Evidence-Based Interventions Used in Trauma

Dissociative Disorders

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Dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Dissociative symptoms can potentially disrupt every area of psychological functioning. This chapter includes dissociative identity disorder, dissociative amnesia, depersonalization/derealization disorder, other specified dissociative disorder, and unspecified dissociative disorder.

Dissociative symptoms are experienced as a) unbidden intrusions into awareness and behavior, with accompanying losses of continuity in subjective experience (i.e., ‘‘positive’’ dissociative symptoms such as fragmentation of identity, depersonalization, and derealization) and/or b) inability to access information or to control mental functions that normally are readily amenable to access or control (i.e., “negative’’ dissociative symptoms such as amnesia).

The dissociative disorders are frequently found in the aftermath of trauma, and many of the symptoms, including embarrassment and confusion about the symptoms or a desire to hide them, are influenced by the proximity to trauma. In DSM-5, the dissociative disorders are placed next to, but are not part of, the trauma- and stressor-related disorders, reflecting the close relationship between these diagnostic classes. Both acute stress disorder and posttraumatic stress disorder contain dissociative symptoms, such as amnesia, flashbacks, numbing, and depersonalization/derealization.

Depersonalization/derealization disorder is characterized by clinically significant persistent or recurrent depersonalization (i.e., experiences of unreality or detachment from one’s mind, self, or body) and/or derealization (i.e., experiences of unreality or detachment from one’s surroundings). These alterations of experience are accompanied by intact reality testing. There is no evidence of any distinction between individuals with predominantly depersonalization versus derealization symptoms. Therefore, individuals with this disorder can have depersonalization, derealization, or both.

Dissociative amnesia is characterized by an inability to recall autobiographical information. This amnesia may be localized (i.e., an event or period of time), selective (i.e., a specific aspect of an event), or generalized (i.e., identity and life history). Dissociative amnesia is fundamentally an inability to recall autobiographical information that is inconsistent with normal forgetting. It may or may not involve purposeful travel or bewildered wandering (i.e., fugue). Although some individuals with amnesia promptly notice that they have “lost time” or that they have a gap in their memory, most individuals with dissociative disorders are initially unaware of their amnesias. For them, awareness of amnesia occurs only when personal identity is lost or when circumstances make these individuals aware that autobiographical information is missing (e.g., when they discover evidence of events they cannot recall or when others tell them or ask them about events they cannot recall). Until and unless this happens, these individuals have “amnesia for their amnesia.” Amnesia is experienced as an essential feature of dissociative amnesia; individuals may experience localized or selective amnesia most commonly, or generalized amnesia rarely. Dissociative fugue is rare in persons with dissociative amnesia but common in dissociative identity disorder.

Dissociative identity disorder is characterized by a) the presence of two or more distinct personality states or an experience of possession and b) recurrent episodes of amnesia. The fragmentation of identity may vary with culture (e.g., possession-form presentations) and circumstance. Thus, individuals may experience discontinuities in identity and memory that may not be immediately evident to others or are obscured by attempts to hide dysfunction. Individuals with dissociative identity disorderexperience a) recurrent, inexplicable intrusions into their conscious functioning and sense of self (e.g., voices; dissociated actions and speech; intrusive thoughts, emotions, and impulses), b) alterations of sense of self (e.g., attitudes, preferences, and feeling like one’s body or actions are not one’s own), c) odd changes of perception (e.g., depersonalization or derealization, such as feeling detached from one’s body while cutting), and d) intermittent functional neurological symptoms. Stress often produces transient exacerbation of dissociative symptoms that makes them more evident.

The residual category of other specified dissociative disorder has seven examples: chronic or recurrent mixed dissociative symptoms that approach, but fall short of, the diagnostic criteria for dissociative identity disorder; dissociative states secondary to brainwashing or thought reform; two acute presentations, of less than 1 month’s duration, of mixed dissociative symptoms, one of which is also marked by the presence of psychotic symptoms; and three single-symptom dissociative presentations—dissociative trance, dissociative stupor or coma, and Ganser’s syndrome (the giving of approximate and vague answers).

Dissociative Identity Disorder

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).

Diagnostic Features

The defining feature of dissociative identity disorder is the presence of two or more distinct personality states or an experience of possession (Criterion A). The overtness or covertness of these personality states, however, varies as a function of psychological motivation, current level of stress, culture, internal conflicts and dynamics, and emotional resilience(Kluft 1991). Sustained periods of identity disruption may occur when psychosocial pressures are severe and/or prolonged. In many possession-form cases of dissociative identity disorder, and in a small proportion of non-possession-form cases, manifestations of alternate identities are highly overt(Kluft 1991; Spiegel et al. 2011). Most individuals with non-possession-form dissociative identity disorder do not overtly display their discontinuity of identity for long periods of time; only a small minority present to clinical attention with observable alternation of identities(Dell 2009; Kluft 1991; Spiegel et al. 2011). When alternate personality states are not directly observed, the disorder can be identified by two clusters of symptoms: 1) sudden alterations or discontinuities in sense of self and sense of agency (Criterion A), and 2) recurrent dissociative amnesias (Criterion B).

Criterion A symptoms are related to discontinuities of experience that can affect any aspect of an individual’s functioning. Individuals with dissociative identity disorder may report the feeling that they have suddenly become depersonalized observers of their “own” speech and actions, which they may feel powerless to stop (sense of self)(Dell 2006; Spiegel et al. 2011). Such individuals may also report perceptions of voices (e.g., a child’s voice; crying; the voice of a spiritual being). In some cases, voices are experienced as multiple, perplexing, independent thought streams over which the individual experiences no control. Strong emotions, impulses, and even speech or other actions may suddenly emerge, without a sense of personal ownership or control (sense of agency). These emotions and impulses are frequently reported as ego-dystonic and puzzling. Attitudes, outlooks, and personal preferences (e.g., about food, activities, dress) may suddenly shift and then shift back. Individuals may report that their bodies feel different (e.g., like a small child, like the opposite gender, huge and muscular). Alterations in sense of self and loss of personal agency may be accompanied by a feeling that these attitudes, emotions, and behaviors—even one’s body—are “not mine” and/or are “not under my control.” Although most Criterion A symptoms are subjective, many of these sudden discontinuities in speech, affect, and behavior can be witnessed by family, friends, or the clinician. Non-epileptic seizures and other conversion symptoms are prominent in some presentations of dissociative identity disorder, especially in some non-Western settings(Sar et al. 2000; Saxena and Prasad 1989; Tezcan et al. 2003).

The dissociative amnesia of individuals with dissociative identity disorder manifests in three primary ways: as 1) gaps in remote memory of personal life events (e.g., periods of childhood or adolescence; some important life events, such as the death of a grandparent, getting married, giving birth); 2) lapses in dependable memory (e.g., of what happened today, of well-learned skills such as how to do their job, use a computer, read, drive); and 3) discovery of evidence of their everyday actions and tasks that they do not recollect doing (e.g., finding unexplained objects in their shopping bags or among their possessions; finding perplexing writings or drawings that they must have created; discovering injuries; “coming to” in the midst of doing something)(Dell 2006; Spiegel et al. 2011). Dissociative fugues, wherein the person discovers dissociated travel, are common(Dell 2006; Spiegel et al. 2011). Thus, individuals with dissociative identity disorder may report that they have suddenly found themselves at the beach, at work, in a nightclub, or somewhere at home (e.g., in the closet, on a bed or sofa, in the corner) with no memory of how they came to be there. Amnesia in individuals with dissociative identity disorder is not limited to stressful or traumatic events; these individuals often cannot recall everyday events as well.

