ArticlePDF Available

Figures

Research Article
DEPRESSION AND ANXIETY 28 : 824– 852 (2011)
DISSOCIATIVE DISORDERS IN DSM-5
David Spiegel, M.D.,
1
Richard J. Loewenstein, M.D.,
2,3
Roberto Lewis-Ferna
´ndez, M.D.,
4,5
Vedat Sar, M.D.,
6
Daphne Simeon, M.D.,
7
Eric Vermetten, M.D. Ph.D.,
8
Etzel Carden
˜a, Ph.D.,
9
and Paul F. Dell, Ph.D.
10
Background: We present recommendations for revision of the diagnostic criteria
for the Dissociative Disorders (DDs) for DSM-5. The periodic revision of the
DSM provides an opportunity to revisit the assumptions underlying specific
diagnoses and the empirical support, or lack of it, for the defining diagnostic
criteria. Methods: This paper reviews clinical, phenomenological, epidemiolo-
gical, cultural, and neurobiological data related to the DDs in order to generate
an up-to-date, evidence-based set of DD diagnoses and diagnostic criteria for
DSM-5. First, we review the definitions of dissociation and the differences
between the definitions of dissociation and conceptualization of DDs in the
DSM-IV-TR and the ICD-10, respectively. Also, we review more general
conceptual issues in defining dissociation and dissociative disorders. Based on
this review, we propose a revised definition of dissociation for DSM-5 and
discuss the implications of this definition for understanding dissociative
symptoms and disorders. Results: We make the following recommendations
for DSM-5:
1. Depersonalization Disorder (DPD) should derealization symptoms as
well.
2. Dissociative Fugue should become a subtype of Dissociative Amnesia
(DA).
3. The diagnostic criteria for DID should be changed to emphasize the
disruptive nature of the dissociation and amnesia for everyday as well as
traumatic events. The experience of possession should be included in the
definition of identity disruption.
4. Should Dissociative Trance Disorder should be included in the
Unspecified Dissociative Disorder (UDD) category.
Conclusions: There is a growing body of evidence linking the dissociative
disorders to a trauma history, and to specific neural mechanisms. Depression and
Anxiety 28:824–852, 2011. r2011 Wiley-Liss, Inc.
Key words: hypnosis; breast cancer; sleep; stress
Published online in Wiley Online Library (wileyonlinelibrary.com).
DOI 10.1002/da.20874
Received for publication 8 March 2010; Revised 23 June 2011;
Accepted 24 June 2011
Correspondence to: David Spiegel, Department of Psychiatry,
Stanford University, Palo Alto, California.
E-mail: dspiegel@stanford.edu
The authors report they have no financial relationships within the
past 3 years to disclose.
1
Department of Psychiatry, Stanford University, Palo Alto,
California
2
Sheppard Pratt Health System, Towson, Maryland
3
Department of Psychiatry, University of Maryland, Maryland
4
Department of Psychiatry, Columbia University, Columbia
5
New York State Psychiatric Institute, New York
6
Department of Psychiatry, Istanbul University, Istanbul
7
Psychiatry and Behavioral Sciences, Albert Einstein
College of Medicine, New York
8
University Medical Center, Utrecht, The Netherlands
9
Department of Psychology, Lund University, Lund, Sweden
10
Trauma Recovery Center, Norfolk, Virginia
rr
2011 Wiley-Liss, Inc.
INTRODUCTION
In this article, we present recommendations for
revision of the diagnostic criteria for the Dissociative
Disorders (DDs) for DSM-5. The periodic revision of
the DSM
[1–3]
provides an opportunity to revisit the
assumptions underlying specific diagnoses and the
empirical support, or lack of it, for the defining
diagnostic criteria. This article reviews clinical, phenom-
enological, epidemiological, cultural, and neurobiologi-
cal data related to the DDs in order to generate an up-
to-date, evidence-based set of DD diagnoses and
diagnostic criteria for DSM-5.
