Unit_4 SomaticSymptom&DissociativeDisorder ClassNotes@SaritaSapkota

Unit 4
Somatoform and Dissociative Disorder
In DSM-5, Somatic Symptom Disorders and Dissociative Disorders is used instead of somatoform and
dissociative disorder.
The somatic symptom disorders or somatoform disorders are a group of conditions that involve
physical symptoms combined with abnormal thoughts, feelings and behaviors in response to those
symptoms (APA, 2013)
Soma means “body,” and somatoform disorders/somatic symptom disorders involve patterns in which
individuals complain of bodily symptoms that suggest the presence of medical problems but there is no
obvious medical explanation that satisfactorily explains the symptoms such as paralysis or pain.
Key to these disorders is the fact that the affected patients have no control over their symptoms. They
are also not intentionally faking symptoms or attempting to deceive others. For the most part, they
genuinely and sometimes passionately believe something is terribly wrong with their bodies and so
they frequently visit physicians.
The term dissociation refers to the human mind’s capacity to engage in complex mental activity in channels
split off from, or independent of, conscious awareness
Dissociative disorders are a group of conditions involving disruptions in a person’s normally integrated
functions of consciousness, memory, identity, or perception (APA, 2013).
The hallmark of dissociative disorders is a disturbance of or alteration in the normally well-integrated
functions of identity, memory, and consciousness.
1. Conversion disorder
In DSM-5, conversion disorder (functional neurological symptom disorder) is defined by the presence
of one or more symptoms of altered voluntary motor or sensory function that suggest a neurological or
medical condition.
However, upon a thorough medical examination, it becomes apparent that the pattern of symptoms or
deficits cannot be fully explained by any known medical condition.
A few typical examples include:

• partial paralysis,
• blindness,
• deafness, and
• pseudoseizures (Pseudoseizures resemble true seizures but are unaccompanied by abnormal brain
waves.)
In World War I, conversion disorder was the most frequently diagnosed psychiatric syndrome among
soldiers; it was also relatively common during World War II.
Conversion disorder typically occurred under highly stressful combat conditions and involved men
who would ordinarily be considered stable. Here, conversion symptoms—such as paralysis of the legs—
enabled a soldier to avoid an anxiety-arousing combat situation without being labeled a coward or being
subject to court-martial.

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The physical symptoms in conversion disorder are usually seen as serving the rather obvious function of
providing a plausible bodily “excuse” enabling an individual to escape or avoid an intolerably stressful
situation without having to take responsibility for doing so.
Conversion disorder consists of four categories of symptoms: (1) sensory, (2) motor, (3) seizures, and (4)
mixed presentation of the first three categories (APA, 2013).
DSM-5 Diagnostic Criteria for Conversion Disorder (Functional Neurological Symptom Disorder)
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological
or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning or warrants medical evaluation.
Prevalence, Age of Onset, and Gender Differences
The prevalence in the general population is unknown, but even the highest estimates have been around only
0.005% (APA, 2013).
Conversion symptoms are surprisingly common in hospital and clinic settings. For example, an estimated
20%–25% of the patients admitted to neurology wards have conversion symptoms.
Conversion symptoms are more frequent in women, in patients from rural areas, and in persons with lower
levels of education and income. Conversion disorder occurs two to ten times more often in women than in
men.
Onset can occur at any age but usually tends to be in late childhood or early adulthood.
Co-morbidity
Conversion disorder frequently occurs along with other disorders, especially major depression, anxiety
disorders, and somatization and dissociative disorders.
Etiology
The cause of conversion disorder is not well understood, but most people who receive the diagnosis have
a history of mental illness, such as a mood disorder, a somatic symptom disorder, or a psychotic disorder.
In highly unusual “outbreak” of cases of severe conversion disorder involving serious motor weakness it
is found that each of the patient had experienced substantial psychosocial stressors including behavioral
problems, dysfunctional family dynamics, and significant community stress from a serious local church
crisis.
Treatment
The treatment of conversion disorder is not well established, but symptom removal is the goal.
Reassurance and gentle suggestion (for example, the idea that gradual improvement is expected) are
appropriate, along with efforts to resolve stressful situations that may have accompanied the
symptoms.

