The Diagnostic and Statistical Manual of Mental

Transcription

1 17 Dissociative Disorders ONNO VAN DER HART ELLERT R. S. NIJENHUIS The Diagnostic and Statistical Manual of Mental Disorders (text rev.) (DSM IV TR; American Psychiatric Association [APA], 2000) defines the essential feature of dissociative disorders as a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment (p. 477). Curiously, it does not address the functions of motor control and sensation, even though, by definition, these are also fundamental to an individual s integrated functioning. Dissociative disorders include the following: dissociative amnesia, dissociative fugue, dissociative identity disorder (DID), depersonalization disorder, and a residual category, dissociative disorder not otherwise specified (DDNOS). Neither the definition of dissociation nor the classification of dissociative disorders in DSM IV TR and International Classification of Diseases and Related Health Problems (10th rev) (ICD-10; World Health Organization [WHO], 1992) has consensus within psychiatry. They represent temporary positions, open to debate and modification. In fact, so many definitions of dissociation have been proposed that numerous pleas have been made for the need to reach agreement on the construct (e.g., Holmes et al., 2005; Van der Hart, Nijenhuis, Steele, & Brown, 2004). The development of the DSM V (APA, in press) also invites fresh debates and research, which may lead to new insights and definitions as well as a more satisfactory classification of dissociative disorders. As detailed in this chapter, ongoing deliberations on the conceptualization of dissociation and the planning of new research can be enriched with a thorough understanding of the history of dissociation and the dissociative disorders, which have long been recognized under the label of hysteria. Indeed, what the DSM currently classifies as dissociative disorders and conversion disorders has historically been viewed as the condition of hysteria. An historical discussion of dissociation and the dissociative disorders must therefore include conversion disorder, which was originally an essential manifestation of hysteria. Dissociation and the Dissociative Disorders in Historical Perspective The French psychiatrist Moreau de Tours (1845) was probably the first to use the term dissociation in the social sciences (Dorahy & Van der Hart, 2007; Van der Hart & Horst, 1989). He understood dissociation as a splitting off or isolation of ideas from the ego, as a désagrégation (disaggregation) of the mind. His examination of dissociation took place within the historical context of widespread attention to so-called artificial somnambulism in a variety of patients, most of whom were Blaney-Chap 17.indd 452 8/9/08 5:04:28 PM

2 Dissociative Disorders 453 diagnosed with hysteria (Briquet, 1859). Artificial somnambulism was the term for the emergence of a separate stream of thought and memory, a different existence, operating outside the individual s ordinary conscious awareness, a phenomenon first described by the Marquis de Puységur in the eighteenth century (Crabtree, 1993). In nineteenth-century France the concept of dissociation of the personality or of consciousness referred to this phenomenon. Dissociation of the personality and dissociation of consciousness were used interchangeably. Still other terms were in vogue (Van der Hart & Dorahy, in press), but all involved two ultimately complementary metaphors (O Neil, 1997), one pertaining to a division or splitting, and the other to a doubling or multiplication of the personality. We refer to this conceptualization of dissociation as a structural dissociation of the personality, which involves a lack of integration among two or more psychobiological subsystems of the personality as a whole system, each endowed with at least a rudimentary sense of self (Van der Hart, Nijenhuis, & Steele, 2006). Allport (1961) defined personality as the dynamic organization within the individual of those psychophysical systems that determine his characteristic behavior and thought (p. 28). The term personality thus represents the unique psychobiological system that comprises an individual, however integrated or dissociated among subsystems. This system, and its subsystems, can be described at various levels, that is, biological, psychological, and social. In the old and more recent literature on dissociative disorders, different constructs are used to denote these insufficiently integrated and unduly rigid subsystems. With regard to DID and one DDNOS subgroup, the DSM IV TR speaks of identities or personality states, whereas other sources use expressions such as ego states, dissociative or dissociated states, dissociated self-states, dissociative identity states, (alter) personalities or alters, dissociative or dissociated selves, streams of consciousness, systems of thoughts and functions. Dissociative subsystems are far less than complete personalities but do involve more than a sense of identity or self and in the majority of cases, also include more than one psychobiological state. Each subsystem includes specific subsets of the sum of states that constitute the patient s personality in its entirety, and which are not adequately cohesive and coordinated with the personality. We therefore prefer to call them dissociative parts (of the individual s complete personality) an apt term for clinical practice, as many patients also refer to them as parts of themselves. Pierre Janet Janet (1907) conceptualized hysteria as an illness of the personal synthesis (p. 332), and thus connected the idea of structural dissociation of the personality with hysteria (cf. Putnam, 1989; Van der Kolk & Van der Hart, 1989). The illness involves a form of mental depression [i.e., lowered integrative capacity] characterized by the retraction of the field of consciousness and a tendency to the dissociation and emancipation of the systems of ideas and functions that constitute personality (Janet, 1907, p. 332). Each of these psychobiosocial subsystems or dissociative parts of the personality includes consciousness and its own sense of self, however rudimentary. In the nineteenth and early twentieth centuries, dissociation was not only central to the most complex form of hysteria, that is, DID, formerly known as multiple personality disorder (MPD), but also to its most simple forms such as an anaesthesia of a limb (McDougall, 1926, p. 543). In these cases, the clinician