HOARDING DISORDER

● For people with hoarding disorder, there is a need to acquire things, and they abhor parting with
their objects, even when others cannot see any potential value in them - are extremely
attached to their possessions, and they are very resistant to efforts to get rid of them
● The person can acquires a huge range of different kinds of objects—collections of clothes, tools,
or antiques may be gathered along with old containers, bottle caps, and sandwich wrappers.
● About two-thirds of people who hoard seem to be unaware of the severity of their behavior
(Steketee & Frost, 2003). On self-report scales, about 2 percent of the population acknowledge
moderate problems with hoarding symptoms (Iervolino, Rijsdijk, Cherkas, et al., 2011). Although
hoarding is more common among men than among women (Samuels et al., 2007), very few men
seek treatment (Steketee & Frost, 2003).
● About one-third of people with hoarding disorder also engage in animal hoarding (Patronek &
Nathanson, 2009). People who engage in animal hoarding sometimes view themselves as animal
rescuers, but those who witness the problem see it differently—the accumulating number of
animals often outstrips the person’s ability to provide adequate care, shelter, and food. The
consequences of hoarding can be quite severe. The accrual of objects often overwhelms the
person’s home.
● In one study, case workers for elder services agencies were asked to describe their clients who
suffered from hoarding disorder. Although the sampling strategy likely focused on particularly
severe cases, the findings were notable. The case workers reported that among their clients who
had problems with hoarding,
○ the hoarding led to extremely filthy homes for about a third of people, characterized by
overpowering odors from rotten food or feces.
○ More than 40 percent had accumulated so many items that they were no longer able to use
their refrigerator, kitchen sink, or bathtub, and about 10 percent were unable to use their
toilet (Kim, Steketee, & Frost, 2001).
○ Respiratory conditions, poor hygiene, and difficulties with cooking can all contribute to poor
physical health.
● Many family members sever relationships, unable to understand the attachment to the objects.
About three-quarters of people with hoarding disorder engage in excessive buying (Frost, Tolin,
Steketee, et al., 2009) and many are unable to work (Tolin, Frost, Steketee, et al., 2008), making
poverty all too common among people with this condition (Samuels, Bienvenu III, Pinto, et al.,
2007).
● As the problem escalates, health officials often become involved to try to address the safety and
health concerns.
● About 10 percent of persons with hoarding disorder will be threatened with eviction at some point
in their lives (Tolin et al., 2008). For some, the money spent on acquiring leads to homelessness.
When animals are involved, animal protection agencies sometimes become involved.
● Hoarding behavior usually begins in childhood or early adolescence (Grisham, Frost, Steketee, et
al., 2006). These early symptoms may be kept under control by parents and by limited income,
so severe impairment from the hoarding often does not surface until later in life. Animal hoarding
often does not emerge until middle age or older (Patronek & Nathanson, 2009).
● Although hoarding is often comorbid with OCD, it can also occur among those who do not have
OCD symptoms (Bloch et al., 2008). Depression, generalized anxiety disorder, and social phobia
are common among people diagnosed with hoarding (Mataix-Cols, Frost, Pertusa, et al., 2010).
Occasionally, hoarding develops among people with schizophrenia or dementia (Hwang, Tsai,
Yang, et al., 1998).
Symptoms/DSM Criteria
1. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
2. This difficulty is due to a perceived need to save the items and to distress associated with
discarding them.
 3. The difficulty discarding possessions results in the accumulation of possessions that congest
and clutter active living areas and substantially compromises their intended use. If living
areas are uncluttered, it is, it is only because of the interventions of third parties (e.g., family
members, cleaners, authorities).
4. The hoarding causes clinically significant distress or impairment in social, occupational or
other important areas of functioning (including maintaining a safe environment for self and
others).
5. The hoarding is not attributable to another medical condition (e.g., brain injury,
cerebrovascular disease).
6. The hoarding is not better explained by the symptoms of another mental disorder (e.g.,
obsession in OCD, delusions in schizophrenia or another psychotic disorder, cognitive
deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).
DSM-5 calls clinicians to specify if “excessive acquisition” (e.g., do they acquire items that they don’t
need and for which they don’t have space in their home?) and to specify the person’s level of insight
(good, fair, poor, or absent, delusional), may have good/bad insight. According to the DSM-5, 80-90%
engage in excessive shopping and buying unnecessary things/items and around 2-6% population suffers
from this disorder. More common in older adults (55-94 years), which appears to begin at 11-15 years,
and starts to cause significant impairment when people are in their 30’s.
Etiology
Frost & Hartl (1996) proposed a cognitive model of HD, which includes
(1) information processing deficits- includes deficits in decision-making, deficits in
categorization/organization, and difficulties with memory functions. This deficit in decision making
shows in indecisiveness about the likelihood of future needs; avoiding judgement about whether objects
have sentimental or instrumental value; the fear of mistakes during discarding possessions; doubts as to
whether the people with HD would be able to re-acquire an object if needed. Taken together, HD leads
