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Discriminating among diagnostic categories using the Dissociative Disorders Interview Schedule.

The Dissociative Disorders Interview Schedule was administered to 1,308 subjects in eight diagnostic categories, including 296 with dissociative identity disorder. The study tested three hypotheses: (1) the Mahalanobis distance between dissociative identity disorder and each of seven other diagnostic categories would be large, (2) the closest diagnostic category to dissociative identity disorder would be dissociative disorder not otherwise specified, and (3) nondissociative diagnostic categories would be closer to each other than any one to dissociative identity disorder. All three hypotheses were confirmed by these data. The findings support the conclusion that dissociative identity disorder is a discrete category or taxon.

Adolescent↗

Tracking scientific interest in the dissociative disorders: a study of scientific publication output 1984-2003.

OBJECTIVE: We attempted to track scientific interest in dissociative amnesia and dissociative identity disorder by estimating the annual output of publications regarding these entities over the last 20 years. METHODS: Using a standard medical index, PsycINFO, we counted the number of indexed publications involving dissociative amnesia and dissociative identity disorder listed for each year. We then compared these rates with those of well-established diagnoses such as anorexia nervosa, alcohol abuse, and schizophrenia. We also systematically reviewed all publications involving dissociative amnesia that appeared in 2003. RESULTS: Annual publications involving dissociative amnesia and dissociative identity disorder rose from low levels in the 1980's to a sharp peak in the mid 1990's, followed by an equally sharp decline to only about one quarter of their peak levels by 2002 and 2003. In contrast, all of the 25 comparison diagnoses in our survey showed constant or steadily rising publication rates; none showed the 'bubble' pattern of the dissociative disorders. Of the 34 papers involving dissociative amnesia identified by PsycINFO for 2003, 10 (32%) appeared skeptical of the validity of dissociative amnesia and/or recovered-memory therapy. Despite a detailed search using multiple medical indices and search terms, we could find only 13 explicit cases of individuals with dissociative amnesia worldwide in the 2003 literature. CONCLUSIONS: Dissociative amnesia and dissociative identity disorder have not generated consistent scientific interest over the years, but instead apparently enjoyed a brief period of fashion that now has waned. Overall, our observations suggest that these diagnostic entities presently do not command widespread scientific acceptance.

Amnesia↗

Utilizing hypnosis and ego-state therapy to facilitate healthy adaptive differentiation in the treatment of sexual disorders.

Much of the literature focuses on the pathology that falls to the far right of the Watkins (1997) differentiation-dissociation continuum, such as Dissociative Identity Disorder and Dissociative Disorder NOS. Adding a "far left" to this continuum, as well as a construct of what the "far left" looks like, makes apparent the value of healthy adaptive differentiation for those individuals that fall to the "far left" of the spectrum; those who don't differentiate enough. A discussion of sexual dysfunction at this end of the continuum and cases of Hypoactive Sexual Desire Disorder and Vaginismus demonstrate the clinical effectiveness of an approach combining hypnosis and ego-state therapy to facilitate healthy adaptive differentiation.

Adaptation, Psychological↗

["Multiple personality disorder" in childhood and adolescence].

UNLABELLED: Multiple Personality Disorder (MPD) (ICD 10, DSM-III-R) or Dissociative Identity Disorder (DSM IV) is seen as a dissociative disorder. The diagnosis is mainly made only in adults. Descriptions of MPD in children or adolescents are rare in scientific literature. Both sexual and physical abuse are seen as the most important etiological factors. The diagnostic criteria include the presence of two or more identities within one person, the alternating control of the person's actions by the different personalities and amnesia with regard to episodes in one's life history which cannot be accounted for by forgetfulness. OBJECTIVES: Is MPD diagnosed in children and adolescents? Which criteria are relevant in this disorder? METHODS: All scientific publications found in an online search were individually analyzed. RESULTS: The literature survey yielded 120 published cases of MPD in children and adolescents. The main clinical presentations are affective and anxiety symptoms, auditory hallucinations, amnesia and behavioral disturbances. The sex ratio for children and adolescents is 5:4 f:m, resp. 9:1 for adults. Description of the social and familial backgrounds of children and adolescents with MPD is inadequate. The number of MPD cases among children, adolescents and adults has risen in recent years. CONCLUSION: MPD is diagnosed in children and adolescents. The diagnostic criteria are inconclusive.