could also observe a secondary thinking purposive agent, a self that, though it may be rudimentary, undeveloped, and greatly restricted in the modes of its activity, has yet the fundamental attributes of a self-conscious entity exercising the function of true memory (p. 543). Janet distinguished between retraction of the field of consciousness and (structural) dissociation, a distinction that is lost in most of the modern literature. Retraction of consciousness implied that individuals have in their conscious thought a very limited number of facts (Janet, 1907, p. 307). It involves a failure to attend to particular stimuli, such that they are never encoded, while in dissociation, these stimuli are encoded in at least one dissociative subsystem of the personality, making them potentially retrievable. Janet acknowledged a role for constitutional vulnerability in illnesses of personal synthesis, but he regarded physical illness, exhaustion, and, especially, vehement emotions (i.e., intense emotional states that include mental and behavioral disorganization) inherent in traumatic experiences as the primary causes of this integrative failure (Janet, 1889, 1909, 1911). The dissociative parts that are most obvious to the observer entail traumatic memories, which Janet 17-Blaney-Chap 17.indd 453 8/9/08 5:04:28 PM

3 454 Other Axis I Syndromes originally described as primary idées fixes (fixed ideas; Janet, 1898; Van der Hart & Friedman, 1989). These systems of ideas [i.e., perceptions, sensations, feelings, thoughts, beliefs] and functions consisted of psychological and physiological phenomena, of images and movements of a multiform character (Janet, 1919/1925, p. 597). When these systems are reactivated, patients are continuing the action, or rather the attempt at action, which began when the [traumatizing event] happened; and they exhaust themselves in these everlasting recommencements (Janet, 1919/1925, p. 663). Janet (1904/1911, p. 528) observed that patients with hysteria, or patients with a dissociative disorder, more simply, traumatized patients alternate between experiencing too little and experiencing too much of their trauma (or whatever else they have not been able to integrate). According to Janet, the more an individual is traumatized, the greater the structural division of that individual s personality: [Potentially traumatizing events] produce their disintegrative effects in proportion to their intensity, duration, and repetition (Janet, 1909, p. 1556). This pioneering clinical observation is confirmed by modern research (e.g., Draijer & Boon, 1993; Macfie, Cicchetti, & Toth, 2001; Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1998a; Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997), although there are also other risk factors for structural dissociation, such as lack of social support in the aftermath of terrifying events (Brewin, Andrews, & Valentine, 2000). Janet also drew upon his careful observations of traumatic memories to explain the distinction between the mental stigmata and the mental accidents that characterize hysteria (Janet, 1901, 1907, 1911; cf. Nijenhuis & Van der Hart, 1999). Mental stigmata are negative dissociative symptoms that reflect functional losses, such as losses of memory (amnesia), sensation (anesthesia), and motor control (e.g., paralysis). Mental accidents are positive dissociative symptoms that involve acute, often transient intrusions, such as additional sensations (e.g., pain), movements (e.g., tics) and perceptions, to the extremes of complete interruptions of the dissociative part of the personality that exerted executive control. These intrusions and interruptions are attributed to a different dissociative part of the patient s personality that might be immersed in the reexperience of traumatizing events. Janet proposed that all negative and positive dissociative symptoms are mental in nature but can manifest in what we call psychoform and somatoform phenomena (Nijenhuis, 2004; Van der Hart et al., 2006). Previously we referred to the former phenomena as psychological dissociation. However, somatoform dissociative symptoms are also psychological in nature, hence our choice for the neologism of psychoform. For example, dissociative amnesia is a negative psychoform dissociative symptom, and intrusion of the voice of one dissociative part into the consciousness of another is a positive psychoform dissociative symptom. Similarly, bodily anesthesia that is observed in one dissociative part but is not found in another part is a negative somatoform dissociative symptom in the former part, and physical movement of one dissociative part that intrudes into the experiential domain of another dissociative part is a positive somatoform dissociative symptom. In short, a negative symptom ( too little ) for one part of the personality can be a positive symptom ( too much ) for another part, and vice versa. Janet regarded DID as the most complex form of structural dissociation and noted differences in character, intellectual functioning, and memory among various dissociative parts of the personality (Janet, 1907). He observed that certain dissociative parts had access only to their own past experience, whereas other parts could access a more complete range of the individual s experience. Dissociative parts could be present side by side and/or alternate with each other. First Half of the Twentieth Century Clinicians and researchers outside of France also emphasized DID, which was considered to be a further division of the basic split of hysteria. Some of these include Frederic Myers in England, and William James, Morton Prince (1906), and Boris Sidis (Sidis & Goodhart, 1904) in the United States. In Switzerland, Eugen Bleuler introduced the concept of schizophrenia in his 1911 book, with the argument that the central deficit was a pathological splitting among various psychological functions. As a result of this splitting, Bleuler argued, at different times, different psychic complexes seem to represent the personality (Bleuler, 1911/1950, p. 9). This depiction of schizophrenia exactly describes contemporary notions of structural dissociation, and indeed, MPD was subsumed for a time under the diagnosis of schizophrenia. Although he did not explicitly link his ideas with Janet s, it has been argued that Bleuler s concept of schizophre- 17-Blaney-Chap 17.indd 454 8/9/08 5:04:28 PM