Individuals with dissociative identity disorder vary in their awareness and attitude toward their amnesias. It is common for these individuals to minimize their amnestic symptoms. Some of their amnestic behaviors may be apparent to others—as when these persons do not recall something they were witnessed to have done or said, when they cannot remember their own name, or when they do not recognize their spouse, children, or close friends.

Possession-form identities in dissociative identity disorder typically manifest as behaviors that appear as if a “spirit,” supernatural being, or outside person has taken control, such that the individual begins speaking or acting in a distinctly different manner. For example, an individual’s behavior may give the appearance that her identity has been replaced by the “ghost” of a girl who committed suicide in the same community years before, speaking and acting as though she were still alive. Or an individual may be “taken over” by a demon or deity, resulting in profound impairment, and demanding that the individual or a relative be punished for a past act, followed by more subtle periods of identity alteration. However, the majority of possession states around the world are normal, usually part of spiritual practice, and do not meet criteria for dissociative identity disorder. The identities that arise during possession-form dissociative identity disorder present recurrently, are unwanted and involuntary, cause clinically significant distress or impairment (Criterion C), and are not a normal part of a broadly accepted cultural or religious practice (Criterion D)(Spiegel et al. 2011).

Associated Features Supporting Diagnosis

Individuals with dissociative identity disorder typically present with comorbid depression, anxiety, substance abuse, self-injury, non-epileptic seizures, or another common symptom. They often conceal, or are not fully aware of, disruptions in consciousness, amnesia, or other dissociative symptoms(Dell 2009; Kluft 1991; Spiegel et al. 2011). Many individuals with dissociative identity disorder report dissociative flashbacks during which they undergo a sensory reliving of a previous event as though it were occurring in the present, often with a change of identity, a partial or complete loss of contact with or disorientation to current reality during the flashback, and a subsequent amnesia for the content of the flashback. Individuals with the disorder typically report multiple types of interpersonal maltreatment during childhood and adulthood. Nonmaltreatment forms of overwhelming early life events, such as multiple long, painful, early-life medical procedures, also may be reported(Putnam et al. 1986; Ross et al. 1990; Spiegel et al. 2011). Self-mutilation and suicidal behavior are frequent(Foote et al. 2008; Putnam et al. 1986). On standardized measures, these individuals report higher levels of hypnotizability and dissociativity compared with other clinical groups and healthy control subjects(Carlson et al. 1993;Spiegel et al. 2011). Some individuals experience transient psychotic phenomena or episodes(Spiegel et al. 2011). Several brain regions have been implicated in the pathophysiology of dissociative identity disorder, including the orbitofrontal cortex, hippocampus, parahippocampal gyrus, and amygdala(Ehling et al. 2008; Spiegel et al. 2011; Vermetten et al. 2006).

Prevalence

The 12-month prevalence of dissociative identity disorder among adults in a small U.S. community study was 1.5%(Johnson et al. 2006). The prevalence across genders in that study was 1.6% for males and 1.4% for females.

Development and Course

Dissociative identity disorder is associated with overwhelming experiences, traumatic events, and/or abuse occurring in childhood(Kluft 1985; Dalenberg et al. 2012; Silberg 1996). The full disorder may first manifest at almost any age (from earliest childhood to late life). Dissociation in children may generate problems with memory, concentration, attachment, and traumatic play(Silberg 1996). Nevertheless, children usually do not present with identity changes; instead they present primarily with overlap and interference among mental states (Criterion A phenomena), with symptoms related to discontinuities of experience(Putnam 1997). Sudden changes in identity during adolescence may appear to be just adolescent turmoil or the early stages of another mental disorder(Kluft 1985). Older individuals may present to treatment with what appear to be late-life mood disorders, obsessive-compulsive disorder, paranoia, psychotic mood disorders, or even cognitive disorders due to dissociative amnesia(Kluft 1991). In some cases, disruptive affects and memories may increasingly intrude into awareness with advancing age.

Psychological decompensation and overt changes in identity may be triggered by 1) removal from the traumatizing situation (e.g., through leaving home); 2) the individual’s children reaching the same age at which the individual was originally abused or traumatized; 3) later traumatic experiences, even seemingly inconsequential ones, like a minor motor vehicle accident; or 4) the death of, or the onset of a fatal illness in, their abuser(s).

Risk and Prognostic Factors

Environmental

Interpersonal physical and sexual abuse is associated with an increased risk of dissociative identity disorder(Spiegel et al. 2011). Prevalence of childhood abuse and neglect in the United States, Canada, and Europe among those with the disorder is about 90%. Other forms of traumatizing experiences, including childhood medical and surgical procedures, war, childhood prostitution, and terrorism, have been reported.

Course modifiers

Ongoing abuse, later-life retraumatization, comorbidity with mental disorders, severe medical illness, and delay in appropriate treatment are associated with poorer prognosis.

Culture-Related Diagnostic Issues

Many features of dissociative identity disorder can be influenced by the individual’s cultural background. Individuals with this disorder may present with prominent medically unexplained neurological symptoms, such as non-epileptic seizures, paralyses, or sensory loss, in cultural settings where such symptoms are common(Saxena and Prasad 1989; Tezcan et al. 2003). Similarly, in settings where normative possession is common (e.g., rural areas in the developing world, among certain religious groups in the United States and Europe), the fragmented identities may take the form of possessing spirits, deities, demons, animals, or mythical figures(Spiegel et al. 2011). Acculturation or prolonged intercultural contact may shape the characteristics of the other identities (e.g., identities in India may speak English exclusively and wear Western clothes). Possession-form dissociative identity disorder can be distinguished from culturally accepted possession states in that the former is involuntary, distressing, uncontrollable, and often recurrent or persistent; involves conflict between the individual and his or her surrounding family, social, or work milieu; and is manifested at times and in places that violate the norms of the culture or religion(Spiegel et al. 2011).

Gender-Related Diagnostic Issues

Females with dissociative identity disorder predominate in adult clinical settings but not in child clinical settings(Kluft 1985). Adult males with dissociative identity disorder may deny their symptoms and trauma histories, and this can lead to elevated rates of false negative diagnosis(Kluft 1985). Females with dissociative identity disorder present more frequently with acute dissociative states (e.g., flashbacks, amnesia, fugue, functional neurological [conversion] symptoms, hallucinations, self-mutilation)(Ross and Ness 2010). Males commonly exhibit more criminal or violent behavior than females; among males, common triggers of acute dissociative states include combat, prison conditions, and physical or sexual assaults(Lewis et al. 1997; Maercker and Schützwohl 1997).

Suicide Risk

Over 70% of outpatients with dissociative identity disorder have attempted suicide; multiple attempts are common, and other self-injurious behavior is frequent(Foote et al. 2008; Putnam et al. 1986). Assessment of suicide risk may be complicated when there is amnesia for past suicidal behavior or when the presenting identity does not feel suicidal and is unaware that other dissociated identities do.