to lower threshold for saving due to fear of harm associated with not having a needed object and a fear
of damage to possessions. Keeping the possessions avoids the anticipated experience of deprivation.
The deficit in categorisation manifests itself in a difficulty for the hoarder to decide on the number of
item categories and a sufficient amount of objects per category. Usually the number of objects per
category is less for the people with HD than in people without HD, because for people without HD each
object is unique and irreplaceable, which makes the discarding more difficult. As well, this leads to
difficulty (together with indecisiveness) in the organising of possessions while sorting possession
during decluttering. Difficulties with memory include a lack of confidence in memory and the
overestimation of the importance of remembering or recording information which frequently provokes
people without HD to acquire newspapers, books and others. Together with information processing,
HD results in concerns like “if I forget something”, “if I will need some information”.
(2) problems in forming emotional attachments- Emotional attachment to possessions is shown in pure
sentimentality or in “safety signals” and a sign of a safe familiar environment.
(3) behavioral avoidance- Behavioral avoidance is probably caused by hoarders’ fear of making
mistakes and by avoidance of the emotional trauma associated with discarding of cherished possessions.
(4) erroneous beliefs about the nature of possessions- Beliefs about the nature of possessions and beliefs
about the necessity of maintaining control over possessions, beliefs about responsibility for possessions,
and beliefs about the necessity of perfection.
Many experimental and observational studies corroborate the observations provided in the Frost and
Hartl model of HD and emotional reactivity, intolerance of uncertainty, anxiety sensitivity and
impulsivity. The model has become a basis for classical cognitive-behavioral therapy (CBT) for HD,
whose efficacy has been established in clinical trials. The CBT protocol involves the stages of
psychoeducation and demystification of HD; improvement of decision-making and organisation skills;
exposure with response prevention; cognitive reconstruction; relapse prevention. This model can
explain why and how HD persist, but it does not fully explain how HD starts. Moreover, this model
does not address the idiosyncratic motivations for hoarding and does not describe the synergy between
components of the model.
Treatment
The treatment of Hoarding disorder is a difficult one because as stated earlier, people are not usually
aware that they are suffering from this disease. Since hoarding can create safety and health risks, harm
reduction forms the main focus of the treatment. Community approach involves the support of nurses,
social workers, organizers and support groups while individual treatment may follow psychotherapy
and medication approach. Group Cognitive behavioural therapy, which often involves the treatment of
hoarding, depression and anxiety due to their comorbidity, focuses on understanding why they do hoard
and what values they attach to the items. Two approaches are explained below-
1. ERP Therapy- Hoarding Disorder Treatment for hoarding is based on the ERP therapy that is
employed with OCD (Steketee & Frost, 2003). The exposure element of treatment focuses on the
most feared situation for people with hoarding disorder—getting rid of their objects. Response
prevention focuses on halting the rituals that they engage in to reduce their anxiety, such as
counting or sorting their possessions. Despite the common elements, treatment is tailored in many
ways for hoarding. Motivational strategies are used to help the person consider reasons to change.
Once people decide to change, therapists help them make decisions about their objects, provide
tools to help them get their clutter organized, and schedule sessions to work on “de-cluttering.”
The therapists supplement their office sessions with in-home visits.
In the first randomized controlled trial of this approach, patients who received CBT demonstrated
significantly more improvement than did those assigned to a waiting list (Steketee et al., 2010).
With 26 weeks of treatment, about 70 percent of patients showed at least modest improvement in
hoarding symptoms. Early cognitive behavioral interventions focused on helping clients discard
their objects as quickly as possible, hoping to avoid the quagmire of indecision and anxiety that
might come from too much focus on evaluating possessions. Unfortunately, patients tended to
drop out of treatment, and even those who did remain often showed little response (Abramowitz,
Franklin, Schwartz, et al., 2003; Mataix-Cols, Marks, Greist, et al., 2002).
2. Family - Family relationships are often profoundly damaged for those with hoarding disorder.
Relatives usually try various approaches to helping people rid their life of clutter, only to become
more and more frustrated and angry as those attempts fail. Many resort to coercive strategies,
including removing the hoarder’s possessions while the person is away—strategies that typically
create mistrust and animosity. Family approaches to hoarding begin by building rapport around
these difficult issues (Tompkins & Hartl, 2009). Rather than aiming for a total absence of clutter,
family members are urged to identify the aspects of hoarding and clutter that are most dangerous
for safety. They can use their concern regarding these issues to begin dialogue and set priorities
with the person with hoarding disorder.
FUNCTIONAL NEUROLOGICAL DISORDER:
Functional neurological disorders (FND) consist of somatic symptoms such as blackouts, paralysis and
abnormal movements that suggest the presence of an underlying neurological condition but none of the