4 Dissociative Disorders 455 nia owes a great deal to Janet s dissociation theory (Moskowitz, 2006). Ross (2004) has studied many of Bleuler s putative cases of schizophrenia and suggested that some most likely had DID. Indeed, firstranked symptoms of schizophrenia are more common in patients with DID than in patients with schizophrenia (Ellason & Ross, 1995; Kluft, 1987a; Ross, 2004). It is now known that some patients who are dissociative have been misdiagnosed as schizophrenic, and conversely, that many patients with schizophrenia and other psychoses have a history of trauma and comorbid posttraumatic stress disorder (PTSD) or dissociative disorder. Although a minority of patients may have both disorders, there are typically clear clinical distinctions between DID and schizophrenia in spite of their overlaps (Welburn et al., 2003). During World War I, military clinicians knowledgeable about dissociation observed a basic structural division of the personality in traumatized soldiers. For instance, Myers (1940) found that the mental condition in which his patients reexperienced their trauma could best be described as a (dissociated) personality, that is, an emotional personality that was fixated in and reliving the past with vehement emotion and distressing sensorimotor symptoms. The failure to integrate the various sensory and psychological aspects of horrific experiences led to a division of the personality into this emotional personality that remains fixed in traumatic experiences and an apparently normal personality that functions in daily life. Myers conceptual formulation can be regarded as an important precursor to modern claims that acute stress disorder (ASD) and PTSD are dissociative disorders (cf. Chu, 1998; Spiegel & Cardeña, 1991; Van der Hart et al., 2006). In line with Janet and others, Myers also related disturbances in sensory and motor functions to this dissociative division of the personality, that is, somatoform dissociative symptoms. For example, the individual might have a paralyzed and numb limb as the apparently normal (part of the) personality, but not as the emotional (part of the) personality. Initially, Breuer and Freud (1893) agreed with Janet and other French colleagues on dissociation: we have become convinced that the splitting of consciousness which is so striking in the well known classical cases under the form of double conscience [original in French = double consciousness ] is present in a rudimentary degree in every hysteria, and that a tendency to such a dissociation, and with it the emergence of abnormal states of consciousness (...) is the basic phenomenon of this neurosis. (p. 12) [italics in the original] However, following his repudiation of his seduction theory, Freud (1962) labeled somatoform dissociative symptoms as conversion symptoms, based on the idea that unacceptable emotions led to psychological conflict that was then converted into physical symptoms. Although the conversion hypothesis was severely criticized during and after World War I (e.g., McDougall, 1926), and lacks empirical support, the terms conversion and conversion hysteria or disorder became common parlance in psychoanalysis and psychiatry. Among the early psychoanalysts, Sandor Ferenczi was the only one who paid serious attention to the phenomenon of a dissociative personality, not only in traumatized World War I combat soldiers (cf. Van der Hart, Van Dijke, Van Son, & Steele, 2000) but also in adult survivors of chronic childhood abuse and neglect a domain of traumatization severely neglected in psychoanalysis until most recently. Renaissance of Dissociation Dissociative disorders, including dissociative amnesia, dissociative fugue, and DID, attracted only minimal attention in the 1930s, 1940s, and 1950s (Kanzer, 1939; Lipton, 1943; Maddison, 1953; Stengel, 1941; Taylor & Martin, 1944). Various World War II studies focused on acute traumatic amnesia in combat soldiers (D. Brown, Scheflin, & Whitfield, 1999), but without comment on other symptoms of dissociation. The 1950s produced the famous multiple personality case of Eve (Osgood & Luria, 1954; Thigpen & Cleckly, 1957). The general dearth of interest continued until the end of the 1960s, which was marked by a rise in academic, nonclinical interest in dissociation (or, at least, dissociation-like experiences). It was then, for the first time, that the concept of dissociation began to be applied to experiences that were unrelated to divisions of personality and consciousness, such as absorption and daydreams (Ludwig, 1983; Tart, 1969). The important concepts of Janet and others who pioneered work on dissociation seemed to be forgotten, marking the beginning of today s conceptual confusion (Van der Hart & Dorahy, in press; Van der Hart et al., 2004). This confusion has since affected the 17-Blaney-Chap 17.indd 455 8/9/08 5:04:29 PM

5 456 Other Axis I Syndromes development of most of the instruments designed to measure dissociation in the 1980s and 1990s (Van der Hart et al., 2004). It is manifest in many publications on dissociation (e.g., Kihlstrom, Tataryn, & Hoyt, 1993) and compromises the scientific study of dissociation. In his monumental oeuvre, The Discovery of the Unconscious, Ellenberger (1970) reintroduced the modern reader to Janet s dissociative model of hysteria and detailed his role in the development of dynamic psychiatry. At least four other developments occurred in the early 1970s: (1) the publication of Sybil (Schreiber, 1973); (2) the publication of several papers that outlined treatment approaches for DID (e.g., Allison, 1974; Bowers et al., 1971); (3) the publication of one of the first controlled attempts to examine the transfer of cognitive information across so-called dissociative barriers in DID (Ludwig, Brandsma, Wilbur, Bendfeldt, & Jameson, 1972); and (4) the publication of Hilgard s (1974, 1977) neo-dissociation theory. Following Hilgard s contribution, mainstream cognitive psychology became seriously interested in dissociation. Hilgard (1974, 1977) used laboratory-based studies of hypnosis to investigate the nature of dissociation in individuals who are highly hypnotizable. Similar to the studies of artificial somnambulism, Hilgard observed the division of consciousness and the operation of one stream of consciousness outside the awareness of another (i.e., an individual had amnesia in one stream for experiences and behaviors in the other stream). In the language of this chapter, these different streams of consciousness imply some structural psychobiological organization