First, we review the definitions of dissociation and
the differences between the definitions of dissociation
and conceptualization of DDs in the DSM-IV-TR
[4]
and the ICD-10,
[5]
respectively. Also, we review more
general conceptual issues in defining dissociation and
DDs. Based on this review, we propose a revised
definition of dissociation for DSM-5 and discuss the
implications of this definition for understanding
dissociative symptoms and disorders.
Next, we review a series of questions related to the
proposed DSM-5 DDs section and, when needed,
revised diagnostic criteria for the DSM-5 DDs.
These include:
1. Should Depersonalization Disorder (DPD)
remain in the DSM-5 DDs section, or should
it be moved to another section of the DSM-5?
Or, should DPD be considered a symptom of
another disorder or disorders, such as anxiety
disorders, psychotic disorders, personality dis-
orders, etc.? If DPD continues as a distinct
DD, what is the relationship of symptoms of
depersonalization to symptoms of derealization
in the proposed diagnostic criteria?
2. Should Dissociative Amnesia (DA) continue to
be conceptualized as a DD, or should it be
included in another section of the DSM that
emphases, emphasizing its relationship to
trauma, e.g. part of the symptom clusters for
Acute Stress Disorder (ASD) or Posttraumatic
Stress Disorder (PTSD)?
3. Does the totality of the data support Dissocia-
tive Fugue (DF) as a separate diagnostic
category in the DSM? Or should this diagnosis
be eliminated? Or is DF better conceptualized
under the rubric of another DD such as
Dissociative Identity Disorder (DID), or DA,
or as an example of DD Not Otherwise
Specified (DDNOS)?
4. Should the diagnostic criteria for DID be
changed? If so, should the diagnostic criteria
follow a polythetic form, a mixed polythetic/
monothetic form, or remain a monothetic
criteria set with modifications?
5. Should Dissociative Trance Disorder (DTD),
currently included only in the appendix of
DSM-IVTR, be conceptualized as a specific
DD in DSM-5? Or, if not, should it be
conceptualized within the framework of an-
other DD, such as DID?
6. Given the proposed reconceptualization of
several of the DDs, what examples should
be generated to assist the clinician in making
a diagnosis of DDNOS, as opposed to a
specific DD?
7. Finally, we review recent data, particularly
neurobiological data, supporting the
diagnostic categories of the DDs, in part to
address lingering controversies about these
disorders.
DEFINING DISSOCIATION AND
DISSOCIATIVE DISORDERS
Neither the DSM-IVTR of the American Psychiatric
Association (APA)
[3]
nor the ICD-10 of the World Health
Organization (WHO)
[5]
provides a comprehensive defi-
nition of dissociation. Instead, each sets forth a brief
description of the ‘‘essential features’’ (DSM-IV) or the
‘‘common theme’’ (ICD-10) of the DDs. Among other
issues, the DSM-IV-TR and ICD-10 conceptualizations
of dissociation are inconsistent regarding which disorders
belong in the DD category, as well as the number,
symptoms, course, and outcome of DDs. For example,
ICD-10 regards all DDs as equivalent to Conversion
Disorders, including among the DDs pseudo-epileptic
seizures (non-epileptic seizures or NES), ‘‘psychogenic
aphonia’’ and dissociative ‘‘anesthesia and sensory loss,’’
among others. The DSM-IV-TRIVTR and ICD-10
DDs are listed in Table 1.
TABLE 1. DSM-IVTR dissociative disorders and
ICD-10 dissociative (conversion) disorders
DSM-IVTR dissociative disorders
Depersonalization disorder
Dissociative amnesia
Dissociative fugue
Dissociative identity disorder
Dissociative disorder NOS
ICD-10 dissociative disorders
Dissociative amnesia
Dissociative fugue
Dissociative stupor
Trance and possession disorders
Dissociative motor disorders
Dissociative convulsions
Dissociative anesthesia and sensory loss
Mixed dissociative (conversion) disorders
Other dissociative (conversion) disorders
Ganser’s syndrome
Multiple personality disorder (DID)
Transient dissociative (conversion)
Disorders in children and adolescents
Dissociative [conversion] disorder, unspecified
825Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
Recent research documents the utility of combining
the concepts of the domain of dissociative symptoms
from both the DSM-IV and the ICD-10 in a new
definition for DSM-5.
