as age regression can be employed. When hypnosis with age regression is used in a patient with dissociative amnesia or dissociative fugue, the patient can be helped to reorient temporally and achieve access to dissociated memories. Through psychotherapy, patients must learn to integrate not only the avoided memories but also the associated affect into consciousness. It is best if this process takes place slowly so that patients do not experience a reinfliction of the traumatic stress. However, at times, strong affect is Dissociative Disorders suddenly elicited when these memories return to conscious awareness (ie, abreaction). Long-term psychotherapy aimed at identifying and resolving interpersonal conflict is often used post-fugue with good benefits. Transference and transference distortions during therapy are important treatment considerations for all patients who have been physically or sexually abused during childhood, because such individuals expect similar betrayal from the therapist. Another treatment technique that is useful for patients with dissociative disorders is the “screen technique.” In this approach, which can be performed under hypnosis or in another very relaxed state, the patient is taught to recall the traumatic event as if it were being watched on a movie screen. This technique is helpful because it can provide some separation between psychological and somatic aspects of memory retrieval. Depersonalization disorder may respond to training in self-hypnosis, in which the patient knowingly selfinduces a depersonalized state in order to learn to control the induction of this state. In this way, the patient learns how to avoid depersonalizing and stays more “in the present” when appropriate. Although depersonalization and derealization episodes are usually associated with anxiety, treatment with antianxiety drugs is not necessarily helpful, because the side effects of these drugs may increase the sense of depersonalization. Patients with dissociative identity disorder experience themselves as fragmented. The therapist should acknowledge this feeling but, at the same time, stress that the reality is that the patient has not integrated aspects of the self that are all part of the total self. Initially, hypnosis may be helpful in accessing dissociated personalities, but often, they occur spontaneously as well. Age regression is also helpful in working with these patients; it can aid in understanding the circumstances surrounding the manifestation of one of the alters at that point in the person’s life. The ultimate goal of treatment is integration of the disparate personality states (alters). Patients resist this integration early in therapy because they have experienced the presence of alters as being helpful to them; one or more of the alters (especially the most hostile ones) also may fear that the therapist is trying to obliterate their existence. These issues must be dealt with before integration can occur.24 Psychotherapy for patients who have dissociative identity disorder can be augmented by antidepressants, because most patients have either dysthymia or major depressive disorder as well. Antipsychotic agents are used occasionally when dangerous or impulsive behavior is Table 8. DSM-IV-TR Diagnostic Criteria for Acute Stress Disorder A. The person has been exposed to a traumatic event in which both of the following were present: (1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of the self or others (2) The person’s response involved intense fear, helplessness, or horror B. Either while experiencing or after experiencing the distressing event, the individual has 3 (or more) of the following dissociative symptoms: (1) A subjective sense of numbing, detachment, or absence of emotional responsiveness (2) A reduction in awareness of his or her surroundings (eg, “being in a daze”) (3) Derealization (4) Depersonalization (5) Dissociative amnesia (ie, inability to recall an important aspect of the trauma) C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event. D. Marked avoidance of stimuli that arouse recollections of the trauma (eg, thoughts, feelings, conversations, activities, places, people). E. Marked symptoms of anxiety or increased arousal (eg, difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness). F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience. G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event. H. The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder. Reprinted with permission from Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed., text revision. Washington (DC): American Psychiatric Association; 2000:471–2. Psychiatry Volume 7, Part 2 9 Dissociative Disorders present. Anticonvulsants also may help with mood stabilization and treatment of a coexisting seizure disorder. 5. A 32-year-old woman is found asleep on a church pew. She tells the pastor that she is homeless, hungry, and cold. She cannot tell the pastor her name but thinks it might be Mary. She allows the pastor to look in her purse, where he finds the out-ofstate driver’s license of a woman named Mandy with “Mary’s” photograph on it. After giving the woman some food, the pastor drives her to the emergency department at a nearby hospital for evaluation. When the police contact the woman’s husband, he explains that his wife has been missing since the couple’s infant son died 2 weeks previously following emergency open heart surgery. His wife had said she was going to the hospital chapel and then disappeared. Which of the following disorders most likely explains Mandy’s behavior? (A) Dissociative amnesia (B) Dissociative fugue (C) Dissociative identity disorder (D) Dissociative trance disorder (E) Acute stress disorder 6. A 36-year-old woman is walking home from work when she is grabbed by 2 men and raped. She is found at the side of the road by a passerby, who takes her to the hospital. On examination in the emergency department, she states that she was grabbed and possibly raped, but she can give few details of the incident and cannot describe