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Dissociative Disorder
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Dissociative disorders
Definition

The dissociative disorders are a group of mental disorders

that affect consciousness defined as causing significant interference with the
patient's general functioning, including social relationships and employment.

Description

In order to have a clear picture of these disorders, dissociation should first be

understood. Dissociation is a
mechanism that allows the
mind to separate or
compartmentalize certain
memories or thoughts from
normal consciousness. These
split-off mental contents are
not erased. They may resurface
spontaneously or be triggered by
objects or events in the person's
environment.

Dissociation is a process that occurs along a spectrum of severity. It does not

necessarily mean that a person has a dissociative disorder or other mental illness.
A mild degree of dissociation occurs with some physical stressors; people who have
gone without sleep for a long period of time, have had "laughing gas" for dental
surgery, or have been in a minor accident often have brief dissociative experiences.
Another commonplace example of dissociation is a person becoming involved in a
book or movie so completely that the surroundings or the passage of time are not
noticed. Another example might be driving on the highway and taking several exits

2
without noticing or remembering. Dissociation is related to hypnosis in that
hypnotic trance also involves a temporarily altered state of consciousness. Most
patients with dissociative disorders are highly hypnotizable.

People in other cultures sometimes have dissociative experiences in the course of

religious (in certain trance states) or other group activities. These occurrences
should not be judged in terms of what is considered "normal" in the United States.

Moderate or severe forms of dissociation are caused by such traumatic experiences

as childhood abuse, combat, criminal attacks, brainwashing in hostage situations,
or involvement in a natural or transportation disaster. Patients with acute stress
disorder, post-traumatic stress disorder (PTSD), or conversion disorder and
somatization disorder may develop dissociative symptoms. Recent studies of
trauma indicate that the human brain stores traumatic memories in a different
way than normal memories. Traumatic memories are not processed or integrated
into a person's ongoing life in the same fashion as normal memories. Instead they
are dissociated, or "split off," and may erupt into consciousness from time to time
without warning. The affected person cannot control or "edit" these memories.
Over a period of time, these two sets of memories, the normal and the traumatic,
may coexist as parallel sets without being combined or blended. In extreme cases,
different sets of dissociated memories may alter subpersonalities of patients with
dissociative identity disorder (multiple personality disorder).

The dissociative disorders vary in their severity and the suddenness of onset. It is
difficult to give statistics for their frequency in the United States because they are a
relatively new category and are often misdiagnosed. Criteria for diagnosis require
significant impairment in social or vocational functioning.

Dissociative disorders are defined as conditions that involve disruptions or

breakdowns of memory, awareness, identity and/or perception. The hypothesis is

3
that symptoms can result, to the extent of interfering with a person's general
functioning, when one or more of these functions is disrupted.

As  society has become increasingly aware of the prevalence of child abuse and its
serious consequences, there has been an explosion of information on
posttraumatic and dissociative disorders resulting from abuse in childhood. Since
most clinicians learned little about childhood trauma and its aftereffects in their
training, many are struggling to build their knowledge base and clinical skills to
effectively treat survivors and their families.

Understanding dissociation and its relationship to trauma is basic to

understanding the posttraumatic and dissociative disorders. Dissociation is the
disconnection from full awareness of self, time, and/or external circumstances. It is
a complex neuropsychological process. Dissociation exists along a continuum from
normal everyday experiences to disorders that interfere with everyday functioning.
Common examples of normal dissociation are highway hypnosis (a trance-like
feeling that develops as the miles go by), "getting lost" in a book or a movie so that
one loses a sense of passing time and surroundings, and daydreaming.

Researchers and clinicians believe that dissociation is a common, naturally

occurring defense against childhood trauma. Children tend to dissociate more
readily than adults. Faced with overwhelming abuse, it is not surprising that
children would psychologically flee (dissociate) from full awareness of their
experience. Dissociation may become a defensive pattern that persists into
adulthood and can result in a full-fledged dissociative disorder.

The essential feature of dissociative disorders is a disturbance or alteration in the

normally integrative functions of identity, memory, or consciousness. If the
disturbance occurs primarily in memory, Dissociative Amnesia or Fugue (APA,
1994) results; important personal events cannot be recalled. Dissociative Amnesia
with acute loss of memory may result from wartime trauma, a severe accident, or

4
rape. Dissociative Fugue is indicated by not only loss of memory, but also travel to
a new location and the assumption of a new identity. Posttraumatic Stress
Disorder (PTSD), although not officially a dissociative disorder (it is classified as
an anxiety disorder), can be thought of as part of the dissociative spectrum. In
PTSD, recall/re-experiencing of the trauma (flashbacks) alternates with numbing
(detachment or dissociation), and avoidance. Atypical dissociative disorders are
classified as Dissociative Disorders Not Otherwise Specified (DDNOS). If the
disturbance occurs primarily in identity with parts of the self assuming separate
identities, the resulting disorder is Dissociative Identity Disorder (DID), formerly
called Multiple Personality Disorder.

The Dissociative Spectrum

The dissociative spectrum (Braun, 1988) extends from normal dissociation to poly-
fragmented DID. All of the disorders are trauma-based, and symptoms result from
the habitual dissociation of traumatic memories. For example, a rape victim with
Dissociative Amnesia may have no conscious memory of the attack, yet experience
depression, numbness, and distress resulting from environmental stimuli such as
colors, odors, sounds, and images that recall the traumatic experience. The
dissociated memory is alive and active--not forgotten, merely submerged (Tasman
& Goldfinger, 1991). Major studies have confirmed the traumatic origin of DID
(Putnam, 1989, and Ross, 1989), which arises before the age of 12 (and often before
age 5) as a result of severe physical, sexual, and/or emotional abuse. Poly-
fragmented DID (involving over 100 personality states) may be the result of
sadistic abuse by multiple perpetrators over an extended period of time.

5
Although DID is a common disorder (perhaps as common as one in 100) (Ross,
1989), the combination of PTSD-DDNOS is the most frequent diagnosis in
survivors of childhood abuse. These survivors experience the flashbacks and
intrusion of trauma memories, sometimes not until years after the childhood
abuse, with dissociative experiences of distancing, "trancing out", feeling unreal,
the ability to ignore pain, and feeling as if they were looking at the world through a
fog.

Symptoms

The symptom profile of adults who were abuse as children includes posttraumatic
and dissociative disorders combined with depression, anxiety syndromes, and
addictions. These symptoms include (1) recurrent
depression; (2) anxiety, panic, and phobias; (3)
anger and rage; (4) low self-esteem, and feeling
damaged and/or worthless; (5) shame; (6) somatic
pain syndromes (7) self-destructive thoughts
and/or behavior; (8) substance abuse; (9) eating
disorders: bulimia, anorexia, and compulsive
overeating; (10) relationship and intimacy
difficulties; (11) sexual dysfunction, including
addictions and avoidance; (12) time loss, memory
gaps, and a sense of unreality; (13) flashbacks,
intrusive thoughts and images of trauma; (14) hypervigilance; (15) sleep
disturbances: nightmares, insomnia, and sleepwalking; and (16) alternative states
of consciousness or personalities.

There are four major dissociative disorders:

 Dissociative amnesia

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  Dissociative identity disorder

 Dissociative fugue

 Depersonalization disorder

Signs and symptoms common to all types of dissociative disorders include:

 Memory loss (amnesia) of certain time periods, events and people

 Mental health problems, including depression and anxiety

 A sense of being detached from yourself (depersonalization)

 A perception of the people and things around you as distorted and unreal
(derealization)

 A blurred sense of identity

Dissociative disorder symptoms (depending on the type of disorder) may

include:

 Dissociative amnesia. Memory loss that's more extensive than normal

forgetfulness and can't be explained by a physical or neurological condition
is the main symptom of this condition. Sudden-onset amnesia following a
traumatic event, such as a car accident, is rare. More commonly, conscious
recall of traumatic periods, events or people in your life — especially from
childhood — is simply absent from your memory.

 Dissociative identity disorder. This condition, formerly known as

multiple personality disorder, is characterized by "switching" to alternate
identities when you're under stress. In dissociative identity disorder, you
may feel the presence of one or more other people talking or living inside

7
 your head. Each of these identities may have name, personal history and
characteristics, including marked differences in manner, voice, gender and
even such physical qualities as the need for corrective eyewear. There often
is considerable variation in each alternate personality's familiarity with the
others. People with dissociative identity disorder typically also have
dissociative amnesia.