Adolescent↗

[Personality disorders and psychopathology following trauma. Reflection on diagnostic classification].

Pervasive personality disorders have been shown to be long-term sequelae of cumulative childhood physical and sexual traumatization. This finding is not reflected in DSM-IV and ICD-10 classifications where post-traumatic stress disorder is confined to intrusions, avoidance, numbing, and hyperarousal. However, there is growing evidence that trauma etiology should be taken into account in planning treatment for personality disorders. It is not yet clear whether childhood traumatization is more strongly associated with borderline personality disorder than with other personality disorders. The finding of a substantial overlap between borderline personality disorder and dissociative identity disorder gives rise to discussions concerning the relationship of these two pathologies.

Adult↗

Dissociative disorders in the psychiatric emergency ward.

OBJECTIVE: The aim of this study was to determine the prevalence of dissociative disorders among emergency psychiatric admissions. METHOD: Forty-three of the 97 consecutive outpatients admitted to the psychiatric emergency unit of a university hospital were screened using the Dissociative Experiences Scale (DES). Seventeen (39.5% of the 43 evaluated) patients with a DES score above 25.0 were then interviewed with the Dissociative Disorders Interview Schedule and the Structured Clinical Interview for Dissociative Disorders. RESULTS: Fifteen emergency unit patients (34.9% of the 43 evaluated participants) were diagnosed as having a dissociative disorder. Six (14.0%) patients had dissociative identity disorder, 6 (14.0%) had dissociative disorder not otherwise specified, and 3 (7.0%) had dissociative amnesia. The average DES score of dissociative patients was 43.7. A majority of them had comorbid major depression, somatization disorder, and borderline personality disorder. Most of the patients with dissociative disorder reported auditory hallucinations, symptoms associated with psychogenic amnesia, flashback experiences, and childhood abuse and/or neglect. CONCLUSIONS: Dissociative disorders constitute one of the diagnostic groups with high relevance in emergency psychiatry.

Adolescent↗

Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity.

OBJECTIVE: To investigate the association of dissociative disorder (DD) with impaired functioning and co-occurring Axis I and personality disorders among adults in the community. METHOD: Psychiatric interviews were administered to a sample of 658 adult participants in the Children in the Community Study, a community-based longitudinal study. RESULTS: Depersonalization disorder (prevalence: 0.8%), dissociative amnesia (prevalence: 1.8%), dissociative identity disorder (prevalence: 1.5%), and dissociative disorder not otherwise specified (prevalence: 4.4%), evident within the past year, were each associated with impaired functioning, as assessed by the clinician-administered Global Assessment of Functioning Scale. These associations remained significant after controlling for age, sex, and co-occurring disorders. Individuals with anxiety, mood, and personality disorders were significantly more likely than individuals without these disorders were to have DD, after the covariates were controlled. Individuals with Cluster A (DD prevalence: 58%), B (DD prevalence: 68%), and C (DD prevalence: 37%) personality disorders were substantially more likely than those without personality disorders were to have DD. CONCLUSIONS: DD is associated with clinically significant impairment among adults in the community. DD may be particularly prevalent among individuals with personality disorders.

Adult↗

Dissociative trance disorder: clinical and Rorschach findings in ten persons reporting demon possession and treated by exorcism.

