Dissociative disorder

Dissociative Identity disorders

• 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 ob- served by
others or reported by the individual.

• Recurrent gaps in the recall of everyday events, important personal information, and/ or traumatic events that are inconsistent with ordinary
forgetting.

• The symptoms cause clinically signi cant distress or impairment in social, occupational, or other important areas of functioning.

• 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.

• 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).

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Dissociative Amnesia
Diagnostic Criteria 300.12 (F44.0)
• 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 speci c event or events; or generalized amnesia for identity and life history.

• The symptoms cause clinically signi cant distress or impairment in social, occupational, or other important areas of functioning.

• 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).

• 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.

Coding note: The code for dissociative amnesia without dissociative fugue is 300.12 (F44.0). The code for dissociative amnesia with dissociative fugue is 300.13 (F44.1).
Specify if:
300.13 (F44.1) With dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobio- graphical
information.
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Localized amnesia, a failure to recall events during a circumscribed period of time, is the most common form of dissociative amnesia.
Localized amnesia may be broader than am- nesia for a single traumatic event (e.g., months or years associated with child abuse or in-
tense combat). In selective amnesia, the individual can recall some, but not all, of the events during a circumscribed period of time. Thus,
the individual may remember part of a traumatic event but not other parts. Some individuals report both localized and selective amnesias.
Generalized amnesia, a complete loss of memory for one’s life history, is rare. Individuals with generalized amnesia may forget personal
identity. Some lose previous knowledge about the world (i.e., semantic knowledge) and can no longer access well-learned skills (i.e.,
procedural knowledge).
Dissociative Amnesia
Generalized amnesia has an acute onset; the perplexity, disorientation, and purposeless wandering of individuals with generalized
amnesia usually bring them to the attention of the police or psychiatric emergency services. Generalized amnesia may be more common
among combat veterans, sexual assault victims, and indi- viduals experiencing extreme emotional stress or con ict.
Individuals with dissociative amnesia are frequently unaware (or only partially aware) of their memory problems. Many, especially those
with localized amnesia, minimize the importance of their memory loss and may become uncomfortable when prompted to ad- dress it. In
systematized amnesia, the individual loses memory for a speci c category of in- formation (e.g., all memories relating to one’s family, a
particular person, or childhood sexual abuse). In continuous amnesia, an individual forgets each new event as it occur
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Depersonalization/Derealization Disorder
Diagnostic Criteria 300.6 (F48.1)
• 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 surround- ings (e.g., individuals or objects are
experienced as unreal, dreamlike, foggy, life- less, or visually distorted).
• During the depersonalization or derealization experiences,reality testing remains intact.
• The symptoms cause clinically signi cant distress or impairment in social, occupational, or other important areas of functioning.
• 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).

• The disturbance is not better explained by another mental disorder, such as schizo- phrenia, panic disorder, major depressive
disorder, acute stress disorder, posttrau-
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Typically the treatment for DID is psychodynamic and insight-oriented, focused on uncovering and working through the trauma and other con icts that
are thought to have led to the disorder (Kihlstrom, 2005). One of the primary tech- niques used in most treatments of DID is hypnosis (e.g., Kluft, 1993;
Maldonado & Spiegel, 2007; Maldonado et al., 2002). Most DID patients are hypnotizable and when hypno- tized are often able to recover past
unconscious and frequently traumatic memories, often from childhood. Then these mem- ories can be processed, and the patient can become aware that
the dangers once present are no longer there.
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. Clearly,
successful negotiation of this critical phase of treatment requires therapeutic skills of the highest order; that is, the therapist must be strongly committed
as well as professionally competent.
For DID patients, most current therapeutic approaches are based on the assumption of posttraumatic theory that the disor- der was caused by abuse
(Kihlstrom, 2005). Most therapists set integration of the previously separate alters, together with their collective merging into the host personality, as the
ultimate goal of treatment (e.g., Maldonado & Spiegel, 2007). There is often considerable resistance to this process by the DID patients, who often
consider dissociation as a protective device.If successful integration occurs, the patient eventually develops a uni ed personality, although it is not
uncommon for only partial integration to be achieved. But it is also very important to assess whether improve- ment in other symptoms of DID and
associated disorders has occurred. Indeed, it seems that treatment is more likely to produce symptom improvement, as well as associated improvements
in functioning, than to achieve full and stable integration of the different alter identities.

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Somatic related disorders

Somatic Symptom Disorder

Diagnostic Criteria 300.82
• One or more somatic symptoms that are distressing or result in signi cant disruption of daily life.

• Excessivethoughts,feelings,orbehaviorsrelatedtothesomaticsymptomsorassoci- ated health concerns as manifested by at least one of the following:

1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms. 2. Persistentlyhighlevelofanxietyabouthealthorsymptoms.
3. Excessivetimeandenergydevotedtothesesymptomsorhealthconcerns.
C. Although any one somatic symptom may not be continuously present, the state of be- ing symptomatic is persistent (typically more than 6 months).
Specify if:
With predominant pain (previously pain disorder): This speci er is for individuals whose somatic symptoms predominantly involve pain.
Specify if:
Persistent: A persistent course is characterized by severe symptoms, marked impair- ment, and long duration (more than 6 months).
Specify current severity:
Mild: Only one of the symptoms speci ed in Criterion B is ful lled.
Moderate: Two or more of the symptoms speci ed in Criterion B are ful lled. Severe: Two or more of the symptoms speci ed in Criterion B are ful lled, plus there are
multiple somatic complaints (or one very severe somatic symptom).
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Illness Anxiety Disorder

Diagnostic Criteria 300.7
• Preoccupation with having or acquiring a serious illness.
• 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
dispro- portionate.
• There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
• 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
doc- tor appointments and hospitals).
• Illness preoccupation has been present for at least 6 months, but the speci c illness that is feared may change over that period of time.
• Theillness-relatedpreoccupationisnotbetterexplainedbyanothermentaldisorder,such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body
dysmor- phic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.