 Dissociative fugue. People with this condition dissociate by putting real

distance between themselves and their identity. For example, you may
abruptly leave home or work and travel away, forgetting who you are and
possibly adopting a new identity in a new location. People experiencing
dissociative fugue may be very capable of blending in wherever they end up.
A fugue episode may last only a few hours or, rarely, as long as many
months. Dissociative fugue typically ends as abruptly as it begins. When it
lifts, you may feel intensely disoriented, depressed and angry, with no
recollection of what happened during the fugue or how you arrived in such
unfamiliar circumstances.

 Depersonalization disorder. This disorder is characterized by a sudden

sense of being outside yourself, observing your actions from a distance as
though watching a movie. It may be accompanied by a perceived distortion
of the size and shape of your body or of other people and objects around
you. Time may seem to slow down, and the world may seem unreal.
Symptoms may last only a few moments or may come and go over many
years.

Causes

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Dissociative disorders usually develop as a way to cope with trauma. The disorders
most often form in children subjected to chronic physical, sexual or emotional
abuse or, less frequently, a home environment that is otherwise frightening or
highly unpredictable.

Personal identity is still forming during childhood, so a child is more able than is
an adult to step outside herself or himself and observe trauma as though it's
happening to a different person. A child who learns to dissociate in order to
endure an extended period of his or her youth may use this coping mechanism in
response to stressful situations throughout life.

Rarely, adults may develop dissociative disorders in response to severe trauma.

Risk factors

People who experience chronic physical, sexual or emotional abuse during

childhood are at greatest risk of developing dissociative disorders. Children and
adults who experience other traumatic events, including war, natural disasters,
kidnapping, torture and invasive medical procedures, also may develop these
conditions.

Complications

People with a dissociative disorder are

at increased risk of complications that
include:

 Self-mutilation

 Suicide attempts

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  Sexual dysfunction, including sexual addiction or avoidance

 Alcoholism and substance abuse

 Depression

 Sleep disorders, including nightmares, insomnia and sleepwalking

 Anxiety disorders

 Eating disorders Dissociative disorders are also associated with significant

difficulties in relationships and at work. People with these conditions often
aren't able to cope well with emotional or professional stress, and their
dissociative reactions — from tuning out to disappearing — may worry
loved ones and cause colleagues
to view them as unreliable.

Diagnosis

The diagnosis of dissociative disorders

starts with an awareness of the
prevalence of childhood abuse and its
relation to these clinical disorders with
their complex symptomatology. A
clinical interview, whether the client is male or female, should always include
questions about significant childhood and adult trauma. The interview should
include questions related to the above list of symptoms with a particular focus on
dissociative experiences. Pertinent questions include those related to
blackouts/time loss, disremembered behaviors, fugues, unexplained possessions,
inexplicable changes in relationships, fluctuations in skills and knowledge,
fragmentary recall of life history, spontaneous trances, enthrallment, spontaneous

10
age regression, out-of-body
experiences, and awareness of other
parts of self (Loewenstein, 1991).

Structured diagnostic interviews such

as the Dissociative Experiences Scale (DES) (Putnam, 1989), the Dissociative
Disorders Interview Schedule (DDIS) (Ross, 1989), and the Structured Clinical
Interview for Dissociative Disorders (SCID-D) (Steinberg, 1990) are now available
for the assessment of dissociative disorders. This can result in more rapid and
appropriate help for survivors. Dissociative disorders can also be diagnosed by the
Diagnostic Drawing Series (DDS) (Mills & Cohen, 1993).

In the past, individuals with dissociative disorders

were often in the mental health system for years
before receiving an accurate diagnosis and
appropriate treatment. As clinicians become more
skilled in the identification and treatment
dissociative disorders, there should no longer be such delay.

Treatment and Drug Therapy

The heart of the treatment of dissociative disorders is long-term

psychodynamic/cognitive psychotherapy facilitated by hypnotherapy. It is not
uncommon for survivors to need three to five years of intensive therapy work.
Setting the frame for the trauma work is the most important part of therapy. One
cannot do trauma work without some destabilization, so the therapy starts with
assessment and stabilization before any abreactive work (revisiting the trauma).

11
A careful assessment should cover the basic issues of history (what happened to
you?), sense of self (how do you think/feel about yourself?), symptoms (e.g.,
depression, anxiety, hypervigilance, rage, flashbacks, intrusive memories, inner
voices, amnesias, numbing, nightmares, recurrent dreams), safety (of self, to and
from others), relationship difficulties, substance abuse, eating disorders, family
history (family of origin and current), social support system, and medical status.

After gathering important information, the therapist and client should jointly
develop a plan for stabilization (Turkus, 1991). Treatment modalities should be
carefully considered. These include individual psychotherapy, group therapy,
expressive therapies (art, poetry, movement, psychodrama, music), family therapy
(current family), psychoeducation, and pharmacotherapy. Hospital treatment may
be necessary in some cases for a comprehensive assessment and stabilization. The
Empowerment Model (Turkus, Cohen, & Courtois, 1991) for the treatment of
survivors of childhood abuse--which can be adapted to outpatient treatment--uses
ego-enhancing, progressive treatment to encourage the highest level of function
("how to keep your life together while doing the work"). The use of sequenced
treatment using the above modalities for safe expression and processing of painful
material within the structure of a therapeutic community of connectedness with
healthy boundaries is particularly effective. Group experiences are critical to all
survivors if they are to overcome the secrecy, shame, and isolation of survivorship.

Stabilization may include contracts to ensure physical and emotional safety and
discussion before any disclosure or confrontation related to the abuse, and to
prevent any precipitous stop in therapy. Physician consultants should be selected
for medical needs or psychopharmacologic treatment. Antidepressant and
antianxiety medications can be helpful adjunctive treatment for survivors, but they
should be viewed as adjunctive to the psychotherapy, not as an alternative to it.

12
Developing a cognitive framework is
also an essential part of stabilization.
This involves sorting out how an
abused child thinks and feels, undoing
damaging self-concepts, and learning
about what is "normal". Stabilization is
a time to learn how to ask for help and
build support networks. The
stabilization stage may take a year or
longer--as much time as is necessary
for the patient to move safely into the
next phase of treatment.

If the dissociative disorder is DID, stabilization involves the survivor's acceptance

of the diagnosis and commitment to treatment. Diagnosis is in itself a crisis, and
much work must be done to reframe DID as a creative survival tool (which it is)
rather than a disease or stigma. The treatment frame for DID includes developing
acceptance and respect for each alter as a part of the internal system. Each alter
must be treated equally, whether it presents as a delightful child or an angry
persecutor. Mapping of the dissociative personality system is the next step,
followed by the work of internal dialogue and cooperation between alters. This is
the critical stage in DID therapy, one that must be in place before trauma work
begins. Communication and cooperation among the alters facilitates the gathering
of ego strength that stabilizes the internal system, hence the whole person.

Revisiting and reworking the trauma is the next stage. This may involve
abreactions, which can release pain and allow dissociated trauma back into the

13
normal memory track. An abreaction might be described as the vivid re-
experiencing of a traumatic event accompanied by the release of related emotion
and the recovery of repressed or dissociated aspects of that event (Steele & Colrain,
1990). The retrieval of traumatic memories should be staged with planned
abreactions. Hypnosis, when facilitated by a trained professional, is extremely
useful in abreactive work to safely contain the abreaction and release the painful
emotions more quickly. Some survivors may only be able to do abreactive work on
an inpatient basis in a safe and supportive environment. In any setting, the work
must be paced and contained to prevent retraumatization and to give the client a
feeling of mastery. This means that the speed of the work must be carefully
monitored, and the release painful material must be thoughtfully managed and
controlled, so as not to be overwhelming. An abreaction of a person diagnosed
with DID may involve a number of different alters, who must all participate in the
work. The reworking of the trauma involves sharing the abuse story, undoing
unnecessary shame and guilt, doing some anger work, and grieving. Grief work
pertains to both the abuse and abandonment and the damage to one's life.
Throughout this mid-level work, there is integration of memories and, in DID,
alternate personalities; the substitution of adult methods of coping for
dissociation; and the learning of new life skills.