Although dissociative trance disorders, especially possession disorder, are probably more common than is usually though, precise clinical data are lacking. Ten persons undergoing exorcisms for devil trance possession state were studied with the Dissociative Disorders Diagnostic Schedule and the Rorschach test. These persons had many traits in common with dissociative identity disorder patients. They were overwhelmed by paranormal experiences. Despite claiming possession by a demon, most of them managed to maintain normal social functioning. Rorschach findings showed that these persons had a complex personality organization: Some of them displayed a tendency to oversimplify stimulus perception whereas others seemed more committed to psychological complexity. Most had severe impairment of reality testing, and 6 of the participants had an extratensive coping stile. In this group of persons reporting demon possession, dissociative trance disorder seems to be a distinct clinical manifestation of a dissociative continuum, sharing some features with dissociative identity disorder.

Adult↗

Somatoform dissociation discriminates among diagnostic categories over and above general psychopathology.

OBJECTIVE: The primary aim of this study was to investigate the hypothesis that somatoform dissociation would differentiate among specific diagnostic categories after controlling for general psychopathology. METHOD: The Somatoform Dissociation Questionnaire (SDQ-20), the Dissociative Experiences Scale, and the Symptom Checklist-90-R were completed by patients with DSM-IV diagnoses of dissociative disorders (n = 44), somatoform disorders (n = 47), eating disorders (n = 50), bipolar mood disorder (n = 23), and a group of consecutive psychiatric outpatients with other psychiatric disorders (n = 45), mainly including anxiety disorders, depression, and adjustment disorder. RESULTS: The SDQ-20 significantly differentiated among diagnostic groups in the hypothesised order of increasing somatoform dissociation, both before and after statistically controlling for general psychopathology. Somatoform dissociation was extreme in dissociative identity disorder, high in dissociative disorder, not otherwise specified, and increased in somatoform disorders, as well as in a subgroup of patients with eating disorders. In contrast with somatoform dissociation, psychological dissociation did not discriminate between bipolar mood disorder and somatoform disorders. CONCLUSIONS: Somatoform dissociation is a unique construct that discriminates among diagnostic categories. It is highly characteristic of dissociative disorder patients, a core feature in many patients with somatoform disorders, and an important symptom cluster in a subgroup of patients with eating disorders.

Adult↗

Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic.

The aim of the study was to determine the frequency of dissociative disorders among psychiatric inpatients in Germany and to investigate the relationship between childhood trauma and dissociation. The German version of the Dissociative Experiences Scale (DES), the Fragebogen für Dissoziative Symptome (FDS), was used to screen 115 consecutive inpatients admitted to the psychiatric clinic of a university hospital. Patients with FDS scores higher than 20 were interviewed by a trained clinician, using the German translation of the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R). The German version of the Childhood Trauma Questionnaire (CTQ) was administered to investigate prevalence of childhood trauma and relations between childhood trauma and dissociation in adult life. Twenty-five of the 115 patients (21.7%) had a score higher than 20 on the FDS. Of these, 15 patients were interviewed with the SCID-D-R. One patient was diagnosed with a dissociative identity disorder, three with dissociative disorders not otherwise specified, and one patient with depersonalization disorder. All diagnoses were confirmed clinically. A significant positive relationship was found between the severity of childhood trauma and dissociation. Dissociative disorders are common among German psychiatric inpatients. Clinicians who work in psychiatric inpatient units should be mindful of these disorders.

Adolescent↗

Different types of "dissociation" have different psychological mechanisms.

The term "dissociation" has been used to describe a wide range of psychological and psychiatric phenomena. The popular conception of dissociation describes it as a unitary phenomenon, with only quantitative differences in severity between the various dissociative conditions. More recently, it has been argued that the available evidence is more consistent with a model that identifies at least two distinct categories of dissociative phenomena-"detachment" and "compartmentalization"- that have different definitions, mechanisms and treatment implications (Holmes, Brown, Mansell, Fearon, Hunter, Frasquilho & Oakley 2005). This paper presents evidence for this bipartite model of dissociation, followed by definitions and descriptions of detachment and compartmentalization. Possible psychological mechanisms underlying these phenomena are then discussed, with particular emphasis on the nature of compartmentalization in conversion disorder, hypnosis, dissociative amnesia and dissociative identity disorder.