Functional Consequences of Dissociative Identity Disorder

Impairment varies widely, from apparently minimal (e.g., in high-functioning professionals) to profound. Regardless of level of disability, individuals with dissociative identity disorder commonly minimize the impact of their dissociative and posttraumatic symptoms. The symptoms of higher-functioning individuals may impair their relational, marital, family, and parenting functions more than their occupational and professional life (although the latter also may be affected). With appropriate treatment, many impaired individuals show marked improvement in occupational and personal functioning. However, some remain highly impaired in most activities of living. These individuals may only respond to treatment very slowly, with gradual reduction in or improved tolerance of their dissociative and posttraumatic symptoms. Long-term supportive treatment may slowly increase these individuals’ ability to manage their symptoms and decrease use of more restrictive levels of care(Loewenstein 1994).

Differential Diagnosis

Other specified dissociative disorder

The core of dissociative identity disorder is the division of identity, with recurrent disruption of conscious functioning and sense of self. This central feature is shared with one form of other specified dissociative disorder, which may be distinguished from dissociative identity disorder by the presence of chronic or recurrent mixed dissociative symptoms that do not meet Criterion A for dissociative identity disorder or are not accompanied by recurrent amnesia.

Major depressive disorder

Individuals with dissociative identity disorder are often depressed, and their symptoms may appear to meet the criteria for a major depressive episode. Rigorous assessment indicates that this depression in some cases does not meet full criteria for major depressive disorder. Other specified depressive disorder in individuals with dissociative identity disorder often has an important feature: the depressed mood and cognitions fluctuate because they are experienced in some identity states but not others.

Bipolar disorders

Individuals with dissociative identity disorder are often misdiagnosed with a bipolar disorder, most often bipolar II disorder. The relatively rapid shifts in mood in individuals with this disorder—typically within minutes or hours, in contrast to the slower mood changes typically seen in individuals with bipolar disorders—are due to the rapid, subjective shifts in mood commonly reported across dissociative states, sometimes accompanied by fluctuation in levels of activation. Furthermore, in dissociative identity disorder, elevated or depressed mood may be displayed in conjunction with overt identities, so one or the other mood may predominate for a relatively long period of time (often for days) or may shift within minutes.

Posttraumatic stress disorder

Some traumatized individuals have both posttraumatic stress disorder (PTSD) and dissociative identity disorder. Accordingly, it is crucial to distinguish between individuals with PTSD only and individuals who have both PTSD and dissociative identity disorder. This differential diagnosis requires that the clinician establish the presence or absence of dissociative symptoms that are not characteristic of acute stress disorder or PTSD. Some individuals with PTSD manifest dissociative symptoms that also occur in dissociative identity disorder: 1) amnesia for some aspects of trauma, 2) dissociative flashbacks (i.e., reliving of the trauma, with reduced awareness of one’s current orientation), and 3) symptoms of intrusion and avoidance, negative alterations in cognition and mood, and hyperarousal that are focused around the traumatic event. On the other hand, individuals with dissociative identity disorder manifest dissociative symptoms that are not a manifestation of PTSD: 1) amnesias for many everyday (i.e., nontraumatic) events, 2) dissociative flashbacks that may be followed by amnesia for the content of the flashback, 3) disruptive intrusions (unrelated to traumatic material) by dissociated identity states into the individual’s sense of self and agency, and 4) infrequent, full-blown changes among different identity states.

Psychotic disorders

Dissociative identity disorder may be confused with schizophrenia or other psychotic disorders. The personified, internally communicative inner voices of dissociative identity disorder, especially of a child (e.g., “I hear a little girl crying in a closet and an angry man yelling at her”), may be mistaken for psychotic hallucinations(Dorahy et al. 2009; Laddis and Dell 2012). Dissociative experiences of identity fragmentation or possession, and of perceived loss of control over thoughts, feelings, impulses, and acts, may be confused with signs of formal thought disorder, such as thought insertion or withdrawal(Kluft 1985; Ross et al. 1990). Individuals with dissociative identity disorder may also report visual, tactile, olfactory, gustatory, and somatic hallucinations, which are usually related to posttraumatic and dissociative factors, such as partial flashbacks. Individuals with dissociative identity disorder experience these symptoms as caused by alternate identities, do not have delusional explanations for the phenomena, and often describe the symptoms in a personified way (e.g., “I feel like someone else wants to cry with my eyes”)(Spiegel et al. 2011). Persecutory and derogatory internal voices in dissociative identity disorder associated with depressive symptoms may be misdiagnosed as major depression with psychotic features. Chaotic identity change and acute intrusions that disrupt thought processes may be distinguished from brief psychotic disorder by the predominance of dissociative symptoms and amnesia for the episode, and diagnostic evaluation after cessation of the crisis can help confirm the diagnosis.

Substance/medication-induced disorders

Symptoms associated with the physiological effects of a substance can be distinguished from dissociative identity disorder if the substance in question is judged to be etiologically related to the disturbance.

Personality disorders

Individuals with dissociative identity disorder often present identities that appear to encapsulate a variety of severe personality disorder features, suggesting a differential diagnosis of personality disorder, especially of the borderline type. Importantly, however, the individual’s longitudinal variability in personality style (due to inconsistency among identities) differs from the pervasive and persistent dysfunction in affect management and interpersonal relationships typical of those with personality disorders.

Conversion disorder (functional neurological symptom disorder)

This disorder may be distinguished from dissociative identity disorder by the absence of an identity disruption characterized by two or more distinct personality states or an experience of possession. Dissociative amnesia in conversion disorder is more limited and circumscribed (e.g., amnesia for a non-epileptic seizure).

Seizure disorders

Individuals with dissociative identity disorder may present with seizurelike symptoms and behaviors that resemble complex partial seizures with temporal lobe foci. These include déjà vu, jamais vu, depersonalization, derealization, out-of-body experiences, amnesia, disruptions of consciousness, hallucinations, and other intrusion phenomena of sensation, affect, and thought. Normal electroencephalographic findings, including telemetry, differentiate non-epileptic seizures from the seizurelike symptoms of dissociative identity disorder. Also, individuals with dissociative identity disorder obtain very high dissociation scores, whereas individuals with complex partial seizures do not(Loewenstein and Putnam 1988; Ross et al. 1989).

Factitious disorder and malingering

Individuals who feign dissociative identity disorder do not report the subtle symptoms of intrusion characteristic of the disorder; instead they tend to overreport well-publicized symptoms of the disorder, such as dissociative amnesia, while underreporting less-publicized comorbid symptoms, such as depression(Brand et al. 2006b; Draijer and Boon 1999). Individuals who feign dissociative identity disorder tend to be relatively undisturbed by or may even seem to enjoy “having” the disorder. In contrast, individuals with genuine dissociative identity disorder tend to be ashamed of and overwhelmed by their symptoms and to underreport their symptoms or deny their condition(Draijer and Boon 1999). Sequential observation, corroborating history, and intensive psychometric and psychological assessment may be helpful in assessment(Goodwin 1988; Brand et al. 2006b).