This leads into the final phase of the therapy work. There is continued processing
of traumatic memories and cognitive distortions, and further letting go of shame.
At the end of the grieving process, creative energy is released. The survivor can
reclaim self-worth and personal power and rebuild life after so much focus on
healing. There are often important life choices to be made about vocation and
relationships at this time, as well as solidifying gains from treatment.

This is challenging and satisfying work for both survivors and therapists. The
journey is painful, but the rewards are great. Successfully working through the

14
healing journey can significantly impact a survivor's life and philosophy. Coming
through this intense, self-reflective process might lead one to discover a desire to
contribute to society in a variety of vital ways.

Psychotherapy is the primary treatment for dissociative disorders. This form of

therapy, also known as talk therapy, counseling or psychosocial therapy, involves
talking about your disorder and related issues with a mental health provider. Your
therapist will work to help you understand the cause of your condition and to form
new ways of coping with stressful circumstances.

Psychotherapy for dissociative disorders often involves techniques, such as

hypnosis, that help you remember and work through the trauma that triggered
your dissociative symptoms. The course of your psychotherapy may be long and
painful, but this treatment approach often is very effective in treating dissociative
disorders.

Other dissociative disorder treatment may include:

 Creative art therapy. This type of therapy uses the creative process to help
people who might have difficulty expressing their thoughts and feelings.
Creative arts can help you increase self-awareness, cope with symptoms and
traumatic experiences, and foster positive changes. Creative art therapy
includes art, dance and movement, drama, music, and poetry.

 Cognitive therapy. This type of talk therapy helps you identify unhealthy,
negative beliefs and behaviors and replace them with healthy, positive ones.
It's based on the idea that your own thoughts — not other people or
situations — determine how you behave. Even if an unwanted situation has
not changed, you can change the way you think and behave in a positive
way.

15
  Medication. Although there are no medications that specifically treat
dissociative disorders,
your doctor may
prescribe
antidepressants, anti-
anxiety medications or
tranquilizers to help
control the mental
health symptoms
associated with dissociative disorders

Alternative medicine

Therapist may recommend using hypnosis, which is sometimes referred to as

hypnotherapy or hypnotic suggestion, as part of your treatment for a dissociative
disorder.

Hypnosis creates a state of deep relaxation and quiets the mind. When you're
hypnotized, you can concentrate intensely on a specific thought, memory, feeling
or sensation while blocking out distractions. Because you're more open than usual
to suggestions while under hypnosis, there is some controversy that therapists may
unintentionally "implant" false memories by suggestion. However, when
conducted under the care of a trained therapist, hypnosis is generally safe as a
complementary treatment method

Types of dissociative disorder

Dissociative disorders are so-called because they are marked by a dissociation from
or interruption of a person's fundamental aspects of waking consciousness (such as
one's personal identity, one's personal history, etc.). Dissociative disorders come in
many forms, the most famous of which is dissociative identity disorder (formerly

16
known as multiple personality disorder). All of the dissociative disorders are
thought to stem from trauma experienced by the individual with this disorder. The
dissociative aspect is thought to be a coping mechanism -- the person literally
dissociates himself from a situation or experience too traumatic to integrate with
his conscious self. Symptoms of these disorders, or even one or more of the
disorders themselves, are also seen in a number of other mental illnesses,
including post-traumatic stress disorder, panic disorder, and obsessive compulsive
disorder.

The four dissociative disorders listed in the DSM IV TR are as follows:

 Depersonalization disorder (DSM-IV Codes 300.6) - periods of detachment

from self or surrounding which may be experienced as "unreal" (lacking in
control of or "outside of" self) while retaining awareness that this is only a
feeling and not a reality.
 Dissociative amnesia (DSM-IV Codes 300.12) (formerly Psychogenic
Amnesia) - noticeable impairment of recall resulting from emotional
trauma
 Dissociative fugue (DSM-IV Codes 300.13) (formerly Psychogenic Fugue) -
physical desertion of familiar surroundings and experience of impaired
recall of the past. This may lead to confusion about actual identity and the
assumption of a new identity.
 Dissociative identity disorder (DSM-IV Codes 300.14) (formerly Multiple
Personality Disorder) - the alternation of two or more distinct personality
states with impaired recall, among personality states, of important
information.

In addition, there is the diagnosis of dissociative disorder not otherwise specified

(DSM-IV Codes 300.15) which can be used for forms of pathological dissociation
not covered by any of the specified dissociative disorders.

17
18
Psychogenic Amnesia
Psychogenic amnesia, also known as functional or dissociative amnesia, is a
disorder characterized by abnormal memory functioning in the absence of
structural brain damage or a known neurobiological cause; severe cases are very
rare. It is defined by the presence of retrograde amnesia or the inability to retrieve
stored memories and events leading up to the onset of amnesia and an absence of
anterograde amnesia or the inability
to form new long term memories. In
most cases, patients lose their
autobiographical memory and
personal identity even though they
are able to learn new information and
perform everyday functions normally.
Other times, there may be a loss of
basic semantic knowledge and
procedural skills such as reading and
writing.

There are two types of psychogenic

amnesia, global and situation-
specific. Global amnesia, also known
as fugue state, refers to a sudden loss
of personal identity that lasts a few hours to days. This is preceded by severe stress
and/or depressed mood. Fugue state is very rare, and usually resolves over time,
often helped by therapy. Situation-specific amnesia is a type of dissociative
amnesia occurs as a result of a severely stressful event, as in post-traumatic stress
disorder. Dissociative amnesia is due to psychological rather than physiological
causes and can sometimes be helped by therapy.

19
 Memory and the brain

There are three types of memory – sensory, short-term, and long-term memory.
Sensory memory lasts up to hundreds of milliseconds and short-term memory lasts
from seconds to minutes while anything else longer than short-term memory is
considered to be a long-term memory.

The information obtained from the peripheral nervous system (PNS) is processed
in four stages - encoding, consolidating, storage, and retrieval. During encoding,
the limbic system is responsible for bottlenecking or filtering information obtained
from the PNS. According to the
type of information given, the
duration of consolidating stage
varies drastically. The majority
of consolidated information gets
stored in the cerebral cortical
networks where the limbic
system record episodic-
autobiographical events. These
stored episodic and semantic
memories can be obtained by triggering the uncinate fascicle that interconnects
the regions of the temporofrontal junction area.

Emotion seems to play an important role in memory processing in structures like

the cingulated gyrus, the septal nuclei, and the amygdala that is primarily involved
in emotional memories. Functional imaging of normal patients reveal that right-
hemisperic amygdala and ventral prefrontal regions are activated when they were
retrieving autobiographical information and events. Additionally, the hippocampal
region is known to be linked to recognizing faces. Researchers have found that
emotional memories can be suppressed in non-mentally ill individuals via the

20
prefrontal cortex in two stages - an initial suppression of the sensory aspects of the
memory, followed by a suppression of the emotional aspect. It has also been
proposed that glucocorticoids can impair memory retrieval; rats and human males
have been shown to be affected by this mechanism.

Traumas can interfere with several memory functions. Dr. Bessel van der Kolk
divided these functional disturbances into four sets: traumatic amnesia, global
memory impairment, dissociative processes and traumatic memories'
sensorimotor organization. Traumatic amnesia involves the loss of remembering
traumatic experiences. The younger the subject and the longer the traumatic event
is, the greater the chance of significant amnesia. Global memory impairment
makes it difficult for these subjects to construct an accurate account of their
present and past history. Dissociation refers to memories being stored as
fragments and not as unitary wholes. Not being able to integrate traumatic
memories seems to be the main element which leads to PTSD. In the sensorimotor
organization of traumatic memories, sensations are fragmented into different
sensory components.

Psychogenic and organic amnesia

Clinically, psychogenic amnesia is characterized by the loss of the ability to

retrieve stored memory without having damages to the brain; while organic
amnesia is characterized by damages to the medial or anterior temporal and/or
prefrontal regions caused by stroke, traumatic brain injury, ischemia, and
encephalitis. Some characteristics that define organic amnesia is the maintenance
of personal identity, basic semantic knowledge and procedural skills as well as
neuroradiological images showing cerebral damage to the cortical and/or
subcortical areas known to be associated with long-term memory while some
characteristics that define psychogenic amnesia is the loss of personal identity,
semantic knowledge, and procedural abilities at least in the early phase of amnesia

21
as well as damage directly affecting cerebral areas critical for memory functioning
that cannot be detected in clinical history or neuroradiological exams.