symptoms are explained by diseases. FND is caused by a complex combination of biological,
psychological and social factors on the brain. People may experience partial or complete paralysis of
arms or legs; seizures and coordination disturbances; a sensation of prickling, tingling, or creeping on
the skin; insensitivity to pain; or anesthesia—the loss of sensation. Vision may be seriously impaired;
the person may become partially or completely blind or have tunnel vision, in which the visual field is
constricted as it would be if the person were peering through a tube. Aphonia, loss of the voice other
than whispered speech, and anosmia, loss of the sense of smell, can also occur.
This disorder has a long history, dating back to the earliest writings on mental disorders. Hysteria was
the term originally used to describe the disorder, which the Greek physician Hippocrates considered to
be an affliction limited to women and brought on by the wandering of the uterus through the body. (The
Greek word hystera means “womb”; the wandering uterus symbolized the longing of the woman’s body
for the production of a child.) Sigmund Freud popularized the term conversion (conversion hysteria)
who believed that the anxiety resulting from unconscious conflicts was “converted” into physical
symptoms which allowed individuals to release some anxiety without experiencing it. In DSM-5,
conversion disorder is given the subtitle ‘Functional Neurological Symptom Disorder’. Functional
Neurological Symptom refers to symptoms that result in absence of an organic cause. Most conversion
symptoms suggest that some kind of neurological disease is affecting the sensory-motor systems, but
no organic or physical malfunctioning is present. Conversion disorder is one of the most fascinating of
all mental disorders. How does one go blind when all visual processes are normal? How does one
experience paralysis of limbs when there is no neurological damage?
Proposed DSM-5 Criteria for Functional Neurological Disorder
l One or more neurologic symptoms affecting voluntary motor function, sensory function, cognition, or
seizure-like episodes.
2. The physical signs or diagnostic findings are internally inconsistent or incongruent with recognized
neurological disorder.
3.Symptoms cannot be explained by a medical condition.
4.Symptoms cause significant distress or functional impairment or warrant medical evaluation.
Specify symptom type: With weakness or paralysis, with abnormal movement, with swallowing
symptoms, with speech symptom, with attacks or seizures, with anesthesia or sensory loss, with special
sensory symptom, with mixed symptoms.
Specify if: Acute episode: Symptoms present for less than 6 months;Persistent: Symptoms occurring
for 6 months or more.
Specify if: With psychological stressor (specific stressor), Without psychological stressor.
Case Study: 23-year-old Naina was brought to the emergency department of a hospital. She reported
“suddenly passing out for a couple of seconds at work.” She stated that she woke up with blurred vision
that developed into loss of vision in both eyes. She also reported an inability to stand due to weakness
in her left leg. While in the emergency department, the patient described seeing only shadows. She
stated that she was generally in good health without significant medical issues or any history of chronic
medical conditions or surgeries, which was confirmed by her mother. She had no reported mental health
history and no history of stressful childhood experiences (i.e., abuse or neglect). Naina’s mother
reported that her daughter was in a lot of stress since the last couple of years. Her parents got her married
right after graduation. She wanted to study more but at that time her parents did not encourage. Her
marriage turned out to be extremely stressful as her husband would often get drunk and become abusive
towards her. She left her husband’s home one year after marriage and came back to live with her parent.
After facing significant financial difficulties, Naina finally found a job, but her difficulties were far
from over. Her husband sent her a divorce notice and she recently found out that she was pregnant. On
physical examination, the patient was alert, awake, and oriented to person, time, and place. On
neurological examination, her speech was normal, her pupils were slightly sluggish but reactive, she
was able to see light that was shined into her eyes, and she demonstrated a full range of eye movement,
but there was no visual acuity to hand motion or finger counts. She had some trouble lifting her left leg
off the bed but was able to walk with assistance. All tests came to be normal.
Symptoms of functional neurological disorder usually develop in adolescence or early adulthood,
typically after a major life stressor. An episode may end abruptly, but sooner or later the disorder is
likely to return, either in its original form or with a different symptom. The prevalence of functional
neurological disorder is less than 1 percent, and more women than men are given the diagnosis
(Faravelli, Salvatori, Galassi, et al., 1997). The disorder is more common among patients visiting
neurology clinics, where as many as 3 percent meet criteria for DSM-IV-TR conversion disorder (Fink,
Hansen, & Sondergaard, 2005). Patients with functional neurological disorder are highly likely to meet
criteria for another somatic symptom disorder (Brown et al., 2007), and about half meet criteria for a
dissociative disorder (Sar, Akyuz, Kundakci, et al., 2004). Other common comorbid disorders include
major depressive disorder, substance use disorders, and personality disorders (Brown et al., 2007).
Causal Factors:
Although it was earlier believed that there is a possibility of genetic influence in the causality of
conversion disorder, twin studies did not support this. There is a suggestion of overriding influence of
