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Transcript of 15 Dissociative Disorders
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org1
Slide show includes
Topic Headings
Tables and Figures
Key Points
Dissociative DisordersJos R. Maldonado, M.D., F.A.P.M., F.A.C.F.E.,
David Spiegel, M.D.
The American Psychiatric Publishing
TEXTBOOK OF PSYCHIATRYFifth EditionEdited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.
2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 15
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org2
CHAPTER 15 Topic Headings
DEVELOPMENT OF THE CONCEPT
MODELS AND MECHANISMS OF DISSOCIATION
Dissociation and Information Processing
Dissociation and Memory Systems
Dissociation and Trauma
Universality and Transcultural Aspects of
Dissociation
ACUTE STRESS DISORDER
DISSOCIATIVE AMNESIA
TreatmentDISSOCIATIVE FUGUE
DEPERSONALIZATION DISORDER
Treatment
DISSOCIATIVE IDENTITY DISORDER
(MULTIPLE PERSONALITY DISORDER)
Prevalence
Course
Comorbidity
Genetics
Psychological TestingPhysiological Measures
Treatment
Psychotherapy
Cognitive-Behavioral Approaches
Psychopharmacology
OtherTherapeutic Approaches
Legal Aspects of Memory Work and Hypnosis
Recall
DISSOCIATIVE TRANCE DISORDERCultural Context
Classification
Dissociative Trance
Possession Trance
Treatment
DISSOCIATIVE DISORDERCONVERSION TYPE?
CONCLUSION
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org3
CHAPTER 15 Tables and Figures
Table 151. DSM-IV-TR dissociative disorders
Table 152. Differences between dissociation and repression
Figure 151. Hippocampal and amygdalar volumes in patients with dissociative identity disorder
(DID) and healthy comparison subjects.
Table 153. DSM-IV-TR diagnostic criteria for acute stress disorder
Table 154. DSM-IV-TR diagnostic criteria for dissociative amnesia
Table 155. DSM-IV-TR diagnostic criteria for dissociative fugue
Table 156. DSM-IV-T
R diagnostic criteria for depersonalization disorderTable 157. DSM-IV-TR diagnostic criteria for dissociative identity disorder
Table 158. Rules of engagement in the treatment of dissociative identity disorder
Table 159. Guidelines for the use of hypnosis in memory work
Table 1510. DSM-IV-TR research criteria for dissociative trance disorder
Table 1511. Comparison of Western and Eastern types of dissociative syndromes
Summary Key Points
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org4
TABLE 151. DSM-IV-TR dissociative disorders
The dissociative disorders involve a disturbance in the integrated organization of identity, memory,
perception, or consciousness. Events normally experienced on a smooth continuum are isolated from
the other mental processes with which they would ordinarily be associated (Table 151).
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org5
TABLE 152. Differences between dissociation and repression
Repression as a general model for keeping information out of conscious awareness differs from dissociation
in six important ways (Table 152).
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org6
FIGURE 151. Hippocampal
and amygdalar volumes in
patients with dissociative
identity disorder (DID) and
healthy comparison subjects.
There is recent evidence of a possible
neural basis for the difficulty
integrating traumatic memory and
components of identity and
consciousness among those with
dissociative disorders. Using magneticresonance imaging, Vermetten et al.
(2006) found that hippocampal and
amygdalar volumes were significantly
smaller (19% and 32%, respectively) in
patients diagnosed with dissociative
identity disorder compared with
healthy volunteers (Figure 151).
aSignificant difference between groups (P< 0.05, ttest for
nonpaired samples).
Source. Reprinted from Vermetten E, Schmahl C, Lindner S,
et al: Hippocampal and Amygdalar Volumes in Dissociative
Identity Disorder. American Journal of Psychiatry163:630636,
2006. Copyright 2006. Used with permission.
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org7
TABLE 153. DSM-IV-TR diagnostic criteria for acute stress disorder
Although acute stress disorder is classified among the anxiety disorders in DSM-IV-TR, we address it
here because half of the symptoms of this disorder are dissociative in nature (Table 153).
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org9
TABLE 155. DSM-IV-TR diagnostic criteria for dissociative fugue
Dissociative fugue combines failure of integration of certain aspects of personal memory with
loss of customary identity and automatisms of motor behavior (Table 155).
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org10
TABLE 156. DSM-IV-TR diagnostic criteria for depersonalization disorder
The essential feature of depersonalization disorder is the occurrence of persistent feelings of
unreality, detachment, or estrangement from oneself or ones body, usually with the feeling that one is
an outside observer of ones own mental processes. Thus, depersonalization disorder is primarily a
disturbance in the integration of perceptual experience (Table 156).
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
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TABLE 157. DSM-IV-TR diagnostic criteria for dissociative identity disorder
The number of reported dissociative identity disorder cases has risen considerably in recent years.
Factors that may account for this increase include a more general awareness of the diagnosis among
mental health professionals; the availability, starting with DSM-III (American Psychiatric Association
1980), of specific diagnostic criteria (Table 157); and reduced misdiagnosis of DID as schizophrenia
or borderline personality disorder.
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
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TABLE 158. Rules of engagement
in the treatment of dissociative
identity disorder
Maldonado (2000) described a series of
rules of engagement (Table 158) to be
used in the treatment of dissociative
identity disorder.
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
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TABLE 159. Guidelines for the use
of hypnosis in memory work
Maldonado (2000) summarized and
adapted the guidelines provided by the
American Medical Association (Orne et
al. 1985) and the American Society of
Clinical Hypnosis (Hammond et al. 1995)
for the use of hypnosis as a method ofmemory enhancement (Table 159).
(continued)
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
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TABLE 159. (continued)
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
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TABLE 1510. DSM-IV-TR research criteria for dissociative trance disorder
The DSM-IV Task Force voted to include dissociative trance disorder in an appendix to DSM-IV to
stimulate further research on the question of whether it should be a separate Axis I disorder rather than
an example in the category of dissociative disorders not otherwise specified (Table 1510).
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
16
TABLE 1511. Comparison of Western and Eastern types of dissociative syndromes
Dissociative trance disorder has been divided into two broad categories: dissociative trance and
possession trance (Table 1511).
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
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CHAPTER 15 Key Points
Dissociative disorders are underdiagnosed.
Dissociation is a common component of acute response to trauma, anddissociative fugue, amnesia, and identity disorders often have a traumatic
etiology.
Dissociation represents a failure of integration of identity, memory,
perception, and consciousness.
The primary treatments for dissociative disorders involve various
psychotherapies, including hypnosis, trauma-related psychotherapies, andcognitive therapies.
Common comorbid conditions requiring treatment include depression,
substance use disorders, and borderline personality disorder.
Dissociative symptoms are ubiquitous around the world, but the content of
the dissociative symptoms varies, involving possession by external entities
more often in the East, and fragmentation of individual identity in the West.