Individuals who malinger dissociative identity disorder usually create limited, stereotyped alternate identities, with feigned amnesia, related to the events for which gain is sought. For example, they may present an “all-good” identity and an “all-bad” identity in hopes of gaining exculpation for a crime(Loewenstein and Putnam 2004; Simeon and Loewenstein 2009).

Comorbidity

Many individuals with dissociative identity disorder present with a comorbid disorder. If not assessed and treated specifically for the dissociative disorder, these individuals often receive prolonged treatment for the comorbid diagnosis only, with limited overall treatment response and resultant demoralization, and disability(Brand et al. 2009; Loewenstein 1994).

Individuals with dissociative identity disorder usually exhibit a large number of comorbid disorders(Ellason et al. 1996;Putnam et al. 1986). In particular, most develop PTSD(Ellason et al. 1996; Spiegel et al. 2011; Vermetten et al. 2006). Other disorders that are highly comorbid with dissociative identity disorder include depressive disorders, trauma- and stressor-related disorders, personality disorders (especially avoidant and borderline personality disorders), conversion disorder (functional neurological symptom disorder), somatic symptom disorder, eating disorders, substance-related disorders, obsessive-compulsive disorder, and sleep disorders. Dissociative alterations in identity, memory, and consciousness may affect the symptom presentation of comorbid disorders.

References: Dissociative Identity Disorder

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Dissociative Amnesia

Diagnostic Criteria

300.12 (F44.0)

A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.

· Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/traumatic brain injury, other neurological condition).

D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.

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 autobiographical information.

Diagnostic Features

The defining characteristic of dissociative amnesia is an inability to recall important autobiographical information that 1) should be successfully stored in memory and 2) ordinarily would be readily remembered (Criterion A). Dissociative amnesiadiffers from the permanent amnesias due to neurobiological damage or toxicity that prevent memory storage or retrieval in that it is always potentially reversible because the memory has been successfully stored(Spiegel et al. 2011).

Localized amnesia, a failure to recall events during a circumscribed period of time, is the most common form of dissociative amnesia (Spiegel et al. 2011). Localized amnesia may be broader than amnesia for a single traumatic event (e.g., months or years associated with child abuse or intense combat)(Edwards et al. 2001). 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(Loewenstein 1996). Some lose previous knowledge about the world (i.e., semantic knowledge) and can no longer access well-learned skills (i.e., procedural knowledge). 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 individuals experiencing extreme emotional stress or conflict(Kaszniak et al. 1988; Sargent and Slater 1941;Witztum et al. 2002).

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 address it(Loewenstein 2001). In systematized amnesia, the individual loses memory for a specific category of information (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 occurs.

Associated Features Supporting Diagnosis

Many individuals with dissociative amnesia are chronically impaired in their ability to form and sustain satisfactory relationships. Histories of trauma, child abuse, and victimization are common. Some individuals with dissociative amnesiareport dissociative flashbacks (i.e., behavioral reexperiencing of traumatic events)(Loewenstein 1991). Many have a history of self-mutilation, suicide attempts, and other high-risk behaviors. Depressive and functional neurological symptoms are common, as are depersonalization, auto-hypnotic symptoms, and high hypnotizability. Sexual dysfunctions are common. Mild traumatic brain injury may precede dissociative amnesia (Kritchevsky et al. 2004).

Prevalence

The 12-month prevalence for dissociative amnesia among adults in a small U.S. community study was 1.8% (1.0% for males; 2.6% for females)(Johnson et al. 2006).

Development and Course

Onset of generalized amnesia is usually sudden. Less is known about the onset of localized and selective amnesias because these amnesias are seldom evident, even to the individual. Although overwhelming or intolerable events typically precede localized amnesia, its onset may be delayed for hours, days, or longer(Loewenstein 1991).

Individuals may report multiple episodes of dissociative amnesia. A single episode may predispose to future episodes. In between episodes of amnesia, the individual may or may not appear to be acutely symptomatic. The duration of the forgotten events can range from minutes to decades. Some episodes of dissociative amnesia resolve rapidly (e.g., when the person is removed from combat or some other stressful situation), whereas other episodes persist for long periods of time. Some individuals may gradually recall the dissociated memories years later. Dissociative capacities may decline with age, but not always(Loewenstein 1991). As the amnesia remits, there may be considerable distress, suicidal behavior, and symptoms of posttraumatic stress disorder (PTSD).

Dissociative amnesia has been observed in young children, adolescents, and adults(Putnam 1997). Children may be the most difficult to evaluate because they often have difficulty understanding questions about amnesia, and interviewers may find it difficult to formulate child-friendly questions about memory and amnesia. Observations of apparent dissociative amnesia are often difficult to differentiate from inattention, absorption, anxiety, oppositional behavior, and learning disorders. Reports from several different sources (e.g., teacher, therapist, case worker) may be needed to diagnose amnesia in children(Putnam1997).

Risk and Prognostic Factors

Environmental

Single or repeated traumatic experiences (e.g., war, childhood maltreatment, natural disaster, internment in concentration camps, genocide) are common antecedents(Dalenberg 2006; Dalenberg et al. 2012). Dissociative amnesia is more likely to occur with 1) a greater number of adverse childhood experiences, particularly physical and/or sexual abuse(Edwards et al. 2001), 2) interpersonal violence(Loewenstein 1991; Loewenstein 1996; Loewenstein 2001); and 3) increased severity, frequency, and violence of the trauma(Edwards et al. 2001; Loewenstein 1991; Loewenstein 1996; Loewenstein 2001).

Genetic and physiological

There are no genetic studies of dissociative amnesia. Studies of dissociation report significant genetic and environmental factors in both clinical and nonclinical samples(Becker-Blease et al. 2004; Jang et al. 1998; Lochner et al. 2007; Pieper et al. 2011; Savitz et al. 2008).

Course modifiers

Removal from the traumatic circumstances underlying the dissociative amnesia (e.g., combat) may bring about a rapid return of memory(Thom and Fenton 1920). The memory loss of individuals with dissociative fugue may be particularly refractory. Onset of PTSD symptoms may decrease localized, selective, or systematized amnesia. The returning memory, however, may be experienced as flashbacks that alternate with amnesia for the content of the flashbacks(van der Hart et al. 1993).

Culture-Related Diagnostic Issues

In Asia, the Middle East, and Latin America, non-epileptic seizures and other functional neurological symptoms may accompany dissociative amnesia. In cultures with highly restrictive social traditions, the precipitants of dissociative amnesiaoften do not involve frank trauma. Instead, the amnesia is preceded by severe psychological stresses or conflicts (e.g., marital conflict, other family disturbances, attachment problems, conflicts due to restriction or oppression).

Suicide Risk

Suicidal and other self-destructive behaviors are common in individuals with dissociative amnesia. Suicidal behavior may be a particular risk when the amnesia remits suddenly and overwhelms the individual with intolerable memories(Coons and Millstein 1992; Gudjonsson and Haward 1982; Takahashi 1988).

Functional Consequences of Dissociative Amnesia

The impairment of individuals with localized, selective, or systematized dissociative amnesia ranges from limited to severe. Individuals with chronic generalized dissociative amnesia usually have impairment in all aspects of functioning. Even when these individuals “re-learn” aspects of their life history, autobiographical memory remains very impaired. Most become vocationally and interpersonally disabled(Kikuchi et al. 2010; Loewenstein 1996).

