Notes on Dissociative Disorders

Prepared By: Prince Rener V. Pera, RN

(Instructor’s Notes)

Dissociative Disorders
- According to the text revision of the fourth edition of the DSM, the essential feature of the
dissociative disorders is a disruption in the usually integrated functions of consciousness,
memory, identity, or perception of the environment. The disturbance may be sudden or gradual,
transient or chronic.

Dissociative Amnesia
- The essential feature of dissociative amnesia is an inability to recall important personal
information, usually of a traumatic or stressful nature, that is too extensive to be explained by
normal forgetfulness.
- This disturbance can be based on neurobiological changes in the brain caused by traumatic
stress.
- It has been reported in approximately 6 percent of the general population. No known difference
is seen in incidence between men and women. Cases generally begin to be reported in late
adolescence and adulthood.

Psych Notes Prepared By: Prince Rener Velasco Pera, RN

Etiology
1. Amnesia and Extreme Intrapsychic Conflict- In many cases of acute dissociative amnesia, the
psychosocial environment out of which the amnesia develops is massively conflictual, with the
patient experiencing intolerable emotions of shame, guilt, despair, rage, and desperation. These
usually result from conflicts over unacceptable urges or impulses, such as intense sexual,
suicidal, or violent compulsions.
2. Betrayal Trauma- attempts to explain amnesia by the intensity of trauma and by the extent that
a negative event represents a betrayal by a trusted, needed other. This betrayal is thought to
influence the way in which the event is processed and remembered. Information about the
abuse is not linked to mental mechanisms that control attachment and attachment behavior.

Diagnosis and Clinical Features

DSM-IV-TR Diagnostic Criteria for Dissociative Amnesia
A. The predominant disturbance is one or more episodes of inability to recall important personal
information, usually of a traumatic or stressful nature, that is too extensive to be explained by
ordinary forgetfulness.
B. The disturbance does not occur exclusively during the course of dissociative identity disorder,
dissociative fugue, posttraumatic stress disorder, acute stress disorder, or somatization disorder
and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a neurological or other general medical condition (e.g., amnestic disorder due to
head trauma).
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

Course and Prognosis

- Frequently spontaneously resolves once the person is removed to safety from traumatic or
overwhelming circumstances. At the other extreme, some patients do develop chronic forms of
generalized, continuous, or severe localized amnesia and are profoundly disabled and require
high levels of social support, such as nursing home placement or intensive family caretaking.

Treatment
- Cognitive therapy may identifies the specific cognitive distortions that are based in the trauma
may provide an entrance into autobiographical memory for which the patient experiences
amnesia.

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- Hypnosis can be used in a number of different ways in the treatment of dissociative amnesia. In
particular, hypnotic interventions can be used to contain, modulate, and titrate the intensity of
symptoms; to facilitate controlled recall of dissociated memories; to provide support and ego
strengthening for the patient; and, finally, to promote working through and integration of
dissociated material.
- Somatic Therapies- A variety of agents have been used for this purpose, including sodium
amobarbital, thiopental (Pentothal), oral benzodiazepines, and amphetamines.

Depersonalization Disorder
- The essential feature of depersonalization as the persistent or recurrent feeling of detachment
or estrangement from one's self. The individual may report feeling like an automaton or as if in a
dream or watching himself or herself in a movie.
- There may be a sensation of being an outside observer of one's mental processes, one's body, or
parts of one's body. Often, the patient has a sense of an absence of control over his or her
actions.

Epidemiology
- Transient experiences of depersonalization and derealization are extremely common in normal
and clinical populations. They are the third most commonly reported psychiatric symptoms,

Psych Notes Prepared By: Prince Rener Velasco Pera, RN

after depression and anxiety.
- It is common in seizure patients and migraine sufferers; they can also occur with use of
psychedelic drugs, especially marijuana, lysergic acid diethylamide (LSD), and mescaline; and
less frequently as a side effect of some medications, such as anticholinergic agents.
- They have been described after certain types of meditation, deep hypnosis, extended mirror or
crystal gazing, and sensory deprivation experiences.
- Depersonalization is found two to four times more in women than in men.