[6–9]
Dissociation is a disruption of and/or discontinuity
in the normal, subjective integration of one or more
aspects of psychological functioning, including—but
not limited to—memory, identity, consciousness, per-
ception, and motor control. In essence, aspects of
psychobiological functioning that should be associated,
coordinated, and/or linked are not.
In more acute pathological dissociative presenta-
tions, the dissociation is primarily related to
traumatic and/or overwhelming experiences. In
life-long dissociative presentations such as
Dissociative Identity Disorder (DID) dissociative
symptoms may routinely also occur in circum-
stances that are unrelated to trauma or overwhelming
circumstances.
Dissociative symptoms are not merely failures of
normal neurocognitive functioning, they are also
perceived as disruptive—as a loss of needed information,
as discontinuity of experience, or as ‘‘recurrent, jarring,
involuntary intrusions into executive functioning and
sense of self’’
[10]
(p 226). Dissociative symptoms invade
and interfere with the person’s continuity of normal
psychological functioning by intruding on and/or
deleting aspects of conscious experience, thought, or
action.
[11]
Dissociative symptoms can be classified as
‘‘positive’’ or ‘‘negative.’Positive dissociative symptoms
(e.g. flashbacks and/or the sudden interruption of
conscious experience by an aspect of identity that had
not previously been part of the person’s awareness or
social interaction)which interfere with or intrude upon
the person’s normal interference, and intrusion symp-
toms). Negative dissociative symptoms disrupt normal
conscious functioning via deficits in memory, sense of
self,, and/or the ability to sense or control different
parts of the body.
In summary. Pathological dissociation is experi-
enced as an involuntary disruption of the normal
integration of conscious awareness and control over
one’s mental processes. Dissociative symptoms can
manifest in every area of psychological functioning.
Dissociative symptoms are characterized by (a) un-
bidden and unpleasant intrusions into awareness and
behavior, with accompanying losses of continuity in
subjective experience: (i.e. ‘‘positive’’ dissociative symp-
toms); and/or (b) an inability to access information or
to control mental functions that normally are readily
amenable to access or control: (i.e. ’’ negative’’
dissociative symptoms).
The DSM-IV states that ‘‘the essential feature’ of the
DDs is a disruption in the ‘‘usually integrated functions of
consciousness, memory, identity, or perception.’’ [
[3]
,
p 519], whereas in the ICD-10, ‘‘the common theme
shared by dissociative (or conversion) disorders is a
partial or complete loss of the normal integration
between memories of the past, awareness of identity
and immediate sensations, and control of bodily
movements.’’ [
[4]
, p 151]. Importantly, the ICD-10
describes DDs as primarily acute disorders that usually
remit within a few weeks or months, and that have an
onset in the immediate context of events that are highly
stressful, traumatic, and/or that involve intolerable,
insoluble problems. In contrast, the DSM-IVTR
conceptualizes several DDs as long-term, chronic
disorders, including DID and some forms of DPD,
DA, and DDNOS.
In formulating a more rigorous definition of
dissociation and the domain of dissociation, it is
helpful to make explicit the conceptual confusion
that has often afflicted the construct of dissociation.
For example, one observer quipped, ‘‘the term dissocia-
tion suffers from multiple meaning disorder’’ (Stephen
Marmer, M.D., personal communication, Chicago, IL,
1993). In short, the term dissociation has been
used to describe a variety of different concepts at
various levels of theoretical abstraction. This situation
is reflected in Kluft’s (unpublished) description of over
201different uses of the term dissociation in the
literature.