Differential Diagnosis

Dissociative identity disorder

Individuals with dissociative amnesia may report depersonalization and auto-hypnotic symptoms. Individuals with dissociative identity disorder report pervasive discontinuities in sense of self and agency, accompanied by many other dissociative symptoms. The amnesias of individuals with localized, selective, and/or systematized dissociative amnesias are relatively stable(Boon and Draijer 1993; Ross et al. 1990). Amnesias in dissociative identity disorder include amnesia for everyday events, finding of unexplained possessions, sudden fluctuations in skills and knowledge, major gaps in recall of life history, and brief amnesic gaps in interpersonal interactions(Boon and Draijer 1993; Ross et al. 1990).

Posttraumatic stress disorder

Some individuals with PTSD cannot recall part or all of a specific traumatic event (e.g., a rape victim with depersonalization and/or derealization symptoms who cannot recall most events for the entire day of the rape). When that amnesia extends beyond the immediate time of the trauma, a comorbid diagnosis of dissociative amnesia is warranted(Lanius et al. 2012).

Neurocognitive disorders

In neurocognitive disorders, memory loss for personal information is usually embedded in cognitive, linguistic, affective, attentional, and behavioral disturbances. In dissociative amnesia, memory deficits are primarily for autobiographical information; intellectual and cognitive abilities are preserved(Loewenstein 1991; Loewenstein 1996; Loewenstein 2001).

Substance-related disorders

In the context of repeated intoxication with alcohol or other substances/medications, there may be episodes of “black outs” or periods for which the individual has no memory. To aid in distinguishing these episodes from dissociative amnesia, a longitudinal history noting that the amnestic episodes occur only in the context of intoxication and do not occur in other situations would help identify the source as substance-induced; however the distinction may be difficult when the individual with dissociative amnesia may also misuse alcohol or other substances in the context of stressful situations that may also exacerbate dissociative symptoms. Some individuals with comorbid dissociative amnesia and substance use disorders will attribute their memory problems solely to the substance use(Loewenstein 2001). Prolonged use of alcohol or other substances may result in a substance-induced neurocognitive disorder that may be associated with impaired cognitive function, but in this context the protracted history of substance use and the persistent deficits associated with the neurocognitive disorder would serve to distinguish it from dissociative amnesia, where there is typically no evidence of persistent impairment in intellectual functioning.

Posttraumatic amnesia due to brain injury

Amnesia may occur in the context of a traumatic brain injury (TBI) when there has been an impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull TBI. Other characteristics of TBI include loss of consciousness, disorientation and confusion, or, in more severe cases, neurological signs (e.g., abnormalities on neuroimaging, a new onset of seizures or a marked worsening of a preexisting seizure disorder, visual field cuts, anosmia). A neurocognitive disorder attributable to TBI must present either immediately after brain injury occurs or immediately after the individual recovers consciousness after the injury, and persist past the acute post-injury period. The cognitive presentation of a neurocognitive disorder following TBI is variable and includes difficulties in the domains of complex attention, executive function, learning and memory as well as slowed speed of information processing and disturbances in social cognition. These additional features help distinguish it from dissociative amnesia.

Seizure disorders

Individuals with seizure disorders may exhibit complex behavior during seizures or post-ictally with subsequent amnesia. Some individuals with a seizure disorder engage in nonpurposive wandering that is limited to the period of seizure activity. Conversely, behavior during a dissociative fugue is usually purposeful, complex, and goal-directed and may last for days, weeks, or longer(Loewenstein 1991). Occasionally, individuals with a seizure disorder will report that earlier autobiographical memories have been “wiped out” as the seizure disorder progresses. Such memory loss is not associated with traumatic circumstances and appears to occur randomly. Serial electroencephalograms usually show abnormalities. Telemetric electroencephalographic monitoring usually shows an association between the episodes of amnesia and seizure activity. Dissociative and epileptic amnesias may coexist.

Catatonic stupor

Mutism in catatonic stupor may suggest dissociative amnesia, but failure of recall is absent. Other catatonic symptoms (e.g., rigidity, posturing, negativism) are usually present.

Factitious disorder and malingering

There is no test, battery of tests, or set of procedures that invariably distinguishes dissociative amnesia from feigned amnesia(Bourget and Whitehurst 2007; Bronks 1987;Schacter 1986). Individuals with factitious disorder or malingering have been noted to continue their deception even during hypnotic or barbiturate-facilitated interviews(Ruedrich et al. 1985). Feigned amnesia is more common in individuals with 1) acute, florid dissociative amnesia; 2) financial, sexual, or legal problems; or 3) a wish to escape stressful circumstances. True amnesia can be associated with those same circumstances. Many individuals who malinger confess spontaneously or when confronted(Kopelman 1987; Parwatikar et al. 1985; Schacter 1986).

Normal and age-related changes in memory

Memory decrements in major and mild neurocognitive disorders differ from those of dissociative amnesia, which are usually associated with stressful events and are more specific, extensive, and/or complex.

Comorbidity

As dissociative amnesia begins to remit, a wide variety of affective phenomena may surface: dysphoria, grief, rage, shame, guilt, psychological conflict and turmoil, and suicidal and homicidal ideation, impulses, and acts. These individuals may have symptoms that then meet diagnostic criteria for persistent depressive disorder (dysthymia); major depressive disorder; other specified or unspecified depressive disorder; adjustment disorder, with depressed mood; or adjustment disorder, with mixed disturbance of emotions and conduct. Many individuals with dissociative amnesia develop PTSD at some point during their life, especially when the traumatic antecedents of their amnesia are brought into conscious awareness.

Many individuals with dissociative amnesia have symptoms that meet diagnostic criteria for a comorbid somatic symptom or related disorder (and vice versa), including somatic symptom disorder and conversion disorder (functional neurological symptom disorder). Many individuals with dissociative amnesia have symptoms that meet diagnostic criteria for a personality disorder, especially dependent, avoidant, and borderline(Coons and Millstein 1992).

References: Dissociative Amnesia

· Becker-Blease KA , Deater-Deckard K , Eley T , et al: A genetic analysis of individual differences in dissociative behaviors in childhood and adolescence. J Child Psychol Psychiatry 45(3):522–532, 2004

· Boon S , Draijer N : Multiple personality disorder in The Netherlands: a clinical investigation of 71 patients. Am J Psychiatry150(3):489–494, 1993

· Bourget D , Whitehurst L : Amnesia and crime. J Am Acad Psychiatry Law 35(4):469–480, 2007

· Bronks IG : Amnesia: organic and psychogenic. Br J Psychiatry 151:414–415, 1987

· Coons PM , Millstein V : Psychogenic amnesia: a clinical investigation of 25 cases. Dissociation 5(2):73–79, 1992

· Courtois CA , Ford JD (eds): Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York, Guilford, 2009

· Dalenberg CJ : Recovered memory and the Daubert criteria: :. recovered memory as professionally tested, peer reviewed, and accepted in the relevant scientific community. Trauma Violence Abuse 7:274–310, 2006

· Dalenberg CJ , Brand BL , Gleaves DH , et al: Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychol Bull 138(3):550–588, 2012