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The spontaneous remission rate for acute conversion symptoms is high, so that even without any specific
intervention, most patients will improve and probably not suffer any serious complications.
A treatment approach for persistent conversion symptoms using behavioral modification for
psychiatric inpatients has been described. The patient is placed at complete bed rest and informed that use
of ward facilities will parallel his or her improvement. As the patient improves, the time out of bed is
gradually increased until full privileges are restored. Nearly all patients (84%) who had conversion
symptoms (ranging from blindness to bilateral wrist drop) treated in this manner remitted.
In treating conversion disorder, hospital staff should remain supportive and show concern while
encouraging self-help.
It is rarely helpful to confront patients about their symptoms or make them feel ashamed or embarrassed.
The pain, weakness, or disability is quite real to the patient.
Illness Anxiety Disorder
Illness anxiety disorder is a new diagnosis in DSM-5 and is used in patients who are preoccupied with the
possibility of having or acquiring a serious illness.
When fears or concerns about having an illness persist despite medical reassurance, the problem may be
illness anxiety disorder (APA, 2013). Illness anxiety disorder is characterized by anxiety or fear that one
has a serious disease.
Criteria for Illness Anxiety Disorder (DSM-5)
A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition
is present or there is a high risk for developing a medical condition (e.g., strong family history is present),
the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health
status.
D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for
signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may
change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic
symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-
compulsive disorder, or delusional disorder, somatic type.
Prevalence:
The prevalence of DSM-IV hypochondriasis, which would encompass illness anxiety disorder and part of
somatic symptom disorder, has been estimated to be from 1% to 5% (American Psychiatric Association,
2000).
Co-morbidity

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Individuals with hypochondriasis often also suffer from mood disorders, panic disorder, or other
somatoform disorders.
Etiology
a. Faulty interpretation of physical signs and sensations as evidence of physical illness is central,
so almost everyone agrees that these disorders are basically disorders of cognition or perception
with strong emotional contributions.
b. Currently, cognitive-behavioral views of illness anxiety disorder are perhaps most widely
accepted.
Central principle in cognitive-behavioral view of is that it is a disorder of cognition and perception.
It is believed that an individual’s past experiences with illnesses (in both him- or herself and others, and as
observed in the mass media) lead to the development of a set of dysfunctional assumptions about symptoms
and diseases that may predispose a person to developing this disorder.
c. These individuals do in fact have an attentional bias for illness-related information. they perceive
their symptoms as more dangerous than they really are and judge a particular disease to be more
likely or dangerous than it really is. Once they have misinterpreted a symptom, they tend to look
for confirming evidence and to discount evidence that they are in good health; in fact, they
seem to believe that being healthy means being completely symptom-free.
Treatment
Selective serotonin reuptake inhibitors (SSRIs) or certain anti-depressants are reported to be effective
in treating DSM-IV hypochondriasis and may well help in treating illness anxiety disorder.
The patient with illness anxiety disorder may further benefit from individual psychotherapy that involves
education about illness attitudes and selective perception of symptoms.
Controlled trials have shown that cognitive-behavioral therapy (CBT) can help to correct faulty beliefs
about illness and counter the patient’s tendency to seek inappropriate care.

• The cognitive components of this treatment approach focus on assessing the patient’s beliefs about
illness and modifying misinterpretations of bodily sensations.
• The behavioral techniques include having patients induce harmless symptoms by intentionally
focusing on parts of their body so that they can learn that selective perception of bodily sensations
plays a major role in their symptoms.

Psychological Factors Affecting Other Medical Conditions

The major characteristics of this disorder is the presence of a diagnosed medical condition such as asthma,
diabetes, or severe pain clearly caused by a known medical condition such as cancer that is adversely
affected (increased in frequency or severity) by one or more psychological or behavioral factors.
These behavioral or psychological factors would have a direct influence on the course or perhaps the
treatment of the medical condition

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For example:
Anxiety severe enough to clearly worsen an asthmatic condition.
Patient with diabetes in denial about the need to regularly check insulin levels and intervene when
necessary.
Criteria
A. A medical symptom or condition (other than a mental disorder) is present.
B. Psychological or behavioral factors adversely affect the medical condition in one of the following ways:
1. The factors have influenced the course of the medical condition as shown by a close temporal
association between the psychological factors and the development or exacerbation of, or delayed
recovery from, the medical condition.
2. The factors interfere with the treatment of the medical condition (e.g., poor adherence).
3. The factors constitute additional well-established health risks for the individual.
4. The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or
necessitating medical attention.
C. The psychological and behavioral factors in Criterion B are not better explained by another mental
disorder (e.g., panic disorder, major depressive disorder, posttraumatic stress disorder)
Etiology
The factors include mental disorders and psychological symptoms (e.g., major depressive disorder,
anxiety), personality traits (e.g., hostile, denying), physiological response to stress, and behavior patterns
detrimental to health (e.g., overeating, excessive alcohol consumption)
Treatment
Medical treatment of anxiety in a patient with hypertension or asthma is reasonable.
The most common types of treatments include relaxation training, hypnosis, traditional CBT
treatments, group therapy.
Factitious Disorder
Factitious disorder differs from other somatic symptom disorders in one very important way: Physical or
psychological signs or symptoms of illness are intentionally produced in what appears to be a desire to
assume a sick role.
Unlike malingering, in which a person intentionally produces physical symptoms to avoid military service,
criminal prosecution, or work or to obtain financial compensation or drugs, symptom production in
factitious disorders is not associated with any external incentives.
People are aware that they are producing the symptoms and making themselves ill but appear to be
unaware of why they do it.
These behaviors include faking elevated body temperature, putting blood in urine to simulate
kidney/urinary tract infections, or taking blood-thinning medications to produce symptoms of
hemophilia. In addition, people with factitious disorder imposed on self deliberately and convincingly
fake chest pain or abdominal pain. They will go through numerous invasive and dangerous diagnostic

