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PSYCHIATRY BOARD REVIEW MANUAL
PUBLISHING STAFF
PRESIDENT, GROUP PUBLISHER
Dissociative Disorders
Bruce M. White
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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
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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
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Mary Beth Cunney
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Table of Contents
Deborah D. Chavis
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
NOTE FROM THE PUBLISHER:
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Diagnosis of Dissociative Disorders . . . . . . . . . . 3
Treatment of Dissociative Disorders. . . . . . . . . . 8
Board Review Questions . . . . . . . . . . . . . . . . . 10
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
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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.
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