Imaging of psychogenic amnesia

Psychogenic amnesia is defined by the lack of structural damage to the brain, but
upon functional imaging, an abnormal brain activity can be seen. Tests using
functional magnetic resonance imaging suggest that patients with psychogenic
amnesia are unable to retrieve emotional memories normally during the amnesic
period, suggesting that changes in the limbic functions are related to the
symptoms of psychogenic amnesia. By performing a positron emission
tomography activation study on psychogenic amnesic patients with face
recognition, it was found that activation of the right anterior medial temporal
region including the amygdala was increased in the patient whereas bilateral
hippocampal regions increased only in the control subjects, demonstrating again
that limbic and limbic-cortical functions are related to the symptoms of
psychogenic amnesia.

Risk factors

Patients exposed to physically or emotionally traumatic events are at a higher risk

for developing psychogenic amnesia because they seem to have damaged the
neurons in the brain. Examples of individuals at greater risk of psychogenic
amnesia due to traumatic events include soldiers who have experienced combat,
individuals sexually and physically abused during childhood and individuals who
have experienced domestic violence, natural disasters, or terrorist acts; essentially
any sufficiently severe psychological stress, internal conflict, or intolerable life
situation. Child abuse, especially chronic child abuse starting at an early age has
been related to the development of high levels of dissociative symptoms, including
amnesia for abuse memories. The study strongly suggested that "independent

22
corroboration of recovered memories of abuse is often present" and that the
recovery of the abuse memories generally is not associated with psychotherapy.

Theoretical explanations

Psychogenic amnesia is far from being completely understood and while several
explanations have been proposed, none of them have been verified as the
mechanism that fits all types of psychogenic amnesia. Different theories include:

 Freudian psychology states that psychogenic amnesia is an act of self-

preservation, an alternative to suicide.

 Cognitive point-of-view states that this disorder utilizes the body’s personal
semantic belief system to repress unwanted memories from entering the
consciousness by altering neuropeptides and neurotransmitters released
during stressful events, affecting the formation and recall of memory.

 "Betrayal trauma theory suggests that psychogenic amnesia is an adaptive

response to childhood abuse. When a parent or other powerful figure
violates a fundamental ethic of human relationships, victims may need to
remain unaware of the trauma not to reduce suffering but rather to
promote survival. Amnesia enables the child to maintain an attachment
with a figure vital to survival, development, and thriving. Analysis of
evolutionary pressures, mental modules, social cognitions, and
developmental needs suggests that the degree to which the most
fundamental human ethics are violated can influence the nature, form, and
processes of trauma and responses to trauma."

 Normal autobiographical memory processing is blocked by imbalance or

altered release of stress hormones such as glucocorticoids and
mineralocorticoids in the brain. The regions of expanded limbic system in

23
 the right hemisphere are more vulnerable to stress and trauma, affecting
the body's opioids, hormones, and neurotransmitters such as
norepinephrine, serotonin, and neuropeptide Y. Increased levels of
glucocorticoid and mineralocorticoid receptor density may affect the
anterior temporal, orbitofrontal cortex, hippocampal, and amygdalar
regions. These morphological changes may be caused by loss of regulation
of gene expressions in those receptors along with inhibition of neurotrophic
factors during chronic stress conditions.

 Stress may directly affect the medial temporal/diencephalic system,

inhibiting the retrieval of autobiographical memories and producing a loss
of personal identity. Negative feedback produced by this system may
dampen the patient's emotions, giving a perplexed or 'flat' appearance.

Treatments

Currently, various treatments are

available for patients with psychogenic
amnesia although no well-controlled
studies on the effectiveness of different
treatments exist.

 Psychoanalysis - uses dream

analysis, interpretation and other
psychoanalytic methods to
retrieve memories; may also
involve placing patients in
threatening situations where they are overwhelmed with intense emotion.

 Medication and relaxation techniques - in conjunction with

benzodiazepines and other hypnotic medications, the patient is urged to

24
 relax and attempt to recall memories. With the help of psychotherapy and
learning their autobiographies from family members, most patients recover
their memories completely.

 It has been proposed that abreaction could be used in conjunction with

midazolam to recover memories. This technique was used during the
second World War but is currently much less popular. The technique is
thought to work either through depressing the function of the cerebral
cortex and therefore making the memory more tolerable when expressed, or
through relieving the strength of an emotion attached to a memory which is
so intense it suppresses memory function.

 Some studies about psychogenic amnesia have concluded that

psychotherapy is not connected to recovered memories of child sexual
abuse. Data suggests that one’s amnesic recovered memory is spontaneous,
and that this is triggered by abuse-related stimuli.

Popular culture

Psychogenic amnesia is a common plot device in many films and books. Notable
examples include the character of Jason Bourne as depicted in the Bourne film
series, Jackie Chan in Who Am I?, Teri Bauer in 24, Goldie Hawn in Overboard,
Leroy Jethro Gibbs in NCIS.

25
Fugue State
A fugue state, formally Dissociative Fugue (previously called Psychogenic
Fugue) (DSM-IV Dissociative Disorders 300.13), is a rare psychiatric disorder
characterized by reversible amnesia for personal identity, including the memories,
personality and other identifying characteristics of individuality. The state is
usually short-lived (hours to days), but can last months or longer. Dissociative
fugue usually involves unplanned travel or wandering, and is sometimes

26
accompanied by the establishment of a new identity. After recovery from fugue,
previous memories usually return intact, however there is complete amnesia for
the fugue episode. Additionally, an episode is not characterized as a fugue if it can
be related to the ingestion of psychotropic substances, to physical trauma, to a
general medical condition, or to psychiatric conditions such as delirium, dementia,
bipolar disorder or depression. Fugues are usually precipitated by a stressful
episode, and upon recovery there may be amnesia for the original stressor
(Dissociative Amnesia)

Clinical definition

The etiology of the fugue state is related to Dissociative Amnesia, (DSM-IV Codes
300.12) which has several other subtypes: Selective Amnesia, Generalised Amnesia,
Continuous Amnesia, Systematised Amnesia, in addition to the subtype
Dissociative Fugue.

Unlike retrograde amnesia (which is popularly referred to simply as "amnesia", the

state where someone completely forgets who they are), Dissociative Amnesia is not
due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication, DSM-IV Codes 291.1 & 292.83) or a neurological or other general
medical condition (e.g., Amnestic Disorder due to a head trauma, DSM-IV Codes
294.0). It is a complex neuropsychological process.

As the person experiencing a Dissociative Fugue may have recently suffered the
reappearance of an event or person representing an earlier life trauma, the
emergence of an armoring or defensive personality seems to be for some, a logical
apprehension of the situation.

Therefore, the terminology fugue state may carry a slight linguistic distinction
from Dissociative Fugue, the former implying a greater degree of motion. For the

27
purposes of this article then, a fugue state would occur while one is acting out a
Dissociative Fugue.

The DSM-IV defines as:

 sudden, unexpected travel away from home or one's customary place of

work, with inability to recall one's past,

 confusion about personal identity, or the assumption of a new identity, or

 significant distress or impairment.

The Merck Manual defines Dissociative Fugue as:

One or more episodes of amnesia in which the inability to recall some or all of
one's past and either the loss of one's identity or the formation of a new identity
occur with sudden, unexpected, purposeful travel away from home.

In support of this definition, the Merck Manual further defines Dissociative

Amnesia as:

An inability to recall important personal information, usually of a traumatic or

stressful nature, that is too extensive to be explained by normal forgetfulness.

Dissociative fugue involves one or more episodes of sudden, unexpected, but

purposeful travel from home during which people cannot remember some or all of
their past life, including who they are (their identity). These episodes are called
fugues.

 Unbearable stress or a traumatic event may trigger dissociative fugue.

 When in a fugue, people disappear from their usual routine and may
assume a new identity, forgetting all or some of their usual life.

28
  Usually, doctors make the diagnosis by reviewing the history and collecting
information about the circumstances before travel, the travel itself, and the
establishment of an alternate life.

 Usually, fugues last only hours or days, then resolve on their own.

 Memory retrieval techniques, including hypnosis and drug-facilitated

interviews, may be tried but may be unsuccessful.

Dissociative fugue affects about 2 of 1,000 people in the United States. It is much
more common among people who have been in wars, accidents, or natural
disasters.

Causes

Dissociative fugue is usually triggered by severe trauma, such as wars, accidents,

natural disasters, or sexual abuse during childhood.