Etiology
1. Psychodynamic
- Traditional psychodynamic formulations have emphasized the disintegration of the ego or have
viewed depersonalization as an affective response in defense of the ego. These explanations
stress the role of overwhelming painful experiences or conflictual impulses as triggering events.
2. Traumatic Stress
- A substantial proportion, typically one third to one half, of patients in clinical depersonalization
case series report histories of significant trauma.
Several studies of accident victims find as much as 60 percent of those with a life-threatening
experience report at least transient depersonalization during the event or immediately
thereafter.
3. Neurobiological Theories
- The association of depersonalization with migraines and marijuana, its generally favorable
response to selective serotonin reuptake inhibitor (SSRI) drugs, and the increase in
depersonalization symptoms seen with the depletion of L-tryptophan, a serotonin precursor,
point to serotoninergic involvement.

DSM-IV-TR Diagnostic Criteria for Depersonalization Disorder

A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside
observer of, one's mental processes or body (e.g., feeling like one is in a dream).
B. During the depersonalization experience, reality testing remains intact.
C. The depersonalization causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The depersonalization experience does not occur exclusively during the course of another
mental disorder, such as schizophrenia, panic disorder, acute stress disorder, or another
dissociative disorder, and is not due to the direct physiological effects of a substance (e.g., a

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drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).

Diagnosis and Clinical Features

- A number of distinct components comprise the experience of depersonalization, including a
sense of:
a) bodily changes
b) duality of self as observer and actor
c) being cut off from others
d) being cut off from one's own emotions.

Differential Diagnosis
- A thorough medical and neurological evaluation is essential, including standard laboratory
studies, an EEG, and any indicated drug screens.

Treatment
- Some systematic evidence indicates that SSRI antidepressants, such as fluoxetine (Prozac), may
be helpful to patients with depersonalization disorder.

Dissociative Fugue
- The essential feature of dissociative fugue is described as sudden, unexpected travel away from

Psych Notes Prepared By: Prince Rener Velasco Pera, RN

home or one's customary place of daily activities, with inability to recall some or all of one's
past.
- This is accompanied by confusion about personal identity or even the assumption of a new
identity. The disturbance does not occur exclusively during the course of dissociative identity
disorder and is not due to the direct physiological effects of a substance or a general medical
condition.

Etiology
- Traumatic circumstances (i.e., combat, rape, recurrent childhood sexual abuse, massive social
dislocations, natural disasters), leading to an altered state of consciousness dominated by a wish
to flee, are the underlying cause of most fugue episodes.
DSM-IV-TR Diagnostic Criteria for Dissociative Fugue
A. The predominant disturbance is sudden, unexpected travel away from home or one's customary
place of work, with inability to recall one's past.
B. Confusion about personal identity or assumption of a new identity (partial or complete).
C. The disturbance does not occur exclusively during the course of dissociative identity disorder
and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., temporal lobe epilepsy).
D. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

Epidemiology
- The disorder is thought to be more common during natural disasters, wartime, or times of major
social dislocation and violence, although no systematic data exist on this point.
- Most cases describe men, primarily in the military. Dissociative fugue is usually described in
adults.

Differential Diagnosis
- Individuals with dissociative amnesia may engage in confused wandering during an amnesia
episode. In dissociative fugue, however, there is purposeful travel away from the individual's
home or customary place of daily activities, usually with the individual preoccupied by a single
idea that is accompanied by a wish to run away.

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- Patients with dissociative identity disorder may have symptoms of dissociative fugue, usually
recurrently throughout their lives. Patients with dissociative identity disorder have multiple
forms of complex amnesias and, usually, multiple alter identities that develop, starting in
childhood.

Course and Prognosis

- Most fugues are relatively brief, lasting from hours to days. Most individuals appear to recover,
although refractory dissociative amnesia may persist in rare cases. Some studies have described
recurrent fugues in most individuals presenting with an episode of dissociative fugue. No
systematic modern data exist that attempt to differentiate dissociative fugue from dissociative
identity disorder with recurrent fugues.
Treatment
- Dissociative fugue is usually treated with an eclectic, psychodynamically oriented psychotherapy
that focuses on helping the patient recover memory for identity and recent experience.
Hypnotherapy and pharmacologically facilitated interviews are frequently necessary adjunctive
techniques to assist with memory recovery. Patients may need medical treatment for injuries
sustained during the fugue, food, and sleep.
- When dissociative fugue involves assumption of a new identity, it is useful to conceptualize this
entity as psychologically vital to protecting the person. Traumatic experiences, memories,
cognitions, identifications, emotions, strivings, or self-perceptions, or a combination of these,

Psych Notes Prepared By: Prince Rener Velasco Pera, RN

have become so conflicting and, yet, so peremptory that the person can resolve them only by
embodying them in an alter identity.