her attackers. She seems dazed, although results of her neurologic evaluation are normal and a computed tomography scan shows no abnormalities. After approximately 3 days, she is able to recall more of the details of her attack, and, although she is very upset, she seems more responsive and “like her old self.” Which of the following disorders most likely explains the patient’s initial symptoms? (A) Dissociative amnesia (B) Dissociative fugue (C) Dissociative identity disorder (D) Dissociative trance disorder (E) Acute stress disorder BOARD REVIEW QUESTIONS 1. Dissociation is characterized by all of the following EXCEPT: (A) Primary process thinking (B) Horizontal organization (C) Relation to trauma history (D) Untransformed traumatic memories (E) Sense of detachment from mental processes 2. Each of the following should be considered in the differential diagnosis of dissociative fugue EXCEPT: (A) Malingering (B) Dementia (C) Substance abuse (D) Multiple sclerosis (E) Transient ischemic attack 3. Which of the following best characterizes dissociative identity disorder? (A) The presence of 2 or more distinct personality states (B) Sudden, unexplained travel away from home (C) Persistent feeling of being detached from one’s mental processes (D) Fluctuating level of arousal (E) Ideas of reference 4. A 54-year-old man who is the chief executive officer of a successful corporation is seated with his wife at a restaurant when a man of similar age approaches him and exclaims, “Why, you’re John Smith!” When John replies, “Yes, I am,” the stranger turns to his companion and says, “This is John Smith, the guy I told you about! He saved my life in Vietnam.” John smiles and responds, “I’m sorry, you have me confused with someone else. I was never in Vietnam.” John’s wife looks at John and says, “Yes, John, you did serve in Vietnam.” Which of the following disorders most likely explains John’s response to the stranger? (A) Dissociative amnesia (B) Dissociative fugue (C) Dissociative identity disorder (D) Dissociative trance disorder (E) Acute stress disorder 10 Hospital Physician Board Review Manual ANSWERS 1. A 4. A 2. D 5. B 3. A 6. E Dissociative Disorders anal 2000;28:609–18. REFERENCES 1. Spiegel D. Dissociative disorders. In: Tasman A, Kay J, Lieberman JA, editors. Psychiatry. Philadelphia: WB Saunders; 1997:1156–72. 2. Rivard JM, Dietz P, Martell D, Widawski M. Acute dissociative responses in law enforcement officers involved in critical shooting incidents: the clinical and forensic implications. J Forensic Sci 2002;47:1093–100. 3. Sterlini GL, Bryant RA. Hyperarousal and dissociation: a study of novice skydivers. Behav Res Ther 2002;40:431–7. 4. Mayou RA, Ehlers A, Bryant B. Posttraumatic stress disorder after motor vehicle accidents: 3-year follow-up of a prospective longitudinal study. Behav Res Ther 2002;40:665–75. 5. Chand SP, Koul R, Al Hussaini AA. Conversion and dissociative disorders in the Sultanate of Oman [letter]. J Am Acad Child Adolesc Psychiatry 2001;40:869–70. 6. Pasquini P, Liotti G, Mazzotti E, et al. Risk factors in the early family life of patients suffering from dissociative disorders. Acta Psychiatr Scand 2002;105:110–6. 7. Trickett PK, Noll JG, Reiffman A, Putnam FW. Variants of intrafamilial sexual abuse experience: implications for short- and long-term development. Dev Psychopathol 2001;13:1001–19. 8. Whitmer G. On the nature of dissociation. Psychoanal Q 2001;70:807–37. 13. Nemiah JC. Dissociative disorders (hysterical neuroses, dissociative type). In: Kaplan HI, Sadock BJ, editors. Comprehensive textbook of psychiatry/V. 5th ed. Baltimore: Williams & Wilkins; 1989:1028–44. 14. Prueter C, Schultz-Venrath U, Rimpau W. Dissociative and associated psychopathological symptoms in patients with epilepsy, pseudoseizures, and both seizure forms. Epilepsia 2002;43:188–92. 15. Prohl J, Resch F, Parzer P, Brunner R. Relationship between dissociative symptomatology and declarative and procedural memory in adolescent psychiatric patients. J Nerv Ment Dis 2001;189:602–7. 16. Harkness D. Testing Cermak’s hypothesis: is dissociation the mediating variable that links substance abuse in the family of origin with offspring codependency? J Psychoactive Drugs 2001;33:75–82. 17. Simeon D, Guralnik O, Schmeidler J, et al. The role of childhood interpersonal trauma in depersonalization disorder. Am J Psychiatry 2001;158:1027–33. 18. Spinelli MG. A systematic investigation of 16 cases of neonaticide. Am J Psychiatry 2001;158:811–3. 19. Armstrong J. Psychological assessment. In: Spira JL, editor. Treating dissociative identity disorder. San Francisco: Jossey-Bass; 1996:3–37. 20. Loewenstein RJ. Multiple personality disorder. Psychiatr Clin North Am 1991;14:489–791. 9. West M, Adam K, Spreng S, Rose S. Attachment disorganization and dissociative symptoms in clinically treated adolescents. Can J Psychiatry 2001;46:627–31. 21. North CS, Ryall JEM, Ricci DA, Wetzel RD. Multiple personalities, multiple disorders: psychiatric classification and media influence. New York: Oxford University Press; 1993:125–57. 10. Narang DS, Contreras JM. Dissociation as a mediator between child abuse history and adult abuse potential. Child Abuse Negl 2000;24:653–65. 22. Ng BY, Yap AK, Su A, et al. Personality profiles of patients with dissociative trance disorder in Singapore. Compr Psychiatry 2002;43:121–6. 11. Kobak R, Little M, Race E, Acosta MC. Attachment disruptions in seriously emotionally disturbed children: implications for treatment. Attach Hum Dev 2001;3: 243–58. 23. Kawai N, Honda M, Nakamura S, et al. Catecholamines and opioid peptides increase in plasma in humans during possession trances. Neuroreport 2001;12:3419–23. 12. Gedo PM. Symptoms, signals, affects: psychotherapeutic techniques with dissociative patients. J Am Acad Psycho- 24. Ishikura R, Tashiro N. Frustration and fulfillment of needs in dissociative and conversion disorders. Psychiatry Clin Neurosci 2002;56:381–90. Copyright 2003 by Turner White Communications Inc., Wayne, PA. All rights reserved. Psychiatry Volume 7, Part 2 11