This article is not the place to review this complex
issue; for an in-depth discussion of much of this, see the
reviews of Carden
˜a and Dell, as well as others.
[12–15]
However, in the literature, dissociation has been used
to describe a range of dimensional,adaptive processes not
just categorical disorders). There is a tendency to
conflate the dimensional and the categorical concep-
tualizations of dissociation, leading to confusion about
what is being described. The ICD discussion of the
DDs emphasizes the categorical psychopathological
notion,: ‘‘The term ‘‘conversion’’ is widely applied to
some of these disorders and implies that the unpleasant
affect, engendered by the problems and conflicts that
the individual cannot solve, is somehow transformed
into symptoms’’ [
[4]
, p 152]. On the other hand, the
DSM-IVTR minimizes the idea that dissociation can
be adaptive (see, the sections on the DDs and
Conversion Disorders).
[16]
The current DSM system places Conversion Dis-
orders among the Somatoform Disorders. Indeed,
Brown et al.
[17]
among others, have recommended
that Conversion Disorders be reunited with the
DDs in DSM-5. The DSM-IV-TR classifies DPD as
a DD, but the ICD-10 classifies DPD under ‘‘other
neurotic disorders.’’ The ICD classifies ‘‘Multiple
Personality Disorder’’ among ‘‘Other DDs, whereas
the DSM-IVTR classifies DID as a separate disorder.
ICD-10 includes Trance and Possession Disorders
(TPD) among the DDs, but in DSM-IVTR DTD
appears in Appendix B: ‘‘Criteria Sets and Axes
Provided for Further Study.’’ In many ways, the ICD
approach to the DDs bears greater similarity to the
DSM-II
[18]
where Hysterical Neurosis was divided into
a ‘‘Conversion type’’ and a ‘‘Dissociative type’’ and
DPD was listed as a separate ‘‘Depersonalization
Neurosis.’’
826 Spiegel et al.
Depression and Anxiety
DIMENSIONAL AND CATEGORICAL
CONCEPTS OF DISSOCIATION
The term dissociation has been used to describe a
variety of processes of the human mind, including
‘‘normal’’ aspects of focused or divided attention and
absorption,
[19,20]
some of which may underlie hypnotic
capacity;
[21]
‘‘semi-independent mental modules’’ that
are not consciously accessible [
[6]
, p 16]; and altered
states of consciousness that can be activated in a variety
of contexts such as religious ecstasies, hypnotic
experience, and/or during traumatic or overwhelming
experiences.
[12,19,21–23]
Dissociation also describes a
psychobiological trait that can be measured in various
populations.
[24]
Taxon analysis has shown that there
may be two categorically distinct dissociative dimen-
sions: ‘‘nonpathological’’ and ‘‘pathological.’’
[25–27]
In
addition, dissociation is used to describe an intrap-
sychic defense, conceptualized in psychodynamic
terms, which can occur in the context of acute trauma,
as well as in later responses to the person’s intrapsychic
experience of trauma, overwhelming experiences, and/
or intolerable conflict engendered by these.
[23,28,29]
Inherent in many of the dimensional conceptualiza-
tions is the adaptive nature of dissociation in the context
of acute or chronic danger and/or trauma, as well as for
psychological survival in the context of inescapable
chronic threat or captivity.
[23,30–33]
Thus, in the
literature, dissociation is described both as a dimen-
sional adaptation as well as a categorical form of
psychopathology. This may seem inherently contra-
dictory. However, in the treatment of DDs, attention to
both conceptualizations of dissociation is helpful in
recognizing the adaptive resources that many dissocia-
tive patients bring to treatment, as well as in not
romanticizing the severely disruptive symptoms, life
dysfunction, and distress that dissociative patients
experience.
[34,35]
Also, attention to the different ways
in which the term dissociation is used may be helpful in
clarifying discussions among different groups of
clinicians and researchers who might otherwise appear
to be talking past each other in discussing different
aspects of dissociation and the DDs. However, it is
difficult to describe DDs without making reference to
the adaptive and maladaptive aspects of dissociation, as
will be apparent in our subsequent discussions.