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and therapeutic procedures. To convince physicians that they are physically ill, they manipulate
laboratory results to substantiate their illness claims.
Presenting Complaint & Laboratory Evidence
Hematuria (blood in urine) →Red candy in urine sample
Nonhealing wound →Mouthwash found in wound
Diarrhea → Excessive ingestion of castor oil or laxatives
Pain from “kidney stones” →Glass fragments in urine
Anemia → “Self-induced” blood draws with substantial blood loss
Criteria
Factitious Disorder Imposed on Self
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated
with identified deception.
B. The individual presents himself or herself to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or another
psychotic disorder.
Factitious Disorder Imposed on Another
(Previously Factitious Disorder by Proxy)
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in
another, associated with identified deception.
B. The individual presents another individual (victim) to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or another
psychotic disorder.
Prevalence
The prevalence of factitious disorder is unknown because most cases are probably never recognized or go
undetected.
Factitious disorders begin in early adulthood and can become chronic.
Co-morbidity
The disorder is typically associated with the presence of a personality disorder.
Etiology

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The exact cause of factitious disorder is not known but researchers believe both biological and
psychological factors play a role. Some theories suggest in a history of abuse or neglect as a child.
Factitious disorders tend to develop in people who have had experience with hospitalization or severe
illness involving either themselves or someone close to them (e.g., a parent).
Treatment
The first task is to make the diagnosis so that additional and potentially harmful procedures can be avoided.
Once sufficient evidence has been assembled to support the diagnosis, the patient should be confronted in
a nonthreatening manner by the attending physician and the consulting psychiatrist.
Individual psychotherapy, Family Therapy, CBT can be used.
2. Dissociative disorder
Dissociative disorders are a group of conditions involving disruptions in a person’s normally integrated
functions of consciousness, memory, identity, or perception (APA, 2013).
The hallmark of dissociative disorders is a disturbance of or alteration in the normally well-integrated
functions of identity, memory, and consciousness.
The term dissociation refers to the human mind’s capacity to engage in complex mental activity in channels
split off from, or independent of, conscious awareness.
We all dissociate to a degree some of the time. Mild dissociative symptoms occur when we daydream or
lose track of what is going on around us, when we drive miles beyond our destination without realizing
how we got there, or when we miss part of a conversation, we are engaged in. Hypnosis and meditation are
examples of induced forms of dissociation
Like somatoform disorders, dissociative disorders appear mainly to be ways of avoiding anxiety and stress
and of managing life problems that threaten to overwhelm the person’s usual coping resources.
Both types of disorders also enable the individual to deny personal responsibility for his or her
“unacceptable” wishes or behavior.
In the case of DSM-defined dissociative disorders, the person avoids the stress by pathologically
dissociating—in essence, by escaping from his or her own autobiographical memory or personal identity.
a. Depersonalization/Derealization disorder
Depersonalization/Derealization disorder is characterized by feeling detached from oneself or one’s
surroundings, as though one were an outside observer; some patients experience a dreamlike state.
When episodes of depersonalization (and derealization) become persistent and recurrent and interfere with
normal functioning, depersonalization disorder may be diagnosed.
Many people who are normal transiently experience mild depersonalization or derealization. For example,
these symptoms can occur when a person is sleep deprived, travels to unfamiliar places, or is intoxicated
with hallucinogens, marijuana, or alcohol. Persons exposed to life threatening situations, such as traumatic
accidents, may also experience these symptoms. For these reasons, depersonalization/derealization disorder
is diagnosed only when it is persistent and causes distress.
Many persons vividly recall their first episode of depersonalization, which may begin abruptly.

