15 dissociative disorders

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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,

Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org1

Slide show includes

Topic Headings

Tables and Figures

Key Points

Dissociative DisordersJos R. Maldonado, M.D., F.A.P.M., F.A.C.F.E.,

David Spiegel, M.D.

The American Psychiatric Publishing

TEXTBOOK OF PSYCHIATRYFifth EditionEdited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.

2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org

CHAPTER 15


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CHAPTER 15 Topic Headings

DEVELOPMENT OF THE CONCEPT

MODELS AND MECHANISMS OF DISSOCIATION

Dissociation and Information Processing

Dissociation and Memory Systems

Dissociation and Trauma

Universality and Transcultural Aspects of

Dissociation

ACUTE STRESS DISORDER

DISSOCIATIVE AMNESIA

TreatmentDISSOCIATIVE FUGUE

DEPERSONALIZATION DISORDER

Treatment

DISSOCIATIVE IDENTITY DISORDER

(MULTIPLE PERSONALITY DISORDER)

Prevalence

Course

Comorbidity

Genetics

Psychological TestingPhysiological Measures

Treatment

Psychotherapy

Cognitive-Behavioral Approaches

Psychopharmacology

OtherTherapeutic Approaches

Legal Aspects of Memory Work and Hypnosis

Recall

DISSOCIATIVE TRANCE DISORDERCultural Context

Classification

Dissociative Trance

Possession Trance

Treatment

DISSOCIATIVE DISORDERCONVERSION TYPE?

CONCLUSION


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CHAPTER 15 Tables and Figures

Table 151. DSM-IV-TR dissociative disorders

Table 152. Differences between dissociation and repression

Figure 151. Hippocampal and amygdalar volumes in patients with dissociative identity disorder

(DID) and healthy comparison subjects.

Table 153. DSM-IV-TR diagnostic criteria for acute stress disorder

Table 154. DSM-IV-TR diagnostic criteria for dissociative amnesia

Table 155. DSM-IV-TR diagnostic criteria for dissociative fugue

Table 156. DSM-IV-T

R diagnostic criteria for depersonalization disorderTable 157. DSM-IV-TR diagnostic criteria for dissociative identity disorder

Table 158. Rules of engagement in the treatment of dissociative identity disorder

Table 159. Guidelines for the use of hypnosis in memory work

Table 1510. DSM-IV-TR research criteria for dissociative trance disorder

Table 1511. Comparison of Western and Eastern types of dissociative syndromes

Summary Key Points


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TABLE 151. DSM-IV-TR dissociative disorders

The dissociative disorders involve a disturbance in the integrated organization of identity, memory,

perception, or consciousness. Events normally experienced on a smooth continuum are isolated from

the other mental processes with which they would ordinarily be associated (Table 151).


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TABLE 152. Differences between dissociation and repression

Repression as a general model for keeping information out of conscious awareness differs from dissociation

in six important ways (Table 152).


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FIGURE 151. Hippocampal

and amygdalar volumes in

patients with dissociative

identity disorder (DID) and

healthy comparison subjects.

There is recent evidence of a possible

neural basis for the difficulty

integrating traumatic memory and

components of identity and

consciousness among those with

dissociative disorders. Using magneticresonance imaging, Vermetten et al.

(2006) found that hippocampal and

amygdalar volumes were significantly

smaller (19% and 32%, respectively) in

patients diagnosed with dissociative

identity disorder compared with

healthy volunteers (Figure 151).

aSignificant difference between groups (P< 0.05, ttest for

nonpaired samples).

Source. Reprinted from Vermetten E, Schmahl C, Lindner S,

et al: Hippocampal and Amygdalar Volumes in Dissociative

Identity Disorder. American Journal of Psychiatry163:630636,

2006. Copyright 2006. Used with permission.


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TABLE 153. DSM-IV-TR diagnostic criteria for acute stress disorder

Although acute stress disorder is classified among the anxiety disorders in DSM-IV-TR, we address it

here because half of the symptoms of this disorder are dissociative in nature (Table 153).


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TABLE 155. DSM-IV-TR diagnostic criteria for dissociative fugue

Dissociative fugue combines failure of integration of certain aspects of personal memory with

loss of customary identity and automatisms of motor behavior (Table 155).


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TABLE 156. DSM-IV-TR diagnostic criteria for depersonalization disorder

The essential feature of depersonalization disorder is the occurrence of persistent feelings of

unreality, detachment, or estrangement from oneself or ones body, usually with the feeling that one is

an outside observer of ones own mental processes. Thus, depersonalization disorder is primarily a

disturbance in the integration of perceptual experience (Table 156).


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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org

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TABLE 157. DSM-IV-TR diagnostic criteria for dissociative identity disorder

The number of reported dissociative identity disorder cases has risen considerably in recent years.

Factors that may account for this increase include a more general awareness of the diagnosis among

mental health professionals; the availability, starting with DSM-III (American Psychiatric Association

1980), of specific diagnostic criteria (Table 157); and reduced misdiagnosis of DID as schizophrenia

or borderline personality disorder.


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TABLE 158. Rules of engagement

in the treatment of dissociative

identity disorder

Maldonado (2000) described a series of

rules of engagement (Table 158) to be

used in the treatment of dissociative

identity disorder.


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TABLE 159. Guidelines for the use

of hypnosis in memory work

Maldonado (2000) summarized and

adapted the guidelines provided by the

American Medical Association (Orne et

al. 1985) and the American Society of

Clinical Hypnosis (Hammond et al. 1995)

for the use of hypnosis as a method ofmemory enhancement (Table 159).

(continued)


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TABLE 159. (continued)


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TABLE 1510. DSM-IV-TR research criteria for dissociative trance disorder

The DSM-IV Task Force voted to include dissociative trance disorder in an appendix to DSM-IV to

stimulate further research on the question of whether it should be a separate Axis I disorder rather than

an example in the category of dissociative disorders not otherwise specified (Table 1510).


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TABLE 1511. Comparison of Western and Eastern types of dissociative syndromes

Dissociative trance disorder has been divided into two broad categories: dissociative trance and

possession trance (Table 1511).


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CHAPTER 15 Key Points

Dissociative disorders are underdiagnosed.

Dissociation is a common component of acute response to trauma, anddissociative fugue, amnesia, and identity disorders often have a traumatic

etiology.

Dissociation represents a failure of integration of identity, memory,

perception, and consciousness.

The primary treatments for dissociative disorders involve various

psychotherapies, including hypnosis, trauma-related psychotherapies, andcognitive therapies.

Common comorbid conditions requiring treatment include depression,

substance use disorders, and borderline personality disorder.

Dissociative symptoms are ubiquitous around the world, but the content of

the dissociative symptoms varies, involving possession by external entities

more often in the East, and fragmentation of individual identity in the West.

15 dissociative disorders

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