· Edwards VJR , Fivush R , Anda RF , et al: Autobiographical memory disturbances in childhood abuse survivors, in Trauma and Cognitive Science: A Meeting of Minds, Science, and Human Experience. Edited by Freyd JJ , DePrince AP . Binghamton, NY, Howarth, 2001

· Gudjonsson GH , Haward LR : Case report—hysterical amnesia as an alternative to suicide. Med Sci Law 22(1):68–72, 1982

· Jang KL , Paris J , Zweig-Frank H , Livesley WJ : Twin study of dissociative experience. J Nerv Ment Dis 186(6):345–351, 1998

· Johnson JG , Cohen P , Kasen S , Brook JS : Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity. J Psychiatr Res 40(2):131–140, 2006

· Kaszniak AW , Nussbaum PD , Berren MR , Santiago J : Amnesia as a consequence of male rape: a case report. J Abnorm Psychol 97(1):100–104, 1988

· Kikuchi H , Fujii T , Abe N , et al: Memory repression: brain mechanisms underlying dissociative amnesia. J Cogn Neurosci22(3):602–613, 2010

· Kopelman MD : Amnesia: organic and psychogenic. Br J Psychiatry 150:428–442, 1987

· Kritchevsky M , Chang J , Squire LR : Functional amnesia: clinical description and neuropsychological profile of 10 cases. Learn Mem 11(2):213–226, 2004

· Lanius R , Brand B , et al: The dissociative subtype of posttraumatic stress disorder: rationale, clinical and neurobiological evidence and implications. Depress Anxiety 29(8):701–708, 2012

· Lochner C , Seedat S , Hemmings SM , et al: Investigating the possible effects of trauma experiences and 5-HTT on the dissociative experiences of patients with OCD using path analysis and multiple regression. Neuropsychobiology 56(1):6–13, 2007

· Loewenstein RJ : Psychogenic amnesia and psychogenic fugue: a comprehensive review, in The American Psychiatric Press Annual Review of Psychiatry, Vol 10. Edited by Tasman A , Goldfinger SM . Washington, DC, American Psychiatric Press, 1991, pp 189–222

· Loewenstein RJ : Dissociative amnesia and dissociative fugue, in Handbook of Dissociation. Edited by Michaelson W , RayHR . New York, Plenum, 1996, pp 307–336

· Loewenstein RJ : Dissociative amnesia and dissociative fugue, in Treatment s of Psychiatric Disorders, 3rd Edition, Vol 2. Edited by Gabbard GO . Washington, DC, American Psychiatric Press, 2001, pp 1623–1652

· Parwatikar SD , Holcomb WR , Menninger KA 2nd : The detection of malingered amnesia in accused murders. Bull Am Acad Psychiatry Law 13(1):97–103, 1985

· Pieper S , Out D , Bakermans-Kranenburg MJ , van Ijzendoorn MH : Behavioral and molecular genetics of dissociation: the role of the serotonin transporter gene promoter polymorphism (5-HTTLPR). J Traumatic Stress 24(4):373–380, 201110.1002/jts.20659

· Putnam FW : Dissociation in Children and Adolescents: A Developmental Model. New York, Guilford, 1997

· Ross CA , Miller SD , Reagor P , et al: Structured interview data on 102 cases of multiple personality disorder from four centers. Am J Psychiatry 147(5):596–601, 1990

· Ruedrich SL , Chu CC , Wadle CV : The amytal interview in the treatment of psychogenic amnesia. Hosp Community Psychiatry 36(10):1045–1046, 1985

· Sargent W , Slater E : Amnestic syndromes in war. Proceedings of the Royal Society of Medicine 34:757–764, 1941

· Savitz JB , van der Merwe L , Newman TK , et al: The relationship between childhood abuse and dissociation: is it influenced by catechol-O-methyltransferase (COMT) activity? Int J Neuropsychopharmacol 11(2):149–161, 2008

· Schacter DL : Amnesia and crime: how much do we really know? Am Psychol 41(3):286–295, 1986

· Spiegel D , Loewenstein RJ , Lewis-Fernández R , et al: Dissociative disorders in DSM-5. Depress Anxiety 28(9):824–852, 2011

· Takahashi Y : Aokigahara-jukai: suicide and amnesia in Mt. Fuji’s Black Forest. Suicide Life Threat Behav 18(2):164–175, 1988

· Thom DA , Fenton N : Amnesias in war cases. Am J Psychiatry 76:437–448, 1920

· van der Hart O , Steele K , Boon S , Brown P : The treatment of traumatic memories: synthesis, realization and integration. Dissociation 6:162–180, 1993

· Witztum E , Margalit H , van der Hart O : Combat-induced dissociative amnesia: review and case example of generalized dissociative amnesia. Journal of Trauma & Dissociation 3(2):35–55, 2002

Depersonalization/Derealization Disorder

Diagnostic Criteria

300.6 (F48.1)

A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:

1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing).

2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).

B. During the depersonalization or derealization experiences, reality testing remains intact.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).

E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.

Diagnostic Features

The essential features of depersonalization/derealization disorder are persistent or recurrent episodes of depersonalization, derealization, or both(Spiegel et al. 2011). Episodes of depersonalization are characterized by a feeling of unreality or detachment from, or unfamiliarity with, one’s whole self or from aspects of the self (Criterion A1). The individual may feel detached from his or her entire being (e.g., “I am no one,” “I have no self”). He or she may also feel subjectively detached from aspects of the self, including feelings (e.g., hypoemotionality: “I know I have feelings but I don’t feel them”), thoughts (e.g., “My thoughts don’t feel like my own,” “head filled with cotton”), whole body or body parts, or sensations (e.g., touch, proprioception, hunger, thirst, libido). There may also be a diminished sense of agency (e.g., feeling robotic, like an automaton; lacking control of one’s speech or movements). The depersonalization experience can sometimes be one of a split self, with one part observing and one participating, known as an “out-of-body experience” in its most extreme form. The unitary symptom of “depersonalization” consists of several symptom factors(Sierra et al. 2005; Simeon et al. 2008): anomalous body experiences (i.e., unreality of the self and perceptual alterations); emotional or physical numbing; and temporal distortions with anomalous subjective recall.

Episodes of derealization are characterized by a feeling of unreality or detachment from, or unfamiliarity with, the world, be it individuals, inanimate objects, or all surroundings (Criterion A2). The individual may feel as if he or she were in a fog, dream, or bubble, or as if there were a veil or a glass wall between the individual and world around. Surroundings may be experienced as artificial, colorless, or lifeless. Derealization is commonly accompanied by subjective visual distortions, such as blurriness, heightened acuity, widened or narrowed visual field, two-dimensionality or flatness, exaggerated three-dimensionality, or altered distance or size of objects (i.e., macropsia or micropsia). Auditory distortions can also occur, whereby voices or sounds are muted or heightened. In addition, Criterion C requires the presence of clinically significant distress or impairment in social, occupational, or other important areas of functioning, and Criteria D and E describe exclusionary diagnoses.