psychosocial factors.
Case: Anna O. was sitting at the bedside of her seriously ill father when she dropped off into a waking
dream. She saw a black snake come toward her sick father to bite him. She tried to ward it off, but her
arm had gone to sleep. When she looked at her hand, her fingers seemed to turn into little snakes with
death’s heads. The next day, when a bent branch recalled her hallucination of the snake, her right arm
became rigidly extended. After that, whenever some object revived her hallucination, her arm
responded in the same way—with rigid extension. Later, her symptoms extended to paralysis and
anesthesia of her entire right side. [Drawn from Breuer & Freud (1895/1982)]
Psychoanalytic Theory: Freud developed a psychoanalytical model of conversion disorder based on the
treatment of the classic case of Anna O (the famous classic case study of Anna O was first discussed in
Studies on Hysteria by Freud and Breur, 1895). He described four basic processes in the development
of conversion disorder. First, the person experiences an unconscious conflict. Second, since the conflict
is unacceptable the conflict and the resulting anxiety are repressed. Third, the anxiety continues to
increase and threatens to become conscious; the person uses the defense mechanisms to “convert” the
conflict into physical symptoms. This leads to reduced anxiety which is considered to be the primary
goal. Fourth, the person receives increased attention and sympathy from loved ones and may also evade
certain undesirable tasks. Studies have supported Freud’s explanation. Researches have concluded that
individuals with conversion disorder have experienced a traumatic event that must be escaped at all
costs. For instance, conversion symptoms such as paralysis of leg were very common in soldiers to
avoid the traumatizing combat situations during the World War period without being labeled as a
coward. In another study, it was found that most of the patients with conversion disorder had history of
traumatic incidents, including history of sexual abuse, recent parental divorce/death, and physical abuse.
Support for secondary gain comes from a study that found that adolescents with conversion symptoms
rated their mother as “overinvolved” or “overprotected”. This suggests that the conversion symptoms
may have been strongly attended to and reinforced.
Cognitive- These are forms of communication, providing a means for people to express emotions that
would otherwise be difficult to convey (Hallquist et al., 2010). Emotions being converted into physical
symptoms. They suggest that the purpose of the conversion is not to defend against anxiety but to
communicate extreme feelings- anger, fear, depression, guilt, jealousy- in a “physical language” that is
familiar and comfortable for the person with the disorder. People who find it particularly hard to
recognize or express their emotions are candidates for this illness. So are those who “know” the
language of physical symptoms through first hand experience with a genuine physical ailment. Because
children are less able to express their emotions verbally, they are particularly likely to develop physical
symptoms as a form of communication (Shaw et al., 2010).
Socio-cultural Perspective: Most Westerners believe it is inappropriate to produce or focus excessively
on somatic symptoms in response to personal distress, due to this, a part is included in DSM. Thus there
exists Some western bias- a bias that sees somatic reactions as an inferior way of dealing with emotion
(Moldavsky, 2004). This is a norm in many non-western cultures- socially and medically correct and
less stigmatizing- reaction to life stressors.
Over the past century there has been an apparent decrease in the incidence of conversion disorder, which
suggests a possible role for socio-cultural factors. The diagnosis of conversion has declined in western
societies such as US and England but has remained more common in countries that may place less
emphasis on ‘psychologizing” distress such as Libya, China and India. Rates of conversion symptoms
are higher in rural regions where medical knowledge is sparse. Growing medical sophistication and
increased awareness about the defensive function of a conversion symptom has been attributed to be
the reasons behind reduced incidence of conversion disorder.
Treatment:
Seek therapy as a last resort. If told psychological, go to another physician. Many focus on the causes
of the disorder (the trauma and anxiety) and apply insight, exposure and drug therapies- psychodynamic,
behavioral (exposure), anti-anxiety, anti-depressant. Others address physical symptoms rather than the
causes- suggestion, reinforcement, or confrontation. Family therapy is also helpful.
Patients with physical symptoms (gait disturbance, weakness, paralysis, dystonia, etc.) will often need
physical treatment. Allied health professionals including: speech pathologist, occupational therapists
and physiotherapists then becomes integral to the patient’s recovery process.
Generally, pharmacological therapy for FND is avoided when possible. In the clinical practice, their
use may not be welcomed by many patients due to: • Psychiatric stigma • Perception of addictive and
harmful properties • Side effects Nevertheless, antidepressants have demonstrated benefits even in those
who do not have comorbid mental disorders. Tricyclics are helpful in those with insomnia and pain.
Around one third of patients with FND have a comorbid psychiatric condition. Some patients
experience depression and anxiety as a result of having their functional symptoms. For others, a history
of trauma or adverse childhood experiences can make them vulnerable to developing 14 FND.
Psychologists and psychiatrists can assist in the management of comorbid mental health conditions and