Dissociative Identity Disorder

- Previously called multiple personality disorder, is characterized by the presence of two or more
distinct identities or personality states that recurrently take control of the individual's behavior
accompanied by an inability to recall important personal information that is too extensive to be
explained by ordinary forgetfulness.
- The identities or personality states, sometimes called alters, self-states, alter identities, or parts,
among other terms, differ from one another in that each presents as having its own relatively
enduring pattern of perceiving, relating to, and thinking about the environment and self.

Epidemiology
- Few systematic epidemiological data exist for dissociative identity disorder. Clinical studies
report female to male ratios between 5 to 1 and 9 to 1 for diagnosed cases.
Etiology
- Dissociative identity disorder is strongly linked to severe experiences of early childhood trauma,
usually maltreatment. The rates of reported severe childhood trauma for child and adult
patients with dissociative identity disorder range from 85 to 97 percent of cases. Physical and
sexual abuse are the most frequently reported sources of childhood trauma. The contribution of
genetic factors is only now being systematically assessed, but preliminary studies have not
found evidence of a significant genetic contribution.

Diagnosis and Clinical Features

Dimensions of Trauma
- A number of common dimensions underlie traumatic sequelae. Affect modulation is frequently
disturbed, giving rise to mood swings, depression, suicidal tendency, and generalized irritability.
Impulse control is often impaired, leading to risk-taking, substance abuse, and inappropriate or
self-destructive behaviors. High levels of anxiety and panic are common.
- Childhood sexual abuse survivors with psychophysiological disorders are more likely to have a
lower threshold for experiencing physiological phenomena as noxious or painful.
DSM-IV-TR Diagnostic Criteria for Dissociative Identity Disorder
A. The presence of two or more distinct identities or personality states (each with its own relatively

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enduring pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the person's
behavior.
C. Inability to recall important personal information that is too extensive to be explained by
ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or
chaotic behavior during alcohol intoxication) or a general medical condition (e.g., complex
partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or
other fantasy play.

Memory and Amnesia Symptoms

- Dissociative disturbances of memory are manifest in several basic ways and are frequently
observable in clinical settings. As part of the general mental status examination, clinicians should
routinely inquire about experiences of losing time, black-out spells, and major gaps in the
continuity of recall for personal information. Dissociative time loss experiences are too extensive
to be explained by normal forgetting and typically have sharply demarcated onsets and offsets.

Mental status examination questions for dissociative amnesia

   If answers are positive, ask the patient to describe the event.
   Make sure to specify that the symptom does not occur during an episode of intoxication.

Psych Notes Prepared By: Prince Rener Velasco Pera, RN

1. Do you ever have blackouts? Blank spells? Memory lapses?
2. Do you lose time? Have gaps in your experience of time?
3. Have you ever traveled a considerable distance without recollection of how you did this or
where you went exactly?
4. Do people tell you of things you have said and done that you do not recall?
5. Do you find objects in your possession (such as clothes, personal items, groceries in your grocery
cart, books, tools, equipment, jewelry, vehicles, weapons, and so on) that you do not remember
acquiring? Out-of-character items? Items that a child might have? Toys? Stuffed animals?
6. Have you ever been told or found evidence that you have talents and abilities that you did not
know that you had? For example, musical, artistic, mechanical, literary, athletic, or other
talents? Do your tastes seem to fluctuate a lot? For example, food preference, personal habits,
taste in music or clothes, and so forth.
7. Do you have gaps in your memory of your life? Are you missing parts of your memory for your
life history? Are you missing memories of some important events in your life? For example,
weddings, birthdays, graduations, pregnancies, birth of children, and so on.
8. Do you lose track of or tune out conversations or therapy sessions as they are occurring? Do you
find that, while you are listening to someone talk, you did not hear all or part of what was just
said?
9. What is the longest period of time that you have lost? Minutes? Hours? Days? Weeks? Months?
Years? Describe.