Dissociative fugue is often mistaken for malingering because both conditions may
give people an excuse to avoid their responsibilities (as in an intolerable marriage),
to avoid accountability for their actions, or to reduce their exposure to a known
hazard, such as a battle. However, dissociative fugue, unlike malingering, occurs
spontaneously and is not faked.

Many fugues seem to represent disguised wish fulfillment (for example, an escape
from overwhelming stresses, such as divorce or financial ruin). Other fugues are
related to feelings of rejection or separation, or they may develop as an alternative
to suicidal or homicidal impulses.

Symptoms

29
A fugue may last from hours to weeks, months, or occasionally even longer. People
in a fugue state, having lost their customary identity, usually disappear from their
usual haunts, leaving their family and job. If the fugue is brief, they may appear
simply to have missed some work or come home late. If the fugue lasts several days
or longer, people may travel far from home and begin a new job with a new
identity, unaware of any change in their life.

During the fugue, they may appear normal

and attract no attention. However, at some
point, they may become aware of the
memory loss or confused about their
identity. If they are confused, they may come
to the attention of medical or legal
authorities. During the fugue, people often
have no symptoms or are only mildly
confused. However, when the fugue ends,
they may experience depression, discomfort,
grief, shame, intense conflict, and suicidal or
aggressive impulses.

Treatment

Most fugues last for hours or days, then disappear on their own.

Treatment, when needed, may include hypnosis or drug-facilitated interviews

(interviews conducted after a sedative is given intravenously to relax people).

30
However, efforts to restore memories of what happened during the fugue itself are
usually unsuccessful.

A therapist may help people explore their patterns of handling the types of
situations, conflicts, and moods that triggered the fugue to prevent subsequent
fugues

Diagnosis

A doctor may suspect dissociative fugue when people seem confused about their
identity or are puzzled about their past or when confrontations challenge their
new identity or absence of one. The doctor carefully reviews symptoms and does a
physical examination to exclude physical disorders that may contribute to or cause
memory loss. A psychologic examination is also done. Sometimes dissociative
fugue cannot be diagnosed until people abruptly return to their pre-fugue identity
and are distressed to find themselves in unfamiliar circumstances. The diagnosis is
usually made retroactively when a doctor reviews the history and collects
information that documents the circumstances before people left home, the travel
itself, and the establishment of an alternative life.

Case studies

Agatha Christie disappeared on 3 December 1926 only to reappear eleven days later
in a hotel in Harrogate, apparently with no memory of the events which happened
during that time span.

Jody Roberts, a reporter for the Tacoma News Tribune, went missing in 1985, only
to be found 12 years later in Sitka, Alaska, living under the name of "Jane Dee
Williams." While there were some initial suspicions that she had been faking
amnesia, some experts have come to believe that she genuinely suffered a
protracted fugue state.

31
David Fitzpatrick, a sufferer of dissociative fugue disorder from the United
Kingdom, was profiled on Five's television series Extraordinary People. He entered
a fugue state on December 22, 2005, and is still working on regaining his entire
life's memories.

Hannah Upp, a teacher from New York, went missing on August 28, 2008. She was
rescued from the New York Harbor on September 16 with no recollection of the
time in between. The episode was diagnosed as dissociative fugue.

Depersonalization Disorder

32
Depersonalization disorder (DPD) is a dissociative disorder in which the
sufferer is affected by persistent or recurrent feelings of depersonalization and/or
derealization. The symptoms include a sense of automation, going through the
motions of life but not experiencing it, feeling as though one is in a movie, feeling
as though one is in a dream, feeling a
disconnection from one's body; out-of-
body experience, a detachment from one's
body, environment and difficulty relating
oneself to reality.

Occasional moments of mild

depersonalization are normal; strong,
severe persistent or recurrent feelings are
not. A diagnosis of a disorder is made
when the dissociation is persistent and
interferes with the social and occupational
functions necessary to everyday living.
Depersonalization Disorder is thought to
be largely caused by severe traumatic lifetime events including childhood sexual,
physical, and emotional abuse, accidents, war, and torture. Drug use may be an
aggravating factor. It is unclear whether genetics play a role, however there is
evidence of physiological factors with respect to DPD.

Depersonalization disorder can be conceptualized as a defense mechanism as the

core symptoms of the disorder are thought to protect the victim from negative
stimuli. Depersonalization disorder is often comorbid with anxiety disorders, panic
disorders, clinical depression and bipolar disorder.

Although depersonalization disorder is an alteration in the subjective experience

of reality, it is by no means related to psychosis as sufferers maintain the ability to

33
distinguish between their own internal experiences and the objective reality of the
outside world. Sufferers are able to distinguish between reality and fantasy, during
episodic and continuous depersonalization, and do not represent a risk to society
since their grasp on reality remains stable at all times.

History

The word depersonalization itself was first used by Henri Frédéric Amiel in The
Journal Intime. The July 8, 1880 entry reads:

"I find myself regarding existence as though from beyond the tomb, from another
world; all is strange to me; I am, as it were, outside my own body and individuality; I
am depersonalized, detached, cut adrift. Is this madness?"

Depersonalization was first used as a clinical term by Ludovic Dugas in 1898 to

refer to "a state in which there is the feeling or sensation that thoughts and acts
elude the self and become strange; there is an alienation of personality; in other
words a depersonalization". This description refers to personalization as a
psychical synthesis of attribution of states to the self.

Early theories of the cause of depersonalization focused on sensory impairment.

Maurice Krishaber proposed depersonalization was the result of pathological
changes to the body's sensory modalities which lead to experiences of "self-
strangeness" and the description of one patient who "feels that he is no longer
himself". One of Carl Wernicke's students suggested all sensations were composed
of a sensory component and a related muscular sensation that came from the
movement itself and served to guide the sensory apparatus to the stimulus. In
depersonalized patients these two components were not synchronized, and the
myogenic sensation failed to reach consciousness. The sensory hypothesis was
challenged by others who suggested that patient complaints were being taken too
literally and that some descriptions were metaphors; attempts describe

34
experiences that are difficult to articulate in words. Pierre Janet approached the
theory by pointing out his patients with clear sensory pathology did not complain
of symptoms of unreality, and that those who suffered from depersonalization
were normal from a sensory viewpoint.

Psychodynamic theory formed the basis for the conceptualization of dissociation

as a defense mechanism. Within this framework, depersonalization is understood
as a defense against a variety of negative feelings, conflicts, or experiences.
Sigmund Freud himself experienced fleeting derealization when visiting the
Acropolis in person; having read about it for years and knowing it existed, seeing
the real thing was overwhelming and proved difficult for him to perceive it as real.
Freudian theory is the basis for the description of depersonalization as a
dissociative reaction, placed within the category of psychoneurotic disorders, in
the first two editions of the Diagnostic and Statistical Manual of Mental Disorders.

Symptoms

The core symptom of depersonalization disorder is the subjective experience of

unreality, and as such there are no clinical signs. Common descriptions are:
watching oneself from a distance; out-of-body experiences; a sense of just going
through the motions; feeling as though one is in a dream or movie; not feeling in
control of one's speech or physical movements; and feeling detached from one's
own thoughts or emotions. Individuals with the disorder commonly describe a
feeling as though time is 'passing' them by and they are not in the notion of the
present. These experiences may cause a person to feel uneasy or anxious since they
strike at the core of a person's identity and consciousness.

Some of the more common factors that exacerbate dissociative symptoms are
negative effects, stress, subjective threatening social interaction, and unfamiliar
environments. Factors that tend to diminish symptoms are comforting
interpersonal interactions, intense physical or emotional stimulation, and

35
relaxation. Factors identified as relieving symptom severity such as diet, exercise,
alcohol and fatigue, are listed by others as worsening symptoms.

Fears of going crazy, brain damage, and losing control are common complaints.
Individuals report occupational impairments as they feel they are working below
their ability, and interpersonal troubles since they have an emotional
disconnection from those they care about. Neuropsychological testing has shown
deficits in attention, short-term memory and spatial-temporal reasoning.
Depersonalization disorder is associated with cognitive disruptions in early
perceptual and attentional processes.