in the treatment of FND. Cognitive behavioral therapy (CBT) is an evidenced based psychological
approach for treating FND. This can include exploring the symptoms and identifying behaviours and
cognitions (thoughts) that maintain or exacerbate the symptoms to increase the patient’s awareness of
their symptoms.
People with conversion disorder respond well to the cognitive-behavioral program. An essential
element and first in the line of treatment of conversion disorder is to identify the traumatic or stressful
life event. The event may be present in real or in the memory of the individual. For instance, in case of
Naina (see example), the traumatic incident was being in an abusive relationship with her husband, the
impending divorce and discovery of her pregnancy. Second, therapist must educate the family regarding
the role of secondary reinforcements such as attention and sympathy. Naina’s family must be educated
against reinforcing her conversion symptoms through excessive attention and concern. For instance, her
mother was advised against restricting Naina’s mobility because of her conversion blindness, instead
she should encourage Naina to carry activities of daily living with support from her family members.
A variety of other physical treatments have been gaining traction in their potential to help the treatment
of FND. Hypnosis and light sedation can transiently or sometimes permanently improve the posture of
a dystonic limb or help regain function of a paralysed limb. The procedure is video recorded and played
back to the patient to help them believe their condition can be reversed. Transcranial magnetic
stimulation (TMS) has been a recent interest in the treatment for functional movement disorders.
Biofeedback treatment for functional tremors use tactile and auditory external cueing for real time visual
feedback to help retrain the patient’s tremor frequency has also been trialed with promising results.
nbb
c) Dissociative Identity Disorder
• A person with dissociative identity disorder develops two or more distinct personalities, often
called subpersonalities, or alternate personalities, each with a unique set of memories, behaviors,
thoughts, and emotions.
• At any given time, one of the subpersonalities takes center stage and dominates the person’s
functioning. Usually one subpersonality, called the primary, or host, personality, appears more
often than the others.
• The transition from one subpersonality to another, called switching, is usually sudden and may be
dramatic (Barlow & Chu, 2014).
• Switching is usually triggered by a stressful event, although clinicians can also bring about the
change with hypnotic suggestion.
• Usually one personality is not aware of the exist- ence of the other(s), i.e. there are amnesic
barriers between the personalities. Both the onset and termina- tion of control of the each
personality is sudden.
• Classical examples in the published literature include ‘Three faces of Eve’ and ‘Sybil’.
• Trance and Possession Disorders
• Trance and possession disorders (possession hysteria) are characterised by the control of person’s
personality by a ‘spirit’, during the episodes. Usually the person is aware of the existence of the
other (i.e. ‘possessor’), unlike in multiple personality. This disorder is very commonly seen in
India and certain African countries.
• Other Dissociative Disorders
• Ganser’s syndrome (hysterical pseudodementia) is commonly found in prison inmates. The
characteristic feature is vorbeireden, which is also called as ‘approxi- mate answers’. The
answers are wrong but show that the person understands the nature of question asked. For
example; when asked the colour of a red pen, the patient calls it blue.
CLINCIAL DESCRIPTION
· According to the proposed DSM-5, a diagnosis of dissociative identity disorder (DID) requires
that a person have at least two separate personalities, or alters—different modes of being,
thinking, feeling, and acting that exist independently of one another and that emerge at different
times.
· Each determines the person’s nature and activities when it is in command. The primary alter may
be totally unaware that the other alters exist and may have no memory of what those other alters
do and experience when they are in control.
· Sometimes there is one primary personality, and this is typically the alter that seeks treatment.
Usually, there are two to four alters at the time a diagnosis is made, but over the course of
treatment others may emerge. The diagnosis also requires that the existence of different alters be
chronic; it cannot be a temporary change resulting from the ingestion of a drug, for example.
· Each alter may be quite complex, with its own behavior patterns, memories, and relation- ships.
Usually the personalities of the different alters are quite different from one another, even polar
opposites.
· Case reports have described alters who have different handedness, wear glasses with different
prescriptions, like different foods, and have allergies to different substances. The alters are all
aware of lost periods of time, and the voices of the others may sometimes echo in an alter’s
consciousness, even though the alter does not know to whom these voices belong.
· DID usually begins in childhood, but it is rarely diagnosed until adulthood. It is more severe and
extensive than the other dissociative disorders, and recovery may be less com- plete. It is much
more common in women than in men. Other diagnoses are often present, including posttraumatic
stress disorder, major depressive disorder, and somatic symptom disorders (Rodewald et al.,
2011). DID is commonly accompanied by other symptoms such as headaches, hallucinations,
suicide attempts, and self-injurious behavior, as well as by other dissociative symptoms such as
amnesia and depersonalization (Scroppo, Drob, Weinberger, et al., 1998).