that at least exists for the time that the individual in a suggested hypnotic state. That is, they involve (partially) different psychobiological subsystems that are organized within themselves and within a more complex system, this is, within the individual as a person. During the 1970s, academic, nonclinical interest in dissociation gave way to a significant rejuvenation of clinical interest in dissociation. Like much of the nineteenth-century fin-de-siècle interest in dissociation, the study of clinical dissociation in the late 1970s focused primarily on DID. A rapidly growing number of cases of DID were identified in North America (Kluft, 2003), evoking some scepticism in mainstream psychiatry, which remained largely ignorant of this disorder (Greaves, 1980). The year 1980 was a watershed for the study of dissociation, with a number of seminal publications on DID (e.g., Bliss, 1980; Coons, 1980; Greaves, 1980). In addition, the third version of the DSM was published and included several changes regarding the classification of dissociative disorders. DSM II hysterical neurosis, dissociative type, became organized in a separate category of dissociative disorders that included psychogenic amnesia, psychogenic fugue, multiple personality, depersonalization disorder (formerly depersonalization neurosis had not been categorized as a dissociative disorder in DSM I and DSM II), and atypical dissociative disorder. DSM II hysterical neurosis, conversion type, was subsumed under the new grouping of the somatoform disorders. The DSM III categorization of the dissociative disorders and conversion disorder was not essentially altered in DSM III R and DSM IV TR, and has, as previous editions of the DSM, strongly influenced clinical perceptions and beliefs about what symptoms and mental disorders are considered to be dissociative. Since 1980 the clinical literature on the DSM (III, III R, IV, and IV TR) dissociative disorders burgeoned. Most attention was directed to MPD/ DID, that is, the most complex dissociative disorder (e.g., Bliss, 1986; Braun, 1986; Cohen, Berzoff, & Elin, 1995; Kluft, 1985; Putnam, 1989; Ross, 1989, 1997) An international professional organization devoted to the study of dissociation the International Society for the Study of Multiple Personality & Dissociation was organized in In 1994 it was renamed the International Society for the Study of Dissociation (ISSD) and in 2006 as the International Society for the Study of Trauma and Dissociation (ISSTD), the last name reflecting recognition that chronic dissociation is highly related to trauma. From 1988 to 1997, the journal Dissociation: Progress in the Dissociative Disorders was published; in 2000 it was succeeded by the Journal of Trauma & Dissociation. A landmark publication in 1996, the Handbook of Dissociation (Michelson & Ray, 1996) finally also paid much needed attention to other DSM IV TR dissociative disorders and related phenomena. The 1980s and 1990s also saw the development of various self-report instruments that evaluate the severity of dissociative symptoms, including an instrument measuring peritraumatic dissociation (Marmar et al., 1994), as well as diagnostic instruments for the DSM IV TR dissociative disorders (see below). A wealth of empirical studies has been published about the prevalence of dissociative symptoms among various clinical and nonclinicial populations (cf. Van IJzendoorn & Schuengel, 1996). 17-Blaney-Chap 17.indd 456 8/9/08 5:04:29 PM

6 Dissociative Disorders 457 During the mid-1990s, the memory controversy (D. Brown et al., 1998, 1999; Pezdek & Banks, 1996) challenged the veracity of recovered or delayed memories of traumatizing events, in particular childhood sexual abuse. A number of therapists of patients with DID symptoms were involved in civil court cases pertaining to recovered memories that were purported to be fabrications due to therapist suggestion. Parallel to this heated controversy the validity of the diagnosis of MPD/DID was also challenged but never convincingly refuted (Lilienfeld et al., 1999; Merskey, 1992; Piper, 1994; Spanos, 1994) (see below). In recent years a renewal of interest in the dissociative disorders can be observed. For example, a third special issue on dissociative disorders of Psychiatric Clinics of North America was published (2006) and new books on trauma-related dissociation and dissociative disorders were published (e.g., Anstrop, Benum, & Jacobson, 2006; Deprince & Demarni, 2007; Eckhardt-Henn & Hoffmann, 2004; Howell, 2005; Huber, 2003; Krakauer, 2001; Nijenhuis, 2004; Ogden, Minton, & Pain, 2006; Reddemann, Hofmann, & Gast, 2003; Rhoades & Şar, 2006; Van der Hart et al., 2006; Vermetten, Dorahy, & Spiegel, 2007; Wöller, 2006). The DSM IV TR Dissociative Disorders In DSM IV TR, MPD was renamed dissociative identity disorder, to provide the dissociative disorders with common nomenclature, and to move away from the heavily criticized and misunderstood diagnosis of MPD. Whereas psychogenic amnesia and psychogenic fugue now became dissociative amnesia and dissociative fugue, the dissociative nature of conversion disorder remained unacknowledged. Dissociative Amnesia Criteria. The main DSM IV TR criterion for the diagnosis of dissociative amnesia is the sudden inability to recall personal information that is too extensive to be explained by ordinary forgetfulness. The diagnosis also requires that no other dissociative disorder be present. The lost memories are often of a traumatic or stressful nature (cf. Van der Hart & Nijenhuis, 2001). Dissociative amnesia has been reported in individuals exposed to combat trauma, Holocaust-related traumatization (Van der Hart & Brom, 2000), traumatic loss, robbery, torture, physical abuse, sexual abuse, as well as suicidal acts and criminal acts (D. Brown et al., 1998). Dissociative symptoms, and additional clinical features and disorders. Dissociative amnesia is a negative psychoform dissociative because it involves the absence of a (traumatic) memory in one dissociative part of the personality that can be found intact in another part. Thus the counterpart of the negative symptom in one part is a positive symptom (e.g., reexperience of traumatic memory) in another part. DSM IV TR states that additional features of patients with dissociative amnesia include other (positive psychoform) dissociative symptoms such as spontaneous age regression and trance states, selfmutilation, aggressive and suicidal impulses and acts, and