Associated Features Supporting Diagnosis

Individuals with depersonalization/derealization disorder may have difficulty describing their symptoms and may think they are “crazy” or “going crazy”(Baker et al. 2003; Simeon et al. 2003). Another common experience is the fear of irreversible brain damage(Simeon et al. 2009). A commonly associated symptom is a subjectively altered sense of time (i.e., too fast or too slow), as well as a subjective difficulty in vividly recalling past memories and owning them as personal and emotional(Baker et al. 2003; Simeon et al. 2003). Vague somatic symptoms, such as head fullness, tingling, or lightheadedness, are not uncommon. Individuals may suffer extreme rumination or obsessional preoccupation (e.g., constantly obsessing about whether they really exist, or checking their perceptions to determine whether they appear real). Varying degrees of anxiety and depression are also common associated features. Individuals with the disorder have been found to have physiological hyporeactivity to emotional stimuli(Sierra et al. 2002). Neural substrates of interest include the hypothalamic-pituitary-adrenocortical axis, inferior parietal lobule, and prefrontal cortical-limbic circuits(Lemche et al. 2007; Phillips et al. 2001;Simeon et al. 2000; Simeon et al. 2007).

Prevalence

Transient depersonalization/derealization symptoms lasting hours to days are common in the general population. The 12-month prevalence of depersonalization/derealization disorder is thought to be markedly less than for transient symptoms, although precise estimates for the disorder are unavailable(Aderibigbe et al. 2001). In general, approximately one-half of all adults have experienced at least one lifetime episode of depersonalization/derealization. However, symptomatology that meets full criteria for depersonalization/derealization disorder is markedly less common than transient symptoms. Lifetime prevalence in U.S. and non-U.S. countries is approximately 2% (range of 0.8% to 2.8%)(Hunter et al. 2004). The gender ratio for the disorder is 1:1.

Development and Course

The mean age at onset of depersonalization/derealization disorder is 16 years, although the disorder can start in early or middle childhood; a minority cannot recall ever not having had the symptoms. Less than 20% of individuals experience onset after age 20 years and only 5% after age 25 years. Onset in the fourth decade of life or later is highly unusual. Onset can range from extremely sudden to gradual. Duration of depersonalization/derealization disorder episodes can vary greatly, from brief (hours or days) to prolonged (weeks, months, or years). Given the rarity of disorder onset after age 40 years, in such cases the individual should be examined more closely for underlying medical conditions (e.g., brain lesions, seizure disorders, sleep apnea). The course of the disorder is often persistent. About one-third of cases involve discrete episodes; another third, continuous symptoms from the start; and still another third, an initially episodic course that eventually becomes continuous.

While in some individuals the intensity of symptoms can wax and wane considerably, others report an unwavering level of intensity that in extreme cases can be constantly present for years or decades. Internal and external factors that affect symptom intensity vary between individuals, yet some typical patterns are reported. Exacerbations can be triggered by stress, worsening mood or anxiety symptoms, novel or overstimulating settings, and physical factors such as lighting or lack of sleep.

Risk and Prognostic Factors

Temperamental

Individuals with depersonalization/derealization disorder are characterized by harm-avoidant temperament, immature defenses, and both disconnection and overconnection schemata(Simeon et al. 2002). Immature defenses such as idealization/devaluation, projection and acting out result in denial of reality and poor adaptation. Cognitive disconnection schemata reflect defectiveness and emotional inhibition and subsume themes of abuse, neglect, and deprivation. Overconnection schemata involve impaired autonomy with themes of dependency, vulnerability, and incompetence.

Environmental

There is a clear association between the disorder and childhood interpersonal traumas in a substantial portion of individuals(Spiegel et al. 2011), although this association is not as prevalent or as extreme in the nature of the traumas as in other dissociative disorders, such as dissociative identity disorder. In particular, emotional abuse and emotional neglect have been most strongly and consistently associated with the disorder(Simeon et al. 2001; Simeon et al. 2007). Other stressors can include physical abuse; witnessing domestic violence; growing up with a seriously impaired, mentally ill parent; or unexpected death or suicide of a family member or close friend. Sexual abuse is a much less common antecedent but can be encountered. The most common proximal precipitants of the disorder are severe stress (interpersonal, financial, occupational), depression, anxiety (particularly panic attacks), and illicit drug use(Simeon et al. 2003; Simeon et al. 2009). Symptoms may be specifically induced by substances such as tetrahydrocannabinol, hallucinogens, ketamine, MDMA (3,4-methylenedioxymethamphetamine; “ecstasy”) and salvia(Medford et al. 2003; Simeon et al. 2009). Marijuana use may precipitate new-onset panic attacks and depersonalization/derealization symptoms simultaneously.

Culture-Related Diagnostic Issues

Volitionally induced experiences of depersonalization/derealization can be a part of meditative practices that are prevalent in many religions and cultures and should not be diagnosed as a disorder. However, there are individuals who initially induce these states intentionally but over time lose control over them and may develop a fear and aversion for related practices.

Functional Consequences of Depersonalization/Derealization Disorder

Symptoms of depersonalization/derealization disorder are highly distressing and are associated with major morbidity(Baker et al. 2003; Simeon et al. 2003). The affectively flattened and robotic demeanor that these individuals often demonstrate may appear incongruent with the extreme emotional pain reported by those with the disorder. Impairment is often experienced in both interpersonal and occupational spheres, largely due to the hypoemotionality with others, subjective difficulty in focusing and retaining information, and a general sense of disconnectedness from life.

Differential Diagnosis

Illness anxiety disorder

Although individuals with depersonalization/derealization disorder can present with vague somatic complaints as well as fears of permanent brain damage, the diagnosis of depersonalization/derealization disorder is characterized by the presence of a constellation of typical depersonalization/derealization symptoms and the absence of other manifestations of illness anxiety disorder.

Major depressive disorder

Feelings of numbness, deadness, apathy, and being in a dream are not uncommon in major depressive episodes. However, in depersonalization/derealization disorder, such symptoms are associated with further symptoms of the disorder. If the depersonalization/derealization clearly precedes the onset of a major depressive episode or clearly continues after its resolution, the diagnosis of depersonalization/derealization disorder applies.

Obsessive-compulsive disorder

Some individuals with depersonalization/derealization disorder can become obsessively preoccupied with their subjective experience or develop rituals checking on the status of their symptoms. However, other symptoms of obsessive-compulsive disorder unrelated to depersonalization/derealization are not present.

Other dissociative disorders

In order to diagnose depersonalization/derealization disorder, the symptoms should not occur in the context of another dissociative disorder, such as dissociative identity disorder. Differentiation from dissociative amnesia and conversion disorder (functional neurological symptom disorder) is simpler, as the symptoms of these disorders do not overlap with those of depersonalization/derealization disorder (Spiegel et al. 2011).

Anxiety disorders

Depersonalization/derealization is one of the symptoms of panic attacks, increasingly common as panic attack severity increases. Therefore, depersonalization/derealization disorder should not be diagnosed when the symptoms occur only during panic attacks that are part of panic disorder, social anxiety disorder, or specific phobia. In addition, it is not uncommon for depersonalization/derealization symptoms to first begin in the context of new-onset panic attacks or as panic disorderprogresses and worsens. In such presentations, the diagnosis of depersonalization/derealization disorder can be made if 1) the depersonalization/derealization component of the presentation is very prominent from the start, clearly exceeding in duration and intensity the occurrence of actual panic attacks; or 2) the depersonalization/derealization continues after panic disorderhas remitted or has been successfully treated.