Amnesia↗

The duality of the brain and the multiplicity of minds: can you have it both ways?

Multiple Personality Disorder (MPD), now known as Dissociative Identity Disorder (DID), has been of great interest to the public for over a century. Case histories of MPD can be found in the literature as far back as the eighteenth century; nevertheless, publications from the latter part of the nineteenth century best describe this disorder as we know it today. This paper traces the case history literature of DID (MPD) from the earliest period to the present. This is done in such a way as to illuminate the basic theoretical and epistemological issues that are necessary to understand the process of dissociation (both normal, and abnormal aspects) and the role of hypnosis and its relationship to organic and 'hysterical epilepsy.' The theories of Fanet, Prince and Sidis are the major authorities discussed. The paper concludes with a discussion of the danger inherent in fostering a deterministic or reductionistic theory of consciousness.

Brain Diseases↗

Canadian and American psychiatrists' attitudes toward dissociative disorders diagnoses.

OBJECTIVE: To compare the opinions of Canadian psychiatrists regarding dissociative disorder diagnoses with those of previously surveyed American psychiatrists. METHOD: We sent a 1-page questionnaire to a stratified representative sample of 550 Canadian psychiatrists. RESULTS: Eighty percent of Canadian psychiatrists responded. Fewer than one-third replied that dissociative amnesia and dissociative identity disorder should be included without reservations in the DSM-IV; fewer than 1 in 7 felt that the validity of these diagnoses was supported by strong scientific evidence. French- and English-speaking Canadians had similar opinions. Overall, Canadians were significantly less accepting than Americans. CONCLUSION: Both Canadian and American psychiatrists show little consensus regarding the diagnostic status or scientific validity of dissociative amnesia and dissociative identity disorder.

Adult↗

Pain-determined dissociation episodes.

OBJECTIVES: Dissociation disorders are a group of conditions characterized by a disruption of integrated function of consciousness, memory, or perception. The purpose of this report is to describe the impact of increased pain levels on the genesis of two types of dissociation disorders, dissociative fugue ( DF) and dissociative identity disorder ( DID), in patients with chronic pain ( PWCP). DESIGN/PATIENTS/INTERVENTIONS/OUTCOME MEASURES: From November 1992 to July 2000, 2 DID and 4 DF patients were identified from 2,544 consecutive PWCP evaluated and/or treated at the University of Miami Comprehensive Pain and Rehabilitation Center. The salient features of these six dissociation PWCP are presented. All four DF PWCP completed a dissociation experience scale first at the time of identification of the dissociation disorder (with chronic pain) and one alleging their experiences with dissociation predevelopment of chronic pain. RESULTS: Frequency percentage for dissociation for this population was 0.235%. For all four of the DF PWCP, dissociation episodes began after the onset of chronic pain. All six (100%) PWCP described or associated their episodes of dissociation to times when their pain would increase. Mean dissociation scale scores for the four DF PWCP were 1.4 +/- 1.11 pre-chronic pain and 20.53 +/- 16.82 at time of identification of the dissociative disorder (with chronic pain). CONCLUSIONS: The frequency percentage for dissociation within PWCP is small compared with psychiatric populations. There may be an etiological association between the development of dissociation episodes and the development of chronic pain and/or increases in chronic pain.

Journal Article↗

Prevalence of dissociative symptoms and disorders in an adult psychiatric inpatient population in Canada.