DSM-5-
Diagnostic Criteria 300.14 (F44.81)
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).

• Most cases are first diagnosed in late adolescence or early adulthood, but more often than not, the
symptoms actually began in early childhood after episodes of trauma or abuse (often sexual
abuse) (Sar et al., 2014; Steele, 2011; Ross & Ness, 2010)
• Those who are aware, called coconscious subpersonalities, are “quiet observers” who watch the
actions and thoughts of the other subpersonalities but do not interact with them.
• Sometimes while another subpersonality is present, the coconscious personality makes itself
known through indirect means, such as auditory hallucinations (perhaps a voice giving
commands) or “automatic writing” (the current personality may find itself writing down words
over which it has no control).
• Earlier though 2-3 personalities. The average number of subpersonalities per patient is much
higher—15 for women and 8 for men (APA, 2000).
• There have been cases in which 100 or more subpersonalities were observed.
• Often the subpersonalities emerge in groups of 2 or 3 at a time.
• Subpersonalities often exhibit dramatically different characteristics.
• They may also have their own names and different identifying features, abilities and preferences,
and even physiological responses.

• Some researchers even argue that many or all cases are iatrogenic—that is, unintentionally
produced by practitioners (Lynn & Deming, 2010; Piper & Merskey, 2005, 2004).
• They believe that therapists create this disorder by subtly suggesting the existence of other
personalities during therapy or by explicitly asking a patient to produce different personalities
while under hypnosis.
• Some diagnosed in the office of the therapist/some already noticed.
• The number of people diagnosed with dissociative identity disorder increased dramatically in the
1980s and 1990s, only to decrease again over the past 15 years (Paris, 2012). Still there.
• 1 % of the population in the United States and other Western countries displays the disorder
(Dorahy et al, 2014).
•

Etiology of DID
· Almost all patients with DID report severe childhood abuse. There is also evidence that children
who are abused are at risk for developing dissociative symptoms, al- though whether these
symptoms reach diagnosable levels is not clear (Chu, 2000).
· There are two major theories of DID: the posttraumatic model and the sociocognitive model.
· Despite their confusing names, both theories actually suggest that severe physical or sexual abuse
during childhood sets the stage for DID.
· Since few people who are abused develop DID, both models focus on why some people do develop
DID after abuse.
The posttraumatic model
· proposes that some people are particularly likely to use dissocia- tion to cope with trauma, and this
is seen as a key factor in causing people to develop alters after trauma (Gleaves, 1996).
· There is evidence that children who dissociate are more likely to develop psychological symptoms
after trauma (Kisiel & Lyons, 2001). But because DID is so rare, no prospective studies have
focused on dissociative coping styles and the development of DID.
Psychodynamic- lifetime of excessive repression (Howell, 2011; Wang & Jiang, 2007).
· This continuous use of repression is motivated by traumatic childhood events, particularly abusive
parenting (Baker, 2010; Ross & Ness, 2010).
· Children who experience such traumas may come to fear the dangerous world they live in and take
flight from it by pretending to be another person who is looking on safely from afar.
· Abused children may also come to fear the impulses that they believe are the reasons for their
excessive punishments. Whenever they experience “bad” thoughts or impulses, they
unconsciously try to disown and deny them by assigning them to other personalities.
· Most report abuse, some do not (Ross & Ness, 2010).