Course and Prognosis

- Little is known about the natural history of untreated dissociative identity disorder. Some
individuals with untreated dissociative identity disorder are thought to continue involvement in
abusive relationships or violent subcultures, or both, that may result in the traumatization of
their children, with the potential for additional family transmission of the disorder.
- Prognosis is poorer in patients with comorbid organic mental disorders, psychotic disorders (not
dissociative identity disorder pseudopsychosis), and severe medical illnesses.

Treatment
1. Psychotherapy
- These modalities include psychoanalytic psychotherapy, cognitive therapy, behavioral therapy,
hypnotherapy, and a familiarity with the psychotherapy and psychopharmacological
management of the traumatized patient.

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- Comfort with family treatment and systems theory is helpful in working with a patient who
subjectively experiences himself or herself as a complex system of selves with alliances, family-
like relationships, and intragroup conflict.
2. Hypnosis
- Can often alleviate self-destructive impulses or reduce symptoms, such as flashbacks,
dissociative hallucinations, and passive-influence experiences. Hypnosis can be useful for
accessing specific alter personality states and their sequestered affects and memories.
- Hypnosis is also used to create relaxed mental states in which negative life events can be
examined without overwhelming anxiety.
3. Psychopharmacological Interventions
- Antidepressant medications are often important in the reduction of depression and stabilization
of mood.
- Clinicians report some success with SSRI, tricyclic, and monamine oxidase (MAO)
antidepressants, β-blockers, clonidine (Catapres), anticonvulsants, and benzodiazepines in
reducing intrusive symptoms, hyperarousal, and anxiety in patients with dissociative identity
disorder.
- Open-label studies suggest that naltrexone (ReVia) may be helpful for amelioration of recurrent
self-injurious behaviors in a subset of traumatized patients.
4. Electroconvulsive Therapy

Psych Notes Prepared By: Prince Rener Velasco Pera, RN

- Helpful in ameliorating refractory mood disorders and does not worsen dissociative memory
problems. This response is usually only partial, however, as is typical for most successful somatic
treatments in the dissociative identity disorder population.

Brainwashing
- States of dissociation that occur in individuals who have been subjected to periods of prolonged
and intense coercive persuasion (e.g., brainwashing, thought reform, or indoctrination while
captive). Persons submitted to such conditions can undergo considerable harm, including loss of
health and life, and they typically manifest a variety of posttraumatic and dissociative
symptoms.

Ganser Syndrome
- A poorly understood condition characterized by the giving of approximate answers (paralogia)
together with a clouding of consciousness, and frequently accompanied by hallucinations and
other dissociative, somatoform, or conversion symptoms.

Epidemiology
- Men outnumber women by approximately 2 to 1.

Etiology
- Some case reports identify precipitating stressors, such as personal conflicts and financial
reverses, whereas others note organic brain syndromes, head injuries, seizures, and medical or
psychiatric illness. Psychodynamic explanations are common in the older literature, but organic
etiologies are stressed in more recent case studies. It is speculated that the organic insults may
act as acute stressors, precipitating the syndrome in vulnerable individuals. Some patients have
reported significant histories of childhood maltreatment and adversity.

Diagnosis and Clinical Features

- The symptom of passing over (vorbeigehen) the correct answer for a related, but incorrect one,
is the hallmark of Ganser syndrome. The approximate answers often just miss the mark but bear
an obvious relation to the question, indicating that it has been understood. When asked how old
she was, a 25-year-old woman answered, I'm not five. If asked to do simple calculations (e.g., 2
+ 2 = 5); for general information (the capital of the United States is New York); to identify simple

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objects (a pencil is a key); or to name colors (green is gray), the patient with Ganser syndrome
gives erroneous but comprehensible answers.
- A clouding of consciousness also occurs, usually manifest by disorientation, amnesias, loss of
personal information, and some impairment of reality testing. Visual and auditory hallucinations
occur in roughly one half of the cases.
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Treatment
- Confrontation or interpretations of the patient's approximate answers are not productive, but
exploration of possible stressors may be helpful.
- Hypnosis and amobarbital narcosynthesis have also been used successfully to help patients
reveal the underlying stressors that preceded the development of the syndrome, with
concomitant cessation of the Ganser symptoms.

“If you remain in Me and My words remain in you.

Ask whatever you wish and it will be given to you”
John 15:7

Psych Notes Prepared By: Prince Rener Velasco Pera, RN