OBJECTIVE: This study attempted to estimate the prevalence of dissociative symptoms and disorders in a Canadian adult psychiatric inpatient population and also attempted to determine the extent to which dissociative disorders were recognized by the attending clinical staff. METHOD: All appropriate and consenting adult psychiatric inpatients at the Kingston Psychiatric Hospital in Kingston, Ontario, were given the Dissociative Experiences Scale. Patients scoring 25 or greater were interviewed with the Dissociative Disorders Interview Schedule and the Structured Clinical Interview for DSM-IV Dissociative Disorders. Admission or discharge diagnoses data were used to determine whether or not dissociative disorders were being recognized. RESULTS: A total of 48 patients completed the Dissociative Experiences Scale and 14 (29%) scored 25 or greater. The prevalence of dissociative disorders in this hospital population was estimated to be 17%. Dissociative identity disorder was found in six percent, dissociative amnesia in eight percent and dissociative disorder not otherwise specified in two percent of the population. These disorders tended to be under-recognized. CONCLUSION: Research on more extensive populations is required to establish the true prevalence of dissociative symptoms and disorders in psychiatric inpatients.

Adult↗

Prevalence of dissociative disorders among women in the general population.

This study sought to determine the prevalence of dissociative disorders among women in the general population, as assessed in a representative sample of a city in central Turkey. The Dissociative Disorders Interview Schedule (DDIS), the Borderline Personality Disorder section of the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II), and the PTSD-Module of the Structured Clinical Interview for DSM-III-R (SCID) were administered to 628 women in 500 homes. The mean age of participants was 34.8 (S.D.=11.5, range: 18-65); 18.3% of participants (n=115) had a lifetime diagnosis of a dissociative disorder. Dissociative disorder not otherwise specified (DDNOS) was the most prevalent diagnosis (8.3%); 1.1% of the population was diagnosed as having dissociative identity disorder (DID). Participants with a dissociative disorder had borderline personality disorder, somatization disorder, major depression, PTSD, and history of suicide attempt more frequently than did participants without a dissociative disorder. Childhood sexual abuse, physical neglect, and emotional abuse were significant predictors of a dissociative disorder diagnosis. Only 28.7% of the dissociative participants had received psychiatric treatment previously. Because dissociative disorders are trauma-related, significant part of the adult clinical consequences of childhood trauma remains obscure in the minds of mental health professionals and of the overall community. Revisions in diagnostic criteria of dissociative disorders in the DSM-IV are recommended.

Adolescent↗

The Rorschach test in clinical diagnosis: a critical review, with a backward look at Garfield (1947).

The present article comments on a classic study by Garfield (1947) then reviews research on the Rorschach and psychiatric diagnoses. Despite a few positive findings, the Rorschach has demonstrated little validity as a diagnostic tool. Deviant verbalizations and bad form on the Rorschach, and indices based on these variables, are related to Schizophrenia and perhaps to Bipolar Disorder and Schizotypal Personality Disorder. Patients with Borderline Personality Disorder also seem to give an above-average number of deviant verbalizations. Otherwise the Rorschach has not shown a well-demonstrated relationship to these disorders or to Major Depressive Disorder, Posttraumatic Stress Disorder (PTSD), anxiety disorders other than PTSD, Dissociative Identity Disorder, Dependent, Narcissistic, or Antisocial Personality Disorders, Conduct Disorder, or psychopathy.

History, 20th Century↗

Understanding placebo, nocebo, and iatrogenic treatment effects.

Placebo and nonplacebo treatments have both positive and negative effects on patient outcomes. To better understand the patterning of treatment effects, three specific interventions will be discussed that are reported to produce more harm than benefit: critical incident stress debriefing, group therapy for adolescents with conduct disorders, and psychotherapy for dissociative identity disorder. In each case, there is an interaction between mechanisms thought to underlie both placebo and specific treatment effects. Mechanisms hypothesized to underlie placebo and nocebo effects include patient expectancy, self-focused attention to symptoms, motivation to change, and sociocultural role-enactment cues. In the three treatments discussed, specific mechanisms interact with nonspecific mechanisms to produce iatrogenic effects. To advance knowledge, it is important both to specify the theory of treatment and its expected outcomes and to put the theory to test. Only with attention to the empirical findings from programmatic research of specific and nonspecific effects and their interaction is it possible to improve the outcomes of treatment beyond the status quo.

Humans↗