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Some report a precipitating event, such as smoking marijuana. The duration of depersonalization episodes
is highly variable, but they can last hours, days, or even weeks.
Although depersonalization disorder is typically experienced as chronic and continuous, some people
experience periods of remission. Depersonalization may follow psychologically stressful situations, such
as the loss of an important relationship.
In DSM-IV, depersonalization and derealization were separate disorders. With DSM-5, the two syndromes
have been merged because research had shown little difference between persons with depersonalization
alone and those with depersonalization accompanied by derealization.
Criteria for Depersonalization/ Derealization Disorder
A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:
1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to
one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense
of time, unreal or absent self, emotional and/or physical numbing).
2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or
objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
B. During the depersonalization or derealization experiences, reality testing remains intact.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse,
medication) or another medical condition (e.g., seizures).
E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder,
major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative
disorder
Prevalence, Age of Onset, and Gender Differences
The prevalence of depersonalization/derealization disorder is around 2% in the general population.
It is equally common in men and women.
The disorder typically begins in adolescence or early adulthood but rarely after age 40.
Co-morbidity
Comorbid personality disorders are frequent, and during their lifetime, about two-thirds of people with
this disorder will experience anxiety disorders and depression.
Etiology
The cause of depersonalization disorder is unknown.
The fact that depersonalization frequently accompanies several central nervous system disturbances (e.g.,
partial complex seizures, tumors, stroke, migraine) suggests a neurobiological basis.
Treatment

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There are no standard treatments for the disorder, but benzodiazepines may be helpful in reducing the
accompanying anxiety.
Patients also have been reported to benefit from hypnosis or CBT to help control their episodes of
depersonalization/derealization. With CBT, patients learn to confront their distorted thoughts and challenge
their feelings of unreality.
b. Dissociative amnesia
Amnesia refers to a partial or total loss of memory. There are two types of Amnesia:

• Retrograde amnesia: the partial or total inability to recall or identify previously acquired
information or past experiences; by contrast
• Anterograde amnesia: the partial or total inability to retain new information
Fugue refers to a loss of awareness of one's identity, often coupled with flight from one's usual environment.
Dissociative amnesia (or psychogenic amnesia) is usually limited to a failure to recall previously stored
personal information (retrograde amnesia) when that failure cannot be accounted for by ordinary forgetting.
With dissociative amnesia, the person is typically confused and puzzled.
He or she may not recall significant personal information or even his or her own name.
The amnesia can develop suddenly and last for minutes to days or longer. In one case series, 79% of
amnestic episodes lasted less than a week.
The gaps in memory most often occur following intolerably stressful circumstances— wartime combat
conditions, for example, or catastrophic events such as serious car accidents, suicide attempts, or violent
outbursts.
In this disorder, apparently forgotten personal information is still there beneath the level of
consciousness, as sometimes becomes apparent in interviews conducted under hypnosis or narcosis and in
cases where the amnesia spontaneously clears up.
Several types of dissociative amnesia are recognized by DSM. One is localized amnesia (a person
remembers nothing that happened during a specific period, most commonly the first few hours or days
following some highly traumatic event). Another is selective amnesia (a person forgets some but not all of
what happened during a given period).
In typical dissociative amnesic reactions, individuals cannot remember certain aspects of their personal
life history or important facts about their identity. Yet their basic habit patterns—such as their abilities
to read, talk, perform skilled work, and so on—remain intact, and they seem normal aside from the
memory deficit.
Thus, the only type of memory that is affected is episodic (pertaining to events experienced) or
autobiographical memory (pertaining to personal events experienced).
The other recognized forms of memory— semantic (pertaining to language and concepts), procedural (how
to do things), and short-term storage—seem usually to remain intact.
Criteria for Dissociative Amnesia

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A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature,