Diagnosis

Diagnosis is based on the self-reported experiences of the person followed by a

clinical assessment by a psychiatrist, social worker, clinical psychologist or other
mental health professional. Psychiatric assessment includes a psychiatric history
and some form of mental status examination. Since some medical and psychiatric
conditions mimic the symptoms of DPD, clinicians must differentiate between and
rule out the following to establish a precise diagnosis: temporal lobe epilepsy,
panic disorder, acute stress disorder, schizophrenia, migraine, drug use, brain
tumour or lesion. No laboratory test for depersonalization disorder currently
exists.

The diagnosis of DPD can be made with the use of the following interviews and
scales: The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-
D) is widely used, especially in research settings. This interview takes about 30
minutes to 1.5 hours, depending on individual's experiences.

The Dissociative Experiences Scale (DES) is a simple, quick, self-administered

questionnaire that has been widely used to measure dissociative symptoms. It has

36
been used in hundreds of dissociative studies, and can detect depersonalization
and derealization experiences.

The Dissociative Disorders Interview Schedule (DDIS) is a highly structured

interview which makes DSM-IV diagnoses of somatization disorder, borderline
personality disorder and major depressive disorder, as well as all the dissociative
disorders. It inquires about positive symptoms of schizophrenia, secondary
features of dissociative identity disorder, extrasensory experiences, substance
abuse and other items relevant to the dissociative disorders. The DDIS can usually
be administered in 30–45 minutes.

DSM-IV-TR criteria

The diagnostic criteria defined in section 300.6 of the Diagnostic and Statistical
Manual of Mental Disorders are as follows:

1. Longstanding or recurring feelings of being detached from one's mental

processes or body, as if one is observing them from the outside or in a
dream.

2. Reality testing is unimpaired during depersonalization

3. Depersonalization causes significant difficulties or distress at work, or social

and other important areas of life functioning.

1. Depersonalization does not only occur while the individual is experiencing

another mental disorder, and is not associated with substance use or a
medical illness.

The DSM-IV-TR specifically recognizes three possible additional features of

depersonalization disorder:

37
 1. Derealization, experiencing the external world as strange or unreal.

2. Macropsia or micropsia, an alteration in the perception of object size or

shape.

3. A sense that other people seem unfamiliar or mechanical.

Etiology

The exact cause of depersonalization is unknown, although biopsychosocial

correlations and triggers have been identified. Childhood interpersonal trauma,
emotional abuse in particular, is a significant predictor of a diagnosis. The most
common immediate precipitants of the disorder are severe stress, major depressive
disorder and panic, marijuana and hallucinogen ingestion. People who live in
highly individualistic cultures may be more vulnerable to depersonalization, due
to threat hypersensitivity and an external locus of control.

One cognitive behavioral conceptualization is that misinterpreting normally

transient dissociative symptoms as an indication of severe mental illness or
neurological impairment leads to the development of the chronic disorder. This
leads to a vicious cycle of heightened anxiety and symptoms of depersonalization
and derealization.

Not much is known about the neurobiology of depersonalization disorder;

however, there is converging evidence that the prefrontal cortex may inhibit
neural circuits that normally form the substrate of emotional experience. A PET
scan found functional abnormalities in the visual, auditory, and somatosensory
cortex, as well as areas responsible for an integrated body schema. In an fMRI
study of DPD patients, emotionally aversive scenes activated the right ventral
prefrontal cortex. Participants demonstrated a reduced neural response in
emotion-sensitive regions, as well as an increased response in regions associated

38
with emotional regulation. In a similar test of emotional memory,
depersonalization disorder patients did not process emotionally salient material in
the same way as healthy controls. In a test of skin conductance responses to
unpleasant stimuli, the subjects showed a selective inhibitory mechanism on
emotional processing.

Depersonalization disorder may be associated with dysregulation of the

hypothalamic-pituitary-adrenal axis, the area of the brain involved in the "fight-or-
flight" response. Patients demonstrate abnormal cortisol levels and basal activity.
Studies found that patients with DPD could be distinguished from patients with
clinical depression and posttraumatic stress disorder.

Epidemiology

Men and women are diagnosed in equal numbers with depersonalization disorder.
A 1991 study on a sample from Winnipeg, Manitoba estimated the prevalence of
depersonalization disorder at 2.4% of the population. A 2008 review of several
studies estimated the prevalence between 0.8% and 2%. This disorder is episodic
in about one-third of individuals, with each episode lasting from hours to months
at a time. Depersonalization can begin episodically, and later become continuous
at constant or varying intensity.

Onset is typically during the teenage years or early 20s, although some report
being depersonalized as long as they can remember, and others report a later
onset. The onset can be acute or insidious. With acute onset, some individuals
remember the exact time and place of their first experience of depersonalization.
This may follow a prolonged period of severe stress, a traumatic event, an episode
of another mental illness, or drug use. Insidious onset may reach back as far as can
be remembered, or it may begin with smaller episodes of lesser severity that
gradually become stronger. Patients with drug-induced depersonalization do not
appear to be a clinically separate group from those with a non-drug precipitant.

39
 Relation to psychiatric disorders

Depersonalization exists as both a primary and secondary phenomenon, although

making a clinical distinction appears easy to make but is not absolute. The most
common comorbid disorders are depression and anxiety, although cases of
depersonalization disorder without symptoms of either do exist. Co morbid
obsessive and compulsive behaviours may exist as attempts to deal with
depersonalization, such as checking if symptoms have changed and avoiding
behavioural and cognitive factors that exacerbate symptoms. Researchers at the
Institute of Psychiatry in London, England suggest depersonalization disorder be
placed with anxiety and mood disorders, as in the ICD-10, instead of with
dissociative disorders as in the DSM-IV-TR.

Treatment

To date, no treatment recommendations or guidelines for depersonalization

disorder have been established, and it remains largely resistant to treatment. A
variety of psychotherapeutic techniques have been used to treat depersonalization
disorder, such as cognitive behavioral therapy, although none of these have
established efficacy to date. Clinical pharmacotherapy research continues to
explore a number of possible options, including selective serotonin reuptake
inhibitors, anticonvulsants, and opioid antagonists.

An open study of cognitive behavior therapy aimed to help patients re-interpret

their symptoms in a non-threatening way, which lead to an improvement on
several standardized measures.

In a retrospective report of 117 subjects with DPD, 18 of 35 benzodiazepine subjects,

reported slight or definite improvement with benzodiazepines and clonazepam in

40
particular.[4] Benzodiazepines are not known to reduce dissociative symptoms,
however they do target the often co-morbid anxiety and stress experienced by
those with DPD, and thus lead to global improvement. To date no clinical trials
have studied the effectiveness of benzodiazepines.

A series of small studies have suggested a possible role of selective serotonin

reuptake inhibitors in treating primary depersonalization disorder. However, a
placebo-controlled trial failed to show benefit with fluoxetine in 54 patients with
depersonalization disorder. SSRI treatment created an overall improvement in
participants, but only by reducing anxiety and depression. Clomipramine is a
tricyclic antidepressant that is helpful with both depression and obsessional
disorders. In a study of four subjects treated with clomipramine, two showed
clinically significant improvement of DPD. A combination of an SSRI and a
benzodiazepine has been proposed to be useful for DPD patients with anxiety.
SSRIs have also been used in combination with lamotrigine, an anticonvulsant.

Naloxone, an antagonist used primarily for the treatment of opiate overdose, was
used in a pilot study in 11 patients with chronic DPD. Of the 11 patients, three
experienced complete remission, and seven had marked improvement of
depersonalization symptoms. The study only reported immediate treatment
results, which makes the efficacy of continued treatment unknown. Naloxone can
only be administered intravenously, which makes long-term treatment difficult.
Naltrexone was used in a preliminary study in 14 individuals with DPD.
Participants were treated for 6–10 weeks, at a fairly high average dose of 120
milligrams per day. Three individuals were very much improved, another one was
much improved, and on average a 30% decrease in depersonalization symptoms
were reported. In another study in borderline personality disorder, doses of 200
milligrams per day of naltrexone was reported to decrease general dissociative
symptoms over a 2-week period of treatment.

41
 Society and culture

The director of the autobiographical documentary

Tarnation, Jonathan Caouette, suffers from
depersonalization disorder. The screenwriter for the 2007
film Numb suffers from depersonalization disorder, as does
the film's protagonist played by Matthew Perry. In print, the
novel The Stranger by Albert Camus has a protagonist who
displays an emotional deadness and views the world as
absurd, which is reminiscent of depersonalization disorder.