impairment in work and interpersonal relationships, as well as analgesia. Given that all of these features may imply a structural dissociative division of the personality, a more complex dissociative disorder may exist and supercede dissociative amnesia (e.g., Coons & Milstein, 1992; Loewenstein, 1993). Additional comorbid disorders may include conversion disorder (i.e., somatoform dissociative disorder), mood disorder, and personality disorders. Etiology. Whereas a history of childhood trauma has a strong relationship with the disorder of dissociative amnesia (Coons & Milstein, 1992; Loewenstein, 1993, 1996), it is unlikely that potentially traumatizing events in and of themselves evoke the condition. The etiological background of the disorder likely consists of some combination of personal and social factors, such as low integrative capacity, exhaustion, shame, and lack of support, in combination with exposure to potentially traumatizing events. Dissociative Fugue Criteria. The main DSM IV TR criterion for dissociative fugue is sudden, unexpected travel away from home or one s customary place of work, with an inability to recall the past in the absence of another dissociative disorder. Dissociative symptoms. Dissociative fugue involves not only (dissociative) amnesia, but also complex positive dissociative symptoms. In fugues, another part of the personality takes complete control of behavior and consciousness from the part that is 17-Blaney-Chap 17.indd 457 8/9/08 5:04:29 PM

7 458 Other Axis I Syndromes usually present (Coons, 1999; Loewenstein, 1996). Some patients experience complete amnesia for their former identity during the fugue, indicating a strong division between two dissociative parts of the personality. Most have some idea of their identity but cannot recall other important aspects of their lives. Fugues may indicate a quite temporary structural division among parts of the personality, but often they are a manifestation of another dissociative part of the personality that is generally not active in daily life, but rather more internal until the time of fugue. In some cases, patients with fugues involve a dissociative part that continues to function in daily life, although this identity or apparently normal part may take on a different kind of work and display a rather abnormally retracted field of consciousness. In other cases, the dissociative part that engages in the fugue is better understood as an emotional part in Myers sense. For example, sometimes the individual acts in a childlike manner or engage in aggressive, fearful, or confused behaviors. Often patients initially diagnosed with dissociative fugue eventually show indications of a more complex set of dissociative symptoms (Boon & Draijer, 1993; Steinberg, 1995) and may have a more complex dissociative disorder. Additional symptoms and disorders. The associated features and disorders include depression, guilt, aggressive and suicidal impulses, mood disorder, PTSD, and substance-related disorder. Etiology. Patients who have dissociative fugue (as a symptom or as a disorder) typically have a history of severe childhood abuse (Berrington, Liddel, & Foulds, 1956; Kirshner, 1973; Loewenstein, 1993), but fugues can also be related to intense conflicts or otherwise stressful situations such as marital discord, financial difficulties, and war events (Kirshner, 1973; Kopelman, 1987). The patient s conscious awareness seems to be dominated largely by a pathogenic kernel statement or idée fixe, such as I need to get away from it all! (Janet, 1901, 1907; Van der Hart, 1985). Dissociative Identity Disorder (DID) Criteria. The DSM IV TR criteria for DID include the presence of two or more distinct identities or personality states; at least two of these identities or personality states recurrently take control of the person s behavior; and the presence of amnesia. These criteria are sufficiently unclear as to present serious clinical problems in making accurate diagnoses, particularly for the majority of patients with DID symptoms who do not present with flamboyantly different identities (Kluft, 1996a). For example, there is no clarity on the range of what is considered to be a dissociative identity or personality state, or the minimal degree of amnesia that must be present. It does not clarify whether a part must take complete control, or whether passive (internal) influence sufficiently meet the criterion of taking control. Neither does it address dissociative identities that act in the present, but that do not have a particular name or other defining characteristics. Experts therefore urge clinicians to administer psychometrically sound diagnostic instruments (see below) to aid in accurate diagnosis. Dissociative symptoms. Increasing severity of dissociative phenomena occurs along a trauma disorders continuum, with patients with DID manifesting the most severe levels of dissociative symptoms. For example, patients with DID score highest of all populations on self-report questionnaires for psychoform and somatoform dissociative symptoms as well as on diagnostic instruments (Boon & Draijer, 1993; Dell, 2002; Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1996; Nijenhuis et al., 1999; Ross, 1989; Steinberg, 1994; Vanderlinden, 1993; Van IJzendoorn & Schluengel, 1996). Additional symptoms and disorders. The long list of DSM IV TR additional features and disorders that are comorbid with DID include symptoms of PTSD, self-mutilation, aggressive and suicidal behavior, impulsivity, repetitive abusive relationships, conversion symptoms, as well as mood, substancerelated, sexual and eating disorders, and personality disorders. Etiology. Consistent with Janet s hypothesis, DID is particularly associated with prolonged, severe, and early childhood trauma (Chu, Frey, Ganzel, & Matthews, 1999; Coons, 1994; Draijer & Boon, 1993; Hornstein & Putnam, 1992; Lewis, Yeager, Swica, Pincus, & Lewis, 1997; Nijenhuis, 2004; Putnam, Guroff, Silberman, Barban, & Post, 1986). The vast majority of patients with DID (85% to 97%) report severe forms of abuse, and a minority of cases may relate to severe neglect without physical or sexual abuse, as well as highly abnormal parental approaches that induce disorganized/disoriented 17-Blaney-Chap 17.indd 458 8/9/08 5:04:30 PM