The sociocognitive model

· considers DID to be the result of learning to enact social roles.
· According to this model, alters appear in response to suggestions by thera- pists, exposure to media
reports of DID, or other cultural influences (Lilienfeld, Lynn, Kirsch, et al., 1999; Spanos, 1994).
· An important implication of this model, then, is that DID could be created within therapy. This
does not mean, however, that DID is viewed as conscious decep- tion; the issue is not whether
DID is real but how it develops.
· A leading advocate of the idea that DID is basically a role-play suggests that people with histories
of trauma may be particularly likely to have a rich fantasy life, to have had considerable practice
at imagining they are other people, and to have a deep desire to please others (Spanos, 1994).
· Lilienfeld and colleagues (1999) note that many of the therapeutic techniques being used with DID
reinforce clients for identifying different alters; this researcher argues that repeated probing and
reinforcement for describing alters may promote these symptoms in vulnerable people.
· The clinical case of Elizabeth provides an extreme example of a therapist who unwittingly
encourages her client to adopt a diagnosis of DID when it isn’t justified by the symptoms. All of
the symptoms that Elizabeth described are common experiences; indeed, none of the symptoms
listed are actual diagnostic criteria for DID.
· According to this theory, people adopt the DID role when given suggestions by a therapist.
We will never have experimental evidence for either the posttraumatic model or the socio- cognitive
model, since it would be unethical to intentionally reinforce dissociative symptoms

Treatment- Treatment for this pattern is complex and difficult.

• Many patients distrust this final treatment goal, and their subpersonalities may see integration as
a form of death.
• Once the subpersonalities are integrated, further therapy is typically needed to maintain the
complete personality and to teach social and coping skills that may help prevent later
dissociations.
• Some report success, but others find that patients continue to resist full integration.
• A few therapists have questioned the need for full integration. ( SUMMARY)

· There seems to be widespread agreement on several principles in the treatment of dissociative

identity disorder, whatever the clinician’s orientation (Kluft, 1994; Ross, 1989).
· These include an empathic and gentle stance, with the goal of helping the client function as one
wholly integrated person.
· The goal of treatment should be to convince the person that splitting into different personalities is
no longer necessary to deal with traumas.
· In addition, as DID is conceptualized as a means of escaping from severe stress, treatment can
help teach the person more effective ways to cope with stress. Often, people with DID are
hospitalized to help them avoid self-harm and to begin the treatment in a more intensive fashion.
· Despite these common principles across treatment, there are important discrepancies across
approaches.
· Psychodynamic treatment is probably used more for DID and the other dissociative disorders than
for any other psychological disorders. The goal of this treatment is to overcome repressions
(MacGregor, 1996), as DID is believed to arise from traumatic events that the person is trying
to block from consciousness.
 · Unfortunately, some practitioners, particularly those who are drawing from a psychody- namic
conceptualization, use hypnosis as a means of helping patients diagnosed with dissocia- tive
disorders to gain access to repressed material (Putnam, 1993). DID patients are unusually
hypnotizable (Butler, Duran, Jasiukaitis, et al., 1996).
· Typically, the person is hypnotized and encouraged to go back in his or her mind to traumatic
events in childhood—a technique called age regression.
· The hope is that accessing these traumatic memories will allow the person to realize that childhood
threats are no longer present and that adult life need not be governed by these ghosts from the
past (Grinker & Spiegel, 1944).
· Treatment involving age regression and recovered memories, though, can actually worsen DID
symptoms (Fetkewicz, Sharma, & Merskey, 2000; Lilienfeld, 2007; Powell & Gee, 2000).
Because of the rarity of diagnosed cases of DID, there are no controlled studies of the results of
treatment. Most of the reports come from the clinical observations of one highly experienced
therapist, Richard Kluft (1994). The greater the number of alters, the longer the treatment lasted
(Putnam, Guroff, Silberman, et al., 1986). In general, therapy took almost 2 years and upwards
of 500 hours per patient.
Years after treatment started, Kluft (1994) reported that 84 percent of an original 123 patients had
achieved stable integration of alters and another 10 percent were at least functioning better. In a
different follow-up study of 12 patients, 6 patients achieved full integration of their alters within
a 10-year period (Coons & Bowman, 2001).
DID is often comorbid with anxiety and depression, which can sometimes be lessened with
antidepressant medications. These medications have no effect on the DID itself, however (Simon,
1998).

d) Disinhibited Social Engagement Disorder

Disinhibited social engagement disorder

● The diagnosis of disinhibited social engagement disorder is given when a child with a history of
trauma behaves in culturally inappropriate, overly familiar behavior with people who are relative
strangers.
● DSM-5 defines disinhibited social engagement disorder as “a pattern of behavior in which a child
actively approaches and interacts with unfamiliar adults.” (American Psychiatric Association,
2013).
● DSED is a trauma and stressor-related disorder,found in children who have experienced an abuse
pattern of social neglect during the first 2 years of life, repeated changes of primary caregivers,
or rearing in institutions with high child-to caregiver ratios. Consequently, such children are
significantly impaired in their ability to interact with other children and adults.