42
Dissociative Identity
Disorder
Dissociative identity disorder is a psychiatric
diagnosis that describes a condition in which a person displays multiple distinct
identities or personalities (known as alter egos or alters), each with its own pattern
of perceiving and interacting with the environment. In the International Statistical
Classification of Diseases and Related Health Problems the name for this diagnosis
is multiple personality disorder. In both systems of terminology, the diagnosis
requires that at least two personalities routinely take control of the individual's
behavior with an associated memory loss that goes beyond normal forgetfulness;
in addition, symptoms cannot be the temporary effects of drug use or a general
medical condition.

There is a great deal of controversy surrounding the topic. There are many
commonly disputed points about DID. These viewpoints critical of DID can be
quite varied, with some taking the position that DID does not actually exist as a
valid medical diagnosis, and others who think that DID may exist but is either
always or usually an adverse side effect of therapy. DID diagnoses appear to be
almost entirely confined to the North American continent; reports from other
continents are at significantly lower rates

Signs and symptoms

Individuals diagnosed with DID demonstrate a variety of symptoms with wide

fluctuations across time; functioning can vary from severe impairment in daily
functioning to normal or high abilities. Symptoms can include:

43
  Multiple mannerisms, attitudes and
beliefs that are not similar to each
other
 Unexplainable headaches and other
body pains
 Distortion or loss of subjective time
 Comorbidity
 Depersonalization
 Derealization
 Severe memory loss
 Depression
 Flashbacks of abuse/trauma
 Unexplainable phobias
 Sudden anger without a justified cause
 Lack of intimacy and personal connections
 Frequent panic/anxiety attacks
 Auditory hallucinations of the personalities inside their mind

Patients may experience an extremely broad array of other symptoms that

resemble epilepsy, schizophrenia, anxiety disorders, mood disorders, post
traumatic stress disorder, personality disorders, and eating disorders.

Causes

According to documents released under the FOIA, psychiatrists linked to Project

MKULTRA deliberately induced this disorder in patients, in mind control
experiments.

This disorder is theoretically linked with the interaction of overwhelming stress,

traumatic antecedents, insufficient childhood nurturing, and an innate ability to
dissociate memories or experiences from consciousness. A high percentage of

44
patients report child abuse. People diagnosed with DID often report that they
have experienced severe physical and sexual abuse, especially during their
childhood. Several psychiatric rating scales of DID sufferers suggested that DID is
strongly related to childhood trauma rather than to an underlying
electrophysiological dysfunction.

Others believe that the symptoms of DID are created iatrogenically by therapists
using certain treatment techniques with suggestible patients, but this idea is not
universally accepted. Skeptics have observed that a small number of therapists are
responsible for diagnosing the majority of individuals with DID; that patients do
not report sexual abuse or manifest alters until after treatment has begun; and the
alternative explanation of the "alters" being rule-governed social roles rather than
separate personalities.

Diagnosis

The diagnosis of Dissociative identity disorder is defined by criteria in the

American Psychiatric Association's Diagnostic and Statistical Manual of Mental
Disorders (DSM). The DSM-II used the term multiple personality disorder, the
DSM-III grouped the diagnosis with the other four major dissociative disorders,
and the DSM-IV-TR categorizes it as dissociative identity disorder. The ICD-10
continues to list the condition as multiple personality disorder.

The diagnostic criteria in section 300.14 (dissociative disorders) of the DSM-IV

require that an adult, for non-physiological reasons, be recurrently controlled by
multiple discrete identity or personality states while also suffering extensive
memory lapses. While otherwise similar, the diagnostic criteria for children
requires also ruling out fantasy.

45
Diagnosis should be performed by a psychiatrist or psychologist who may use
specially designed interviews (such as the SCID-D) and personality assessment
tools to evaluate a person for a dissociative disorder.

The psychiatric history of individuals diagnosed with DID frequently contain

multiple previous diagnoses of various mental disorders and treatment failures.

Screening

The SCID-D may be used to make a diagnosis. This interview takes about 30 to 90
minutes depending on the subject's experiences.

The Dissociative Disorders Interview Schedule (DDIS) is a highly structured

interview which discriminates between various DSM-IV diagnoses. The DDIS can
usually be administered in 30–45 minutes.

The Dissociative Experiences Scale (DES) is a simple, quick, and validate

questionnaire that has been widely used to screen for dissociative symptoms. Tests
such as the DES provide a quick method of screening subjects so that the more
time-consuming structured clinical interview can be used in the group with high
DES scores. Depending on where the cutoff is set, people who would subsequently
be diagnosed can be missed. An early recommended cutoff was 15-20 and in one
study a DES with a cutoff of 30 missed 46 percent of the positive SCID-D diagnoses
and a cutoff of 20 missed 25%. The reliability of the DES in non-clinical samples
has been questioned. There is also a DES scale for children and DES scale for
adolescents. One study argued that old and new trauma may interact, causing
higher DID item test scores.

Differential diagnoses

46
Conditions which may present with similar symptoms include borderline
personality disorder, and the dissociative conditions of dissociative amnesia and
dissociative fugue. The clearest distinction is the lack of discrete formed
personalities in these conditions. Malingering may also be considered, and
schizophrenia, although those with this last condition will have some form of
delusions, hallucinations or thought disorder.

History

One of ten photogravure portraits of Louis Vivé published in Variations de la

personnalité by Bourru and Burot.

Before the 19th century, people exhibiting symptoms similar to those were believed
to be possessed.

An intense interest in spiritualism, parapsychology,

and hypnosis continued throughout the 19th and
early 20th centuries, running in parallel with John
Locke's views that there was an association of ideas
requiring the coexistence of feelings with awareness
of the feelings. Hypnosis, which was pioneered in the
late 1700s by Franz Mesmer and Armand-Marie
Jacques de Chastenet, Marques de Puységur,
challenged Locke's association of ideas. Hypnotists reported what they thought
were second personalities emerging during hypnosis and wondered how two
minds could coexist.

The 19th century saw a number of reported cases of multiple personalities which
Rieber estimated would be close to 100. Epilepsy was seen as a factor in some cases,
and discussion of this connection continues into the present era.

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By the late 19th century there was a general acceptance that emotionally traumatic
experiences could cause long-term disorders which may manifest with a variety of
symptoms. These conversion disorders were found to occur in even the most
resilient individuals, but with profound effect in someone with emotional
instability like Louis Vivé (1863-?)who suffered a traumatic experience as a 13 year-
old when he encountered a viper. Vivé was the subject of countless medical papers
and became the most studied case of dissociation in the 19th century.

Between 1880 and 1920, many great international medical conferences devoted a
lot of time to sessions on dissociation. It was in this climate that Jean-Martin
Charcot introduced his ideas of the impact of nervous shocks as a cause for a
variety of neurological conditions. One of Charcot's students, Pierre Janet, took
these ideas and went on to develop his own theories of dissociation. One of the
first individuals diagnosed with multiple personalities to be scientifically studied
was Clara Norton Fowler, under the pseudonym Christine Beauchamp; American
neurologist Morton Prince studied Fowler between 1898 and 1904, describing her
case study in his 1906 monograph, Dissociation of a Personality. Fowler went on to
marry one of her analyst's colleagues.

In the early 20th century interest in dissociation and multiple personalities waned
for a number of reasons. After Charcot's death in 1893, many of his so-called
hysterical patients were exposed as frauds, and Janet's association with Charcot
tarnished his theories of dissociation. Sigmund Freud recanted his earlier
emphasis on dissociation and childhood trauma.

In 1910, Eugen Bleuler introduced the term schizophrenia to replace dementia

praecox. A review of the Index medicus from 1903 through 1978 showed a dramatic
decline in the number of reports of multiple personality after the diagnosis of
schizophrenia became popular, especially in the United States. A number of
factors helped create a large climate of skepticism and disbelief; paralleling the

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increased suspicion of DID was the decline of interest in dissociation as a
laboratory and clinical phenomenon.

Starting in about 1927, there was a large increase in the number of reported cases
of schizophrenia, which was matched by an equally large decrease in the number
of multiple personality reports. Bleuler also included multiple personality in his
category of schizophrenia. It was concluded in the 1980s that DID patients are
often misdiagnosed as suffering from schizophrenia.

Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde is known for its
portrayal of a split personality

The public, however, was exposed to

psychological ideas which took their interest.
Mary Shelley's Frankenstein, Robert Louis
Stevenson's Strange Case of Dr Jekyll and Mr
Hyde, and many short stories by Edgar Allan Poe
had a formidable impact. In 1957, with the
publication of the book The Three Faces of Eve
and the popular movie which followed it, the American public's interest in
multiple personality was revived. During the 1970s an initially small number of
clinicians campaigned to have it considered a legitimate diagnosis.

The highly influential book Sybil was published in 1974, which popularized the
diagnosis through a detailed discussion of the problems and treatment of the
pseudonymous Sybil. Six years later, the diagnosis of multiple personality disorder
appeared in the DSM III. Controversy over the iconic case has since arisen, with
some calling Sybil's diagnosis the result of iatrogenic therapeutic methods while
others have defended the treatment and reputation of Sybil's therapist, Cornelia B.
Wilbur. As media coverage spiked, diagnoses climbed. There were 200 reported
cases of DID as of 1980, and 20,000 from 1980 to 1990. Joan Acocella reports that

49
40,000 cases were diagnosed from 1985 to 1995. The majority of diagnoses are
made in North America, particularly the United States, and in English-speaking
countries more generally with reports recently emerging from other countries.

Controversy

DID is a controversial diagnosis and condition, with much of the literature on DID
being generated and published in North America, to the extent that it was
regarded as a phenomenon confined to that continent. Even within North
American psychiatrists there is a lack of consensus regarding the validity of DID.
Practitioners who do accept DID as a valid disorder have produced an extensive
literature with some of the more recent papers originating outside North America.
Criticism of the diagnosis continues, with Piper and Merskey describing it as a
culture-bound and often iatrogenic condition which they believe is in decline.
There is considerable controversy over the validity of the multiple personality
profile as a diagnosis. Unlike the more empirically verifiable mood and personality
disorders, dissociation is primarily subjective for both the patient and the
treatment provider. The relationship between dissociation and multiple
personality creates conflict regarding the DID diagnosis. While other disorders
require a certain amount of subjective interpretation, those disorders more readily
present generally accepted, objective symptoms. The controversial nature of the
dissociation hypothesis is shown quite clearly by the manner in which the
American Psychiatric Association's Diagnostic and Statistical Manual of Mental
Disorders (DSM) has addressed, and re-addressed, the categorization over the
years.

The second edition of the DSM referred to this diagnostic profile as multiple
personality disorder. The third edition grouped MPD in with the other four major
dissociative disorders. The current edition, the DSM-IV-TR, categorizes the
disorder as dissociative identity disorder (DID). The ICD-10 (International

50
Statistical Classification of Diseases and Related Health Problems) continues to list
the condition as multiple personality disorder.

Over-representation in North America

In a review, Joel Paris offered three possible causes for the sudden increase in
people diagnosed with DID:

1. The result of therapist suggestions to suggestible people, much as Charcot's

hysterics acted in accordance with his expectations.
2. Psychiatrists' past failure to recognize dissociation being redressed by new
training and knowledge.
3. Dissociative phenomena are actually increasing, but this increase only
represents a new form of an old and protean entity: "hysteria".

Paris believes that the first possible cause is the most likely.

The debate over the validity of this condition, whether as a clinical diagnosis, a
symptomatic presentation, a subjective misrepresentation on the part of the
patient, or a case of unconscious collusion on the part of the patient and the
professional is considerable. There are several main points of disagreement over
the diagnosis.

Skeptics claim that people who present with the appearance of alleged multiple
personality may have learned to exhibit the symptoms in return for social
reinforcement. One case cited as an example for this viewpoint is the "Sybil" case,
popularized by the news media. Psychiatrist Herbert Spiegel stated that "Sybil" had
been provided with the idea of multiple personalities by her treating psychiatrist,
Cornelia Wilbur, to describe states of feeling with which she was unfamiliar.

One of the primary reasons for the ongoing recategorization of this condition is
that there were once so few documented cases (research in 1944 showed only 76)

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of what was once referred to as multiple personality. Dissociation is recognized as
a symptomatic presentation in response to trauma, extreme emotional stress, and,
as noted, in association with emotional dysregulation and borderline personality
disorder.

Development theory

It has been theorized that severe sexual, physical, or psychological trauma in

childhood predisposes an individual to the development of DID. The steps in the
development of a dissociative identity are theorized to be as follows:

1. The child is harmed by a trusted caregiver (often a parent or guardian) and

splits off the awareness and memory of the traumatic event to survive in the
relationship.
2. The memories and feelings go into the subconscious and are experienced
later in the form of a separate personality.
3. The process happens repeatedly at different times so that different
personalities develop, containing different memories and performing
different functions that are helpful or destructive.
4. Dissociation becomes a coping mechanism for the individual when faced
with further stressful situations.

Physiological findings

Reviews of the literature have discussed the findings of various psychophysiologic

investigations of DID. Many of the investigations include testing and observation
in the one person but with different alters. Different alter states have shown
distinct physiological markers and some EEG studies have shown distinct
differences between alters in some subjects, while other subjects' patterns were
consistent across alters. Another study concluded that the differences involved
intensity of concentration, mood changes, degree of muscle tension, and duration

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of recording, rather than some inherent difference between the brains of people
diagnosed with DID. Brain imaging studies have corroborated the transitions of
identity in some DID sufferers. A link between epilepsy and DID has been
postulated but this is disputed. Some brain imaging studies have shown differing
cerebral blood flow with different alters, and distinct differences overall between
subjects with DID and a healthy control group. A different imaging study showed
that findings of smaller hippocampal volumes in patients with a history of
exposure to traumatic stress and an accompanying stress-related psychiatric
disorder were also demonstrated in DID. This study also found smaller amygdala
volumes. Studies have demonstrated various changes in visual parameters between
alters. One twin study showed hereditable factors were present in DID.

Treatment

Treatment of DID may attempt to reconnect the identities of disparate alters into a
single functioning identity. In addition or instead, treatment may focus on
symptoms, to relieve the distressing aspects of the condition and ensure the safety
of the individual. Treatment methods may include psychotherapy and medications
for comorbid disorders. Some behavior therapists initially use behavioral
treatments such as only responding to a single identity, and using more traditional
therapy once a consistent response is established. It has been stated that treatment
recommendations that follow from models that do not believe in the traumatic
origins of DID might be harmful due to the fact that they ignore the posttraumatic
symptomatology of people with DID.

Prognosis

DID does not resolve spontaneously, and symptoms vary over time. Individuals
with primarily dissociative symptoms and features of posttraumatic stress disorder
normally recover with treatment. Those with comorbid addictions, personality,
mood, or eating disorders face a longer, slower, and more complicated recovery

53
process. Individuals still attached to abusers face the poorest prognosis; treatment
may be long-term and consist solely of symptom relief rather than personality
integration. Changes in identity, loss of memory, and awaking in unexplained
locations and situations often leads to chaotic personal lives. [2] Individuals with the
condition commonly attempt suicide.[13]

Epidemiology

The DSM does not provide an estimate of incidence; however the number of
diagnoses of this condition has risen sharply. A possible explanation for the
increase in incidence and prevalence of DID over time is that the condition was
misdiagnosed as schizophrenia, bipolar disorder, or other such disorders in the
past; another explanation is that an increase in awareness of DID and child sexual
abuse has led to earlier, more accurate diagnosis. Other clinicians believe that DID
is an iatrogenic condition overdiagnosed in highly suggestive individuals, though
there is disagreement over the ability of the condition to be induced by hypnosis.
Figures from psychiatric populations (inpatients and outpatients) show a wide
diversity from different countries.

Country Prevalence
India 0.015%
Switzerland 0.05-0.1%
China 0.4%
Germany 0.9%
The Netherlands 2%
U.S. 10%
U.S. 6-8%
U.S. 6-10%
Turkey 14%

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Figures from the general population show less diversity:

Country Prevalence
Canada 1%
Turkey (male) 0.4%
Turkey 1.1%
(female)

Dissociative identity disorder is diagnosed in a sizable minority of patients in drug

abuse treatment facilities.

Co morbidity

Multiple identity disorder frequently co-occurs with other psychiatric diagnoses,

such as anxiety disorders (especially post-traumatic stress disorder-PTSD), mood
disorders, somatoform disorders, eating disorders, as well as sleep problems and
sexual dysfunction. The symptoms of the disorder have a considerable overlap
with borderline personality disorder.

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