8 Dissociative Disorders 459 attachment in the child (Blizard, 2003; Draijer & Langeland, 1999; Liotti, 1999). Although experts maintain that massive exposure to potentially traumatizing events such as chronic childhood emotional, physical and sexual abuse and emotional neglect is a major etiological factor in DID, these are not exclusive etiological factors. Other risk actors that may influence the severity of dissociative symptoms are age of onset of traumatization (Middleton & Butler, 1998; Nijenhuis et al., 1998a), intensity and complexity of the traumatization (Macfie et al., 2001; Nijenhuis, Van der Hart, Kruger, & Steele, 2004) and disorganized attachment in early childhood (Ogawa et al., 1997). Findings regarding a possible role of genetic endowment are inconclusive (Jang, Paris, Zweig-Frank, & Livesley, 1998; Waller & Ross, 1997). Depersonalization Disorder Criteria. The essential features are persistent or recurring episodes of depersonalization characterized by a feeling of detachment or estrangement from one s self, while reality testing remains intact. Dissociative symptoms. DSM IV describes the symptoms of depersonalization disorder as: The individual may feel like an automaton or as if he or she is living in a dream or a movie. There may be a sensation of being an outside observer of one s mental processes, one s body, or parts of one s body (p. 488). In our view, some of these symptoms are cleary dissociative, such as out-of-body experiences that indicate an observing and an experiencing part of the personality. Other symptoms of depersonalization might be better understood as alterations in consciousness that are not necessarily accompanied by a dissociation of the personality: for example, feelings of strangeness or unfamiliarity with oneself, or a sense of unreality such as being in a dream. Associated symptoms and disorders. Depersonalization as a symptom can be accompanied by derealization, anxiety symptoms, depressive symptoms, obssessive rumination, somatic concerns, and a disturbance in sense of time. The symptom is common in individuals with disorders such as hypochondriasis, substance-related disorders, panic disorder, ASD (Harvey & Bryant, 1998), PTSD (Bremner, Steinberg, Southwick, Johnson, & Charney., 1993), and complex dissociative disorders (Boon & Draijer, 1993; Dell, 2002). Etiology. Depersonalization as a symptom is very common in individuals with different types of traumatization (Cardeña & Spiegel, 1993; Carrion & Steiner, 2000; Harvey & Bryant, 1998). It is also the third most common reported symptom among psychiatric patients, after depression and anxiety (Cattell & Cattell, 1974). Thus, depersonalization as a symptom is not unique to structural dissociation of the personality, and DSM IV depersonalization disorder mixes alterations in consciousness with symptoms of structural dissociation of the personality. The symptom can be related to stress and anxiety more generally and can also be an effect of a substance. In some cases, the probable cause of the depersonalization as a symptom or disorder is unclear. Dissociative Disorder Not Otherwise Specified (DDNOS) The DSM IV TR category of DDNOS is a residual diagnostic label, intended to capture disorders whose primary symptoms are dissociative but that do not meet the criteria for any specific DSM IV TR dissociative disorder. The text lists six examples (though it is not limited to these), that is, (1) clinical presentations similar to DID that fail to meet full criteria for this disorder; (2) derealization unaccompanied by depersonalization in adults; (3) dissociative states in individuals who have been subjected to severe coercive persuasion; (4) dissociative trance disorder; (5) medically unexplained loss of consciousness, stupor, or coma; and (6) Ganser syndrome. These examples constitute a heterogeneous grabbag. As will be discussed later, the first condition involves the dissociative disorder with the highest prevalence of all the dissociative disorders (Foote, Smolin, Kaplan, Legatt, & Lipschitz, 2006; Şar, Akyuz, & Dogan, 2007). It pertains to individuals with dissociative symptoms consistent with DID, although less extreme. The identities or dissociative parts exhibit less elaboration and autonomy and are commonly not active or not as active in daily life as some dissociative parts of the personality in patients with DID (Boon & Draijer, 1993; Coons, 1992; Steinberg, 1995). Compared to patients with DID, adults and children with this lesser form of DID have serious, though less severe psychoform and somatoform dissociative symptoms (Nijenhuis et al., 1996, 1999; Putnam, Buchsbaum, & Post, 1993), and less severe personality comorbidity (Boon & Draijer, 1993; Dell, 1998, 2002, 2006a; Steinberg, 1995). They experience prominent positive disso- 17-Blaney-Chap 17.indd 459 8/9/08 5:04:30 PM

9 460 Other Axis I Syndromes ciative symptoms related to the partial intrusion of dissociative parts rather than the complete switches in executive control seen in DID. These research findings and the high prevalence of this dissociative disorder justify the creation of a separate diagnostic entity for this particular example of DDNOS (Şar, 2006). The third example of DDNOS (dissociative states in individuals who have experienced extreme coercive persuasion) is the only dissociative disorder in the DSM IV TR that is explicitly linked with a traumatic cause but lacks a description of dissociative symptoms that might be distinct from other dissociative states. It is unclear why this particular form of traumatization was singled out as being related to DDNOS, as dissociative disorders in general have been related to many types of traumatization. The fourth example pertains to dissociative disorders that are indigenous to particular locations and cultures and lists disorders such as amok (Indonesia), ataque de nervios (Latin America), and possession (India) (p. 490). Although possession is presented as an example in DSM IV TR, it has its own research criteria, and trance and possession disorders constitute a specific group of dissociative disorders in ICD-10. Apart from the fact that possession is not limited to India (e.g., Van Duijl, Cardeña, & De Jong, 2005), this fourth example of DDNOS reveals that the DSM IV TR category of dissociative disorders may include a normative bias toward the typical manifestations of dissociative disorder in Western societies and may not be fully representative of dissociative disorders in other cultures. For example, Alexander, Joseph, and Das (1997) found that a significant percentage of dissociative patients seen in psychiatric practice in India may not fit the DSM IV TR (and ICD-10) defined subcategories of dissociative disorders. Similar conclusions were reached for an Ugandan population (Van Duijl et al., 2005). Nevertheless, highly similar dissociative symptoms may be involved but can be locally interpreted. For example, in Uganda, DID was always diagnosed by local healers as possession disorder. Future research should thus carefully examine to what extent different cultural manifestations of dissociation involve different diagnostic entities or share a common structural division of the personality (cf. Rhoades & Şar, 2006). The fifth example of DDNOS constitutes a specific dissociative (conversion) disorders that is listed in ICD-10 under a larger grouping of dissociative disorders: dissociative stupor. It is unclear why stupor was chosen as a specific type of DDNOS, when historically it was part of conversion disorders, now subsumed under somatoform disorders. The ICD-10 Dissociative Disorders of Movement and Sensation The ICD-10 category of dissociative (conversion) disorders (WHO, 1992) overlaps with the DSM IV TR dissociative disorders but also includes disorders of movement and sensation. These ICD-10 disorders are classified as conversion disorders in the DSM IV TR section of somatoform disorders. They include motor, convulsive, anesthetic, sensory, and mixed dissociative (conversion) disorders. The ICD-10 retains the problematic term conversion for tradition and for reference to the (unsubstantiated) hypothesis that the dissociative disorders of movement and sensation can involve a conversion of affect into a somatoform symptom. The common theme shared by dissociative (or conversion) disorders is a partial or complete loss of the normal integration between memories of the past [sic], awareness of identity and immediate sensations, and control of bodily movements. There is normally a considerable degree of conscious control over the memories and sensations that can be selected for immediate attention and the movements that are to be carried out. In the dissociative disorders it is presumed that this ability to exercise a conscious and selective control is impaired to a degree that can vary from day to day or even from hour to hour. (WHO, 1992, pp ) The dubious grounds for retaining the term conversion in parentheses are tradition and the unsubstantiated hypothesis that conversion involves affect neutralization. There are conceptual, empirical, and clinical cases for including somatoform dissociative disorders in the future DSM V section on dissociative disorders (Bowman, 2006; R. Brown, Cardeña, Nijenhuis, Şar, & Van der Hart, 2007; Kihlstrom, 1992; Nijenhuis, 2004; Van der Hart et al., 2000). For example, the correlation between psychoform and somatoform dissociative symptoms is very high in samples of patients with dissociative disorders and other mental disorders (Dell, 2006a; Nijenhuis, 2004). Furthermore, 17-Blaney-Chap 17.indd 460 8/9/08 5:04:30 PM

10 Dissociative Disorders 461 the severity of somatoform dissociative symptoms correlates with the complexity of the dissociative disorders before and after statistical control for the influence of general psychopathology (Nijenhuis et al., 1999). Somatoform dissociation is also correlated with the degree of reported potentially traumatizing events in a variety of samples, including patients with DSM IV TR conversion disorder (Maaranen et al., 2004; Nijenhuis et al., 1998a; Nijenhuis et al., 2004; Şar, Akyuz, Kundakci, Kiziltan, & Dogan, 2004; Spinhoven et al., 2004), before (Maaranen, Tanskanen, Haaatainen, et al., 2005) and after statistical control for the influence of absorption (Naring & Nijenhuis, 2005). Somatoform dissociation tends to be most strongly associated with major threat to the integrity of the body and pain (Nijenhuis et al., 2003; Nijenhuis et al., 2004; Spinhoven et al., 2004). Some evidence from a general population sample suggests that somatoform dissociation is also correlated with current challenges such as a poor financial situation and inadequate social support (Maaranen, Tanskanen, Honkalampi, et al., 2005). In fact, the etiology of somatoform dissociative disorders may involve a combination of early life stressors and more recent negative life events (Roelofs, Spinhoven, Sandijck, Moene, & Hoogduin, 2005). The reinterpretation of conversion disorder as somatoform dissociation would elucidate why many patients diagnosed with DSM IV TR conversion disorders have major somatoform dissociative symptoms (Kuyk, Spinhoven, Van Emde, & Van Dijck, 1999; Spitzer, Spelsberg, Grabe, Mundt, & Freyberger, 1999), or comorbid DSM IV TR dissociative disorder (Prueter, Schultz-Venrath, & Rimpau, 2002; Tezcan et al., 2003), and why many patients with DSM IV TR dissociative disorders have major somatoform dissociative symptoms and DSM IV TR conversion disorder (Şar, Kundakci, Kiziltan, Bakim, & Bozkurt, 2000). In fact, the two versions of the Somatoform Dissociation Questionnaire (SDQ-20/ SDQ-5; Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1997) are as efficient in the screening for DSM IV TR dissociative disorders as measures of psychoform dissociative symptoms. The ICD-10 category of dissociative (conversion) disorders has its own limitations in that it only highlights a loss of or interference with movements or loss of sensations (WHO, 1992, p. 157), emphasizing negative somatoform dissociative symptoms. Positive sensory dissociative symptoms are vaguely described as additional sensations such as pain and other complex sensation (p. 158). Specific dissociative disorders that essentially involve dissociative sensory intrusions are overlooked. Furthermore, the existence of positive motor dissociative symptoms, such as tics, is not recognized at all. Dissociative Symptoms in Other DSM IV TR Mental Disorders Dissociative symptoms also manifest in other mental disorders than DSM IV TR or ICD-10 dissociative disorders. For example, somatoform dissociation constitutes a major feature of somatization disorder and includes dissociative amnesia (R. J. Brown, Schrag, & Trimble, 2005). Dissociative symptoms are included among the required diagnostic criteria for ASD. They include (1) a subjective sense of numbing, detachment, or absence of emotional responsiveness; (2) a reduction in awareness of his or her surroundings (e.g., being in a daze ); (3) derealization; (4) depersonalization; and (5) dissociative amnesia (i.e., inability to recall an important aspect of the trauma). Reexperiencing