that is inconsistent with ordinary forgetting.
Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or
events; or generalized amnesia for identity and life history.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug
of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient
global amnesia, sequelae of a closed head injury/traumatic brain injury, other neurological condition).
D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder,
acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.
Specify if: With dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated
with amnesia for identity or for other important autobiographical information.
Prevalence, Age of Onset, and Gender Differences
The prevalence of dissociative amnesia has been estimated at around 1%–3% in the general population
It affects more women than men.
It has been reported to occur following severe physical or psychosocial stressors (e.g., natural disasters,
war)
Etiology
No specific genes have been associated with vulnerability to dissociative amnesia.
People experiencing dissociative amnesia are typically faced with extremely unpleasant situations from
which they see no acceptable way to escape such as marital discord, personal rejection, financial or
occupational difficulties, war service, or a natural disaster, but not all amnesias seem to immediately follow
trauma.
Eventually the stress becomes so intolerable that large segments of their personalities and all memory of
the stressful situations are suppressed.
Treatment
There is no established treatment for dissociative amnesia, and recovery tends to occur spontaneously.
For some persons, a safe environment such as that found in a psychiatric hospital may foster recovery.
Hypnosis has been reported to help patients recover missing memories. When memories return, patients
should be helped to understand the reason for their memory loss and to reinforce healthy coping
mechanisms.
c. Dissociative Identity Disorder
Formerly known as Multiple Personality disorder, dissociative identity disorder is characterized by the
presence of two or more distinct personality states, that alternate in some way in taking control of
behavior, which in some cultures may be likened (compared) to possession.

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DID is a condition in which normally integrated aspects of memory, identity, and consciousness are no
longer integrated.
Each identity may appear to have a different personal history, self-image, and name, although there are
some identities that are only partially distinct and independent from other identities.
In most cases the one identity that is most frequently encountered i.e., who has executive control over the
body most of the time and carries the person’s real name is the host identity. The host personality may or
may not be the individual's original personality.
The alter identities may differ in striking ways involving gender, age, handedness, handwriting, sexual
orientation, prescription for eyeglasses, predominant affect, foreign languages spoken, and general
knowledge.
Certain roles such as a child and someone of the opposite sex are extremely common. The transition from
one alter to another may be sudden or gradual, often prompted by stressful situations.
Alter identities take control at different points in time, and the switches typically occur very quickly (in a
matter of seconds), although more gradual switches can also occur.
When switches occur in people with DID, it is often easy to observe the gaps in memories for things that
have happened—often for things that have happened to other identities. But this amnesia is not always
symmetrical; that is, some identities may know more about certain alters than do other identities. Sometimes
one submerged identity gains control by producing hallucinations (such as a voice inside the head giving
instructions).
Additional symptoms of DID include depression, self-mutilation, frequent suicidal ideation and attempts,
erratic behavior, headaches, hallucinations, posttraumatic symptoms, and other amnesic and fugue
symptoms.
Diagnostic Criteria for Dissociative Identity Disorder
A. Disruption of identity characterized by two or more distinct personality states, which may be described
in some cultures as an experience of possession. The disruption in identity involves marked discontinuity
in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness,
memory, perception, cognition, and/ or sensory-motor functioning. These signs and symptoms may be
observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events
that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic
behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).
Prevalence, Age of Onset, and Gender Differences

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Surveys show that dissociative identity disorder has a prevalence of around 1.5% in the general population.
It has also been reported to be fairly common (5%–15%) in inpatient and outpatient psychiatric settings.
DID is thought to have a childhood onset, usually before age 9 years, and is often chronic., although most
patients are in their teens, 20s, or 30s at the time of diagnosis (Maldonado & Spiegel, 2007).
Approximately three to nine times more females than males are diagnosed as having the disorder, and
females tend to have a larger number of alters than do males.
Co-morbidity
Depressive disorders, PTSD, substance-use disorders, and borderline personality disorder are the
most common comorbid diagnoses.
Etiology
The disorder is reported to run in families and as occurring in multiple generations.
Like persons with PTSD, dissociative identity disorder patients are reported to have smaller hippocampal
and amygdala volumes.
Some researchers believe that dissociative identity disorder results from severe physical and sexual abuse
in childhood. They hypothesize that the disorder results from self-induced hypnosis, used by the individual
to cope with abuse, emotional maltreatment, or neglect.
Socio-cognitive theory claims that DID develop when a highly suggestible person learns to adopt and
enact the roles of multiple identities, mostly because clinicians have suggested, legitimized, and
reinforced them and because these different identities are geared to the individual’s own personal goals. It
is important to realize that at the present time, the socio-cognitive perspective maintains that this is not done
intentionally or consciously by the afflicted individual but, rather, occurs spontaneously with little or no
awareness.
Treatment
There is no standard treatment for dissociative identity disorder, but many clinicians recommend long-
term individual psychotherapy to help patients integrate their many alters.
Some experts use hypnosis to help access the different alters in the context of psychotherapy. Cognitive-
behavioral therapy has also been used to help patients achieve reintegration. All agree that therapy is lengthy
and challenging.
Through the use of hypnosis, therapists are often able to make contact with different identities and
reestablish connections between distinct, seemingly separate identity states. An important goal is to
integrate the personalities into one identity that is better able to cope with current stressors.

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