Specify whether:
Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used.
Care-avoidant type: Medical care is rarely used.
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Treatrment of somatic disorder

cognitive-behavioral techniques have been widely used in the treatment of both physical and more
psychological pain syndromes. Treat- ment programs generally include relaxation training, support
and validation that the pain is real, scheduling of daily activi- ties, cognitive restructuring, and
reinforcement of “no-pain” behaviors (Simon, 2002). Patients receiving such treatments tend to show
substantial reductions in disability and distress, although changes in the intensity of their pain tend to
be smaller in magnitude. In addition, antidepressant medications (especially the tricyclic
antidepressants) and certain SSRIs have been shown to reduce pain intensity in a manner
independent of the effects the medications may have on mood (Aragona et al., 2005; Simon, 2002).

 Conversion Disorder (Functional Neurological Symptom Disorder)

Diagnostic Criteria
• One or more symptoms of altered voluntary motor or sensory function.
• Clinical ndings provide evidence of incompatibility between the symptom and recog-
nized neurological or medical conditions.
• The symptom or de cit is not better explained by another medical or mental disorder.
• Thesymptomorde citcausesclinicallysigni cantdistressorimpairmentinsocial,oc-
cupational, or other important areas of functioning or warrants medical evaluation.
Coding note: The ICD-9-CM code for conversion disorder is 300.11, which is assigned regardless of the symptom type. The ICD-10-CM code depends on the symptom type (see below).
Specify symptom type:
(F44.4) With weakness or paralysis
(F44.4) With abnormal movement (e.g., tremor, dystonic movement, myoclonus, gait disorder)
(F44.4) With swallowing symptoms
(F44.4) With speech symptom (e.g., dysphonia, slurred speech)
(F44.5) With attacks or seizures
(F44.6) With anesthesia or sensory loss
(F44.6) With special sensory symptom (e.g., visual, olfactory, or hearing distur- bance)
(F44.7) With mixed symptoms
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 Although the condition is still called a conversion disorder, the physical symptoms are usually seen as serving the rather obvi- ous 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. Typically,
it is thought that the person rst experiences a traumatic event that motivates the desire to escape the unpleasant situation, but literal escape may not be feasible or socially acceptable. More- over, although becoming sick or disabled is more socially ac- ceptable, this is true only if the person’s
motivation to do so is unconscious.

Thus, in contemporary terms, the primary gain for conver- sion symptoms is continued escape or avoidance of a stressful situation. Because this is all unconscious (i.e., the person sees
no relation between the symptoms and the stressful situation), the symptoms go away only if the stressful situation has been removed or resolved. Relatedly, the term secondary gain, which originally referred to advantages that the symptom(s) bestow beyond the “primary gain” of neutralizing
intrapsychic con ict, has also been retained. Generally, it is used to refer to any “exter- nal” circumstance, such as attention from loved ones or nancial compensation, that would tend to reinforce the maintenance of disability.

Given the important role often attributed to stressful life events in precipitating the onset of conversion disorder, it is unfortunate that little is actually known about the exact nature

and timing of these psychological stress factors (Roelofs et al., 2005). However, one study compared the frequency of stressful life events in the recent past in patients with conversion disorder and depressed controls and did not nd a difference in frequency between them. Moreover, the
greater the negative impact of the preceding life events, the greater the severity of the conversion disorder symptoms (Roelofs et al., 2005). Another study com- pared levels of a neurobiological marker of stress (lower levels of brain-derived neurotropic factor) in individuals with conversion
disorder versus major depression versus no disorder. Both those with depression and those with conversion disorder showed reduced levels of this marker relative to the nondisordered con- trols (Deveci et al., 2007). This also provides support for the link between stress and the onset of
conversion disorder.
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• Treatment of conversion disorder
• Our knowledge of how best to treat conversion disorder is very limited because few well-controlled studies have yet
been conducted (e.g., Bowman & Markand, 2005; Looper & Kirmayer, 2002). However, it is known that some
hospitalized patients with motor conversion symptoms have been successfully treated with a behavioral approach in
which speci c exercises are prescribed in order to increase movement or walking, and then reinforcements (e.g.,
praise and gaining privileges) are provided when patients show improvements. Any reinforce- ments of abnormal
motor behaviors are removed in order to eliminate any sources of secondary gain. In one small study using this kind
of treatment for 10 patients, all had regained their ability to move or walk in an average of 12 days, and for seven of
the nine patients available at approximately 2-year follow-up, the improvements had been maintained (Speed,
1996). At least one study has also used cognitive-behavior therapy to successfully treat psychogenic seizures
(LaFrance et al., 2009). Some studies have used hypnosis combined with other problem-solving therapies, and there
are some sugges- tions that hypnosis, or adding hypnosis to other therapeutic techniques, can be useful (Looper &
Kirmayer, 2002; Moene et al., 2003).
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