traumatizing events is a required diagnostic criterion for PTSD. The fact that it constitues a positive dissociative symptom is not commonly recognized. The description of PTSD in DSM IV TR includes the phrase dissociative flashback episodes but is confusing, in that there is no distinction given between dissociative and nondissociative flashbacks. Our view is that intrusive flashbacks of traumatic memories are always a dissociative symptom. Patient with (simple) PTSD can also have dissociative symptoms such as depersonalization and derealization, but these symptoms are more prominent in patients with a more complex form of PTSD (Zucker, Spinazzola, Blaustein, & Van der Kolk, 2006). Panic disorder is associated with symptoms of depersonalization and derealization (Marshall et al., 2000), but it is unclear whether this involves alterations in consciousness rather than a structural dissociation of the personality per se. Dissociative symptoms are a prominent feature of some patients with borderline personality disorder (BPD; Ebner-Priemer et al., 2005) and are are commonly associated with a reported history of abuse and neglect. One criterion for BPD is transient, stress-related paranoid ideation or severe dissociative symptoms (APA, 1994, p. 654). However, there are no guidelines for deciding when a dissociative symptom is to be classified as an Axis I or an Axis II symptom (Ross, 1999). 17-Blaney-Chap 17.indd 461 8/9/08 5:04:30 PM

11 462 Other Axis I Syndromes Epidemiology of DSM IV TR Dissociative Disorders Independent studies from different countries and cultures show that dissociative disorders are common in general population samples and psychiatric samples (cf. Rhoades and Şar, 2006). However, they are often unrecognized in general clinical practice (Dorahy, Lewis, & Mulholland, 2005). In particular the lack of dissociative disorders sections in general psychiatric screening instruments has resulted in the omission of dissociative disorders in many largescale epidemiologic studies (Şar, 2006). Foote et al. (2006) similarly concluded that dissociative disorders have been previously underdiagnosed in such studies and that a much higher prevalence is encountered with proper screening and diagnostic tools. The prevalence of dissociative disorders varies per study. The disparity is due to cultural and methodological factors, and different views on which mental disorders are dissociative. For example, the choice of diagnostic instruments and cultural differences in interpretation of symptoms at least partially explains the differences in the reported prevalence of dissociative disorders as a group, and of DID as a specific diagnosis in European and North American samples (Friedl, Draijer, & De Jonge, 2000). Furthermore, the DSM IV TR does not capture all cultural-bound pathological manifestations of structural dissociation and is biased toward Western practices (Alexander et al., 1997). The estimated prevalence of dissociative disorders as a generic group is also affected by conceptual factors that may confound diagnoses. Using taxometric techniques and studying North American individuals, Waller and Ross (1997) estimated that 3.3% of the general population has pathological degrees of dissociative symptoms, thus may have a dissociative disorder. The lifetime prevalence of dissociative disorders among women in a general urban Turkish community was 18.3%, with 1.1% having DID (Şar, Akyüz, & Doğan, 2007). In a study of an Ethiopian rural community, the prevalence of dissociative disorders was 6.3%, and these disorders were as prevalent as mood disorders (6.2%), somatoform disorders (5.9%), and anxiety disorders (5.7%) (Awas, Kebede, & Alem, 1999). A similar prevalence of ICD-10 dissociative disorders (7.3%) was reported for a sample of psychiatric patients from Saudi Arabia (AbuMadini & Rahim, 2002). The reported prevalence of DSM IV TR dissociative disorders in psychiatric samples was between 5% (Modestin, Ebner, Junghan, & Erni, 1996) in a Swiss sample, 8% in a Dutch sample (Friedl & Draijer, 2000), 9% in a sample from the United States (Lussier, Steiner, Grey, & Hansen, 1997), 10% (Tutkun et al., 1998) and 12% (Şar, Tutkun, Alyanak, Bakim, & Baral, 2000) in Turkish samples, 15% in another sample from the United States (Saxe et al., 1993), 17% in a Finnish sample (Lipsanen et al., 2004), and 17% in a Canadian sample (Horen, Leichner, & Lawson, 1995). DID is misrepresented in the ICD-10 as a rare disorder. The prevalence of DID found in community samples was between 0.4% (Akyuz, Dogan, Şar, Yargic, & Tutkun, 1999) and 1.5% (Johnson, Cohen, Kasen, & Brook, 2006), whereas its prevalence in psychiatric samples falls in the range of 1% (Rifkin, Ghisalbert, Dimatou, Jin, & Sethi, 1998), and 2% (Friedl & Draijer, 2000), to 5.4% (Tutkun et al., 1998) and 6% (Foote et al., 2006). One North American study found a prevalence of 12% (Latz, Kramer, & Hughes, 1995). Although the latter finding is exceptional and possibly due to site-specific ascertainment biases, it seems safe to conclude that the prevalence of the disorder is probably at least as high as that of schizophrenia, which is not a rare disorder. It is remarkable, and unacceptable from a classificatory point of view, that DDNOS includes the majority of cases of DSM IV TR dissociative disorders. For example, studying a community sample, Johnson et al. (2006) found that the prevalence within the past year of depersonalization disorder was 0.8%, of dissociative amnesia 1.8%, of DID 1.5%, and of DDNOS 4.4%. Şar et al. (2007) documented a lifetime prevalence of DDNOS of 8.3% among women in a Turkish community. Future studies should clarify the distinctive features of this disorder, and whether DDNOS differs from the clinical diagnosis of complex PTSD (Pelcovitz et al., 1997). DSM V should have a new diagnostic entity that classifies patients with this lesser form of DID. Research should also explore to what extent the current DDNOS category includes other dissociative disorders that warrant a separate diagnosis. Despite the growing clinical and research interest in dissociative symptoms and disorders, it is also true that the substantial prevalence rates for dissociative disorders are still disproportional to the number of studies addressing these conditions. For example, schizophrenia has a reported rate of 0.55% to 1% of the normal population (Goldner, Hus, Waraich, & Somers, 2002): more or less similar to 17-Blaney-Chap 17.indd 462 8/9/08 5:04:31 PM