DSM-5 CRITERIA
A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults
and exhibits at least two of the following:
● Reduced or absent reticence in approaching and interacting with unfamiliar adults.
● Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and
with age-appropriate social boundaries).
● Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar
settings.
● Willingness to go off with an unfamiliar adult with little or no hesitation.
B. The behaviors in Criterion A are not limited to impulsivity (as in Attention-
Deficit/Hyperactivity Disorder) but include socially disinhibited behavior.
 C. The child has exhibited a pattern of extremes of insufficient care as evidenced by at least one of
the following:
● Social neglect or deprivation in the form of persistent lack of having basic emotional needs for
comfort, stimulation and affection met by caregiving adults.
● Repeated changes of primary caregivers that limit ability to form stable attachments (e.g., frequent
changes in foster care).
● Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g.,
institutions with high child to caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A
(e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
E. The child has a developmental age of at least nine months.
Specify if Persistent: The disorder has been present for more than 12 months.
Specify current severity: Disinhibited Social Engagement Disorder is specified as severe when a child
exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

RISK FACTORS:
● Although any seriously neglected child can show symptoms of disinhibited social engagement
disorder, it is most common among children who spend infancy in an institution (not all
institutionalised though, the Institutionalised children who are often cared for inconsistently and
do not have the opportunity to develop healthy attachments (McLaughlin, Epsie & Minnis, 2010).
The quality of attachment is specifically related to this disorder.
● Researchers conducting a longitudinal study of previously institutionalised Romanian
children found these children developed as indiscriminately social/disinhibited children during
early infancy as a result of poor caregiving. Their disorders did not improve, even when the
quality of their caregiving improved.
● In noninstitutionalized children, parental adjustment problems are the most prevalent risk factors.
Examples include poverty, teen parenting, substance abuse and mental health issues such as a
depression or personality disorder that affect the parent’s ability to form an attachment with the
child (Oliveira, et al, 2013).

Social Concerns
● According to the DSM-5, “DSED significantly impairs young children’s abilities to relate
interpersonally to adults and peers.” (American Psychiatric Association, 2013). This is because
both adults and children are put-off by verbal and behavioural over-familiarity. For example, a
child with disinhibited social engagement disorder may sit on the lap of a stranger, which creates
a very uncomfortable situation for the adult.
● Adolescents with DSED extend this familiarity to peers, creating awkward social situations.
● Caregivers of children with this disorder often experience anxiety and fear that the child’s
behavior will put him or her in a dangerous situation by behaving too comfortably with strangers.
They also feel frustrated that the child is not developing an appropriate attachment (Oliveira, et
al, 2013).
● Many experts believe that during adulthood developmental milestones are reached, symptoms
lessen although indiscriminate friendliness may persist. Possibility for diminished
symptoms- this disorder could be used as an adaptive mechanism used to elicit care from
potential caregivers. As this need diminishes, so do the symptoms (Minnis, Fleming & Cooper,
2010).
Treatment
● An integrative approach to psychotherapy is the most effective way to treat this. The therapy must
facilitate multisensory experiences, communication, social skills, emotional awareness and self-
exploration (Malchiodi & Crenshaw, 2013).
● Establishing a therapeutic relationship is more challenging because children with disinhibited
social engagement disorder only develop shallow, superficial attachments.
● Play therapy and creative arts therapy are two effective approaches for treating DSED as they are
interactive and experiential (Malchiodi & Crenshaw, 2013).
- Play therapy: through this children get a chance to naturally develop attachments that did not
occur during early infancy.In many cases, the primary caregiver is invited to join the play
therapy sessions, so that the new attachment can extend beyond the therapist.
- Creative arts therapy uses painting, drawing, dance, music and theatrical activities as a means
of carrying out psychotherapy.
- Infants develop healthy attachments to parents and primary caregivers through their five
senses. Being held, fed, and talked to, for example, are important components of attachment
development. These needs don’t disappear with age. Children, teens, and adults experience
relationships through hugging, touching, story-telling, and eating together. Both play
therapy and creative arts therapy provide sensory experiences. Also since both are
nonverbal approaches, they are more efficient as young children are not always willing/
able to verbally discuss trauma, thoughts, and feelings (Malchiodi & Crenshaw, 2013).