Dissociative Disorders: Textbook of Psychiatry

The American Psychiatric Publishing
TEXTBOOK OF PSYCHIATRY
Fifth Edition
Edited 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
Dissociative Disorders
José R. Maldonado, M.D., F.A.P.M., F.A.C.F.E.,
David Spiegel, M.D.
Slide show includes…

Topic Headings
Tables and Figures
Key Points
The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, 1
Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 15 • Topic Headings
DEVELOPMENT OF THE CONCEPT Genetics

Psychological Testing
MODELS AND MECHANISMS OF DISSOCIATION
Physiological Measures
Dissociation and Information Processing
Treatment
Dissociation and Memory Systems
Psychotherapy
Dissociation and Trauma
Cognitive-Behavioral Approaches
Universality and Transcultural Aspects of
Psychopharmacology
Dissociation
Other Therapeutic Approaches
ACUTE STRESS DISORDER Legal Aspects of Memory Work and Hypnosis
Recall
DISSOCIATIVE AMNESIA
Treatment DISSOCIATIVE TRANCE DISORDER
Cultural Context
DISSOCIATIVE FUGUE
Classification
DEPERSONALIZATION DISORDER Dissociative Trance
Treatment Possession Trance
DISSOCIATIVE IDENTITY DISORDER Treatment
(MULTIPLE PERSONALITY DISORDER) DISSOCIATIVE DISORDER—CONVERSION TYPE?
Prevalence
CONCLUSION
Course
Comorbidity
CHAPTER 15 • Tables and Figures
Table 15–1. DSM-IV-TR dissociative disorders

Table 15–2. Differences between dissociation and repression
Figure 15–1. Hippocampal and amygdalar volumes in patients with dissociative identity disorder
(DID) and healthy comparison subjects.
Table 15–3. DSM-IV-TR diagnostic criteria for acute stress disorder
Table 15–4. DSM-IV-TR diagnostic criteria for dissociative amnesia
Table 15–5. DSM-IV-TR diagnostic criteria for dissociative fugue
Table 15–6. DSM-IV-TR diagnostic criteria for depersonalization disorder
Table 15–7. DSM-IV-TR diagnostic criteria for dissociative identity disorder
Table 15–8. “Rules of engagement” in the treatment of dissociative identity disorder
Table 15–9. Guidelines for the use of hypnosis in memory work
Table 15–10. DSM-IV-TR research criteria for dissociative trance disorder
Table 15–11. Comparison of Western and Eastern types of dissociative syndromes
Summary Key Points
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 15–1).
TABLE 15–1. DSM-IV-TR dissociative disorders
Repression as a general model for keeping information out of conscious awareness differs from dissociation
in six important ways (Table 15–2).
TABLE 15–2. Differences between dissociation and repression
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 magnetic
resonance 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 15–1).
FIGURE 15–1. Hippocampal

and amygdalar volumes in
patients with dissociative
identity disorder (DID) and
healthy comparison subjects.
a
Significant difference between groups (P < 0.05, t test 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 Psychiatry 163:630–636,
2006. Copyright 2006. Used with permission.
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 15–3).
TABLE 15–3. DSM-IV-TR diagnostic criteria for acute stress disorder
The hallmark of dissociative amnesia is the inability to recall important personal information,
usually of a traumatic or stressful nature, which cannot be explained by ordinary forgetfulness
(Table 15–4).
TABLE 15–4. DSM-IV-TR diagnostic criteria for dissociative amnesia
Dissociative fugue combines failure of integration of certain aspects of personal memory with
loss of customary identity and automatisms of motor behavior (Table 15–5).
TABLE 15–5. DSM-IV-TR diagnostic criteria for dissociative fugue
The essential feature of depersonalization disorder is the occurrence of persistent feelings of
unreality, detachment, or estrangement from oneself or one’s body, usually with the feeling that one is
an outside observer of one’s own mental processes. Thus, depersonalization disorder is primarily a
disturbance in the integration of perceptual experience (Table 15–6).
TABLE 15–6. DSM-IV-TR diagnostic criteria for depersonalization 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 15–7); and reduced misdiagnosis of DID as schizophrenia
or borderline personality disorder.
TABLE 15–7. DSM-IV-TR diagnostic criteria for dissociative identity disorder
Maldonado (2000) described a series of
“rules of engagement” (Table 15–8) to be
used in the treatment of dissociative
identity disorder.
TABLE 15–8. “Rules of engagement”

in the treatment of dissociative
identity disorder
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 of
memory enhancement (Table 15–9).
TABLE 15–9. Guidelines for the use

of hypnosis in memory work
(continued)
TABLE 15–9. (continued)
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 15–10).
TABLE 15–10. DSM-IV-TR research criteria for dissociative trance disorder
Dissociative trance disorder has been divided into two broad categories: dissociative trance and
possession trance (Table 15–11).
TABLE 15–11. Comparison of Western and Eastern types of dissociative syndromes
CHAPTER 15 • Key Points
 Dissociative disorders are underdiagnosed.

 Dissociation is a common component of acute response to trauma, and
dissociative 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, and
cognitive 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.

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DEVELOPMENT OF THE CONCEPT Genetics

Table 15–1. DSM-IV-TR dissociative disorders

TABLE 15–1. DSM-IV-TR dissociative disorders

TABLE 15–2. Differences between dissociation and repression

FIGURE 15–1. Hippocampal

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

TABLE 15–3. DSM-IV-TR diagnostic criteria for acute stress disorder

TABLE 15–4. DSM-IV-TR diagnostic criteria for dissociative amnesia

TABLE 15–5. DSM-IV-TR diagnostic criteria for dissociative fugue

TABLE 15–6. DSM-IV-TR diagnostic criteria for depersonalization disorder

TABLE 15–8. “Rules of engagement”

TABLE 15–9. Guidelines for the use

TABLE 15–10. DSM-IV-TR research criteria for dissociative trance disorder

TABLE 15–11. Comparison of Western and Eastern types of dissociative syndromes

 Dissociative disorders are underdiagnosed.

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