Psychotic disorders

The presence of intact reality testing specifically regarding the depersonalization/derealization symptoms is essential to differentiating depersonalization/derealization disorder from psychotic disorders. Rarely, positive-symptom schizophreniacan pose a diagnostic challenge when nihilistic delusions are present. For example, an individual may complain that he or she is dead or the world is not real; this could be either a subjective experience that the individual knows is not true or a delusional conviction.

Substance/medication-induced disorders

Depersonalization/derealization associated with the physiological effects of substances during acute intoxication or withdrawal is not diagnosed as depersonalization/derealization disorder. The most common precipitating substances are the illicit drugs marijuana, hallucinogens, ketamine, ecstasy, and salvia(Simeon et al. 2009). In about 15% of all cases of depersonalization/derealization disorder, the symptoms are precipitated by ingestion of such substances. If the symptoms persist for some time in the absence of any further substance or medication use, the diagnosis of depersonalization/derealization disorder applies. This diagnosis is usually easy to establish since the vast majority of individuals with this presentation become highly phobic and aversive to the triggering substance and do not use it again(Simeon et al. 2009).

Mental disorders due to another medical condition

Features such as onset after age 40 years or the presence of atypical symptoms and course in any individual suggest the possibility of an underlying medical condition. In such cases, it is essential to conduct a thorough medical and neurological evaluation, which may include standard laboratory studies, viral titers, an electroencephalogram, vestibular testing, visual testing, sleep studies, and/or brain imaging. When the suspicion of an underlying seizure disorder proves difficult to confirm, an ambulatory electroencephalogram may be indicated; although temporal lobe epilepsy is most commonly implicated, parietal and frontal lobe epilepsy may also be associated(Lambert et al. 2002).

Comorbidity

In a convenience sample of adults recruited for a number of depersonalization research studies, lifetime comorbidities were high for unipolar depressive disorder and for any anxiety disorder, with a significant proportion of the sample having both disorders. Comorbidity with posttraumatic stress disorder was low. The three most commonly co-occurring personality disorders were avoidant, borderline, and obsessive-compulsive(Simeon et al. 2003).

References: Depersonalization/Derealization Disorder

· Aderibigbe YA , Bloch RR , Walker WR : Prevalence of depersonalization and derealization experiences in a rural population. Soc Psychiatry Psychiatr Epidemiol 36(2):63–69, 2001

· Baker D , Hunter E , Lawrence E , et al: Depersonalisation disorder: clinical features of 204 cases. Br J Psychiatry 182:428–433, 2003

· Hunter EC , Sierra M , David AS : The epidemiology of depersonalisation and derealisation: a systematic review. Soc Psychiatry Psychiatr Epidemiol 39(1):9–18, 2004

· Lambert MV , Sierra M , Phillips ML , David AS : The spectrum of organic depersonalization: a review plus four new cases. J Neuropsychiatry Clin Neurosci 14(2):141–154, 2002

· Lemche E , Surguladze SA , Giampietro VP , et al: Limbic and prefrontal responses to facial emotion expressions in depersonalization. Neuroreport 18(5):473–477, 2007

· Medford N , Baker D , Hunter E , et al: Chronic depersonalization following illicit drug use: a controlled analysis of 40 cases. Addiction 98(12):1731–1736, 2003

· Phillips ML , Medford N , Senior C , et al: Depersonalization disorder: thinking without feeling. Psychiatry Res 108(3):145–160, 2001

· Sierra M , Senior C , Dalton J , et al: Autonomic response in depersonalization disorder. Arch Gen Psychiatry 59(9):833–838, 2002

· Sierra M , Baker D , Medford N , David AS : Unpacking the depersonalization syndrome: an exploratory factor analysis on the Cambridge Depersonalization Scale. Psychol Med 35(10):1523–1532, 2005

· Simeon D , Guralnik O , Hazlett E , et al: Feeling unreal: a PET study of depersonalization disorder. Am J Psychiatry157(11):1782–1788, 2000

· Simeon D , Guralnik O , Schmeidler J , et al: The role of childhood interpersonal trauma in depersonalization disorder. Am J Psychiatry 158(7):1027–1033, 2001

· Simeon D , Guralnik O , Knutelska M , Schmeidler J : Personality factors associated with dissociation: temperament, defenses, and cognitive schemata. Am J Psychiatry 159(3):489–491, 2002

· Simeon D , Knutelska M , Nelson D , Guralnik O : Feeling unreal: a depersonalization disorder update of 117 cases. J Clin Psychiatry 64(9):990–997, 2003

· Simeon D , Knutelska M , Yehuda R , et al: Hypothalamic-pituitary-adrenal axis function in dissociative disorders, post-traumatic stress disorder, and healthy volunteers. Biol Psychiatry 61(8):966–973, 2007

· Simeon D , Kozin DS , Segal K , et al: De-constructing depersonalization: further evidence for symptom clusters. Psychiatry Res 157(1–3):303–306, 2008

· Simeon D , Kozin DS , Segal K , Lerch B : Is depersonalization disorder initiated by illicit drug use any different? A survey of 394 adults. J Clin Psychiatry 70(10):1358–1364, 2009

· Spiegel D , Loewenstein RJ , Lewis-Fernández R , et al: Dissociative disorders in DSM-5. Depress Anxiety 28(9):824–852, 2011 10.1002/da.20874

Other Specified Dissociative Disorder

300.15 (F44.89)

This category applies to presentations in which symptoms characteristic of a dissociative disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the dissociative disorders diagnostic class. The other specified dissociative disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific dissociative disorder. This is done by recording “other specified dissociative disorder” followed by the specific reason (e.g., “dissociative trance”).

Examples of presentations that can be specified using the “other specified” designation include the following:

1. Chronic and recurrent syndromes of mixed dissociative symptoms: This category includes identity disturbance associated with less-than-marked discontinuities in sense of self and agency, or alterations of identity or episodes of possession in an individual who reports no dissociative amnesia.

2. Identity disturbance due to prolonged and intense coercive persuasion: Individuals who have been subjected to intense coercive persuasion (e.g., brainwashing, thought reform, indoctrination while captive, torture, long-term political imprisonment, recruitment by sects/cults or by terror organizations) may present with prolonged changes in, or conscious questioning of, their identity.

3. Acute dissociative reactions to stressful events: This category is for acute, transient conditions that typically last less than 1 month, and sometimes only a few hours or days. These conditions are characterized by constriction of consciousness; depersonalization; derealization; perceptual disturbances (e.g., time slowing, macropsia); micro-amnesias; transient stupor; and/or alterations in sensory-motor functioning (e.g., analgesia, paralysis).

4. Dissociative trance: This condition is characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness may be accompanied by minor stereotyped behaviors (e.g., finger movements) of which the individual is unaware and/or that he or she cannot control, as well as transient paralysis or loss of consciousness. The dissociative trance is not a normal part of a broadly accepted collective cultural or religious practice.

Unspecified Dissociative Disorder

300.15 (F44.9)

This category applies to presentations in which symptoms characteristic of a dissociative disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the dissociative disorders diagnostic class. The unspecified dissociative disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific dissociative disorder, and includes presentations for which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).