NONPATHOLOGICAL AND PATHOLOGICAL
DISSOCIATION
Defining the ‘‘normal’’ or ‘‘usually integrated’’ func-
tions of the mind is not a trivial issue, although an in-
depth discussion is well beyond the scope of this review.
In general, dissociative symptoms are conceptualized as
more pervasive, disruptive, and/or distressing than
normal psychobiological capacities and their failures
(e.g. ordinary forgetting, absorption in imaginative
activities, uncertainty whether one has done something
or not, etc.) However, rather than a continuum of
dissociation from ‘‘normal’’ to ‘‘pathological,’’ taxon
analysis suggests a categorical division between two
continua: the normal and the pathological.
[26,36]
Dalenberg
[20]
has offered an alternative view that, at
least in part, normal dissociative capacities and
responses, particularly the capacity for absorption,
may more represent substrates for pathological dissocia-
tion, rather than phenomena that are categorically
different. This view may have support in genetic
studies of dissociation (see below, section on genetic
studies).
[37]
However, it is consistent with a stress-
diathesis explanation of the adaptive/pathological
dissociation distinction.
[25,38]
Indeed, these may not
be incompatible models. At extreme levels of patholo-
gical dissociation, with multiple chronic complex
symptoms that pervasively recruit and modify normal
tendencies, especially beginning in early development,
qualitative and categorical differences may emerge
between normal and pathological dissociation.
The DSM and ICD formulations originate in Janet’s
conceptualization of dissociation, which he termed
‘‘de´sagre´gation mentale’’.
[39]
Janet postulated that a
failure of integration of mental elements was the
fundamental aspect of hysterical (i.e. dissociative and
conversion) disorders. These ideas also fit modern
connectionist, ‘‘bottom-up’’ models of mental proces-
sing, such as the parallel distributed processing model
proposed by McClelland and Rumelhart.
[40,41]
In this
computational model of neural networks, integration
of information is a goal, rather than a given. Neural
systems that process the simultaneous firing of millions
of neurons must extract coherence. Accordingly, it is
not surprising that complete integration of the
information is not always achieved. Such neural nets
may become ‘‘stuck’’ in local minima, unable to proceed,
unless some new ‘‘activation energy’’ is introduced.
This conceptualization has been used as a mathema-
tical model for dissociative phenomena.
[42]
DISSOCIATIVE SYMPTOMS AND THE
SUBJECTIVE EXPERIENCE OF
DISSOCIATION
In addition, it may be helpful to understand that the
subjective experience of dissociative symptoms may
differ due to a variety of factors in different diagnostic
groups within the DDs category. For example, DID is
currently understood as a complex posttraumatic
developmental disorder that usually begins before the
age of 5–6.
[43,44]
It is hypothesized that, after that
developmental window, the consolidation of a more
unified sense of subjective self and other developmental
cognitive changes have occurred. This leads to different
kinds of identity disturbances than that of the DID
alternate identities in response to overwhelming and/or
traumatic circumstances, although other complex dis-
sociative symptoms may continue to develop.
[22]
Individuals with DID and related forms of childhood
onset complex DDs experience a life-long adaptation to
chronic complex dissociative symptoms. For example,
827Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
these individuals may only realize in later life that not
everyone has amnesia for significant parts of ongoing
experience and/or that, in most families, adults do not
have sex with children. In addition, dissociation may
protect the person from awareness of dissociative
symptoms themselves. For example, individuals with
DA may not recall that they have demonstrated
amnesia for personal experience in the clinical inter-
view; they display ‘‘amnesia for amnesia.’’
[45]
Thus, individuals with childhood-onset DDs may
have a different relationship to these life-long symp-
toms than individuals who develop adult-onset dissocia-
tive symptoms during an episode of acute trauma, and
different again from chronic DPD patients who often
describe continuous, painfully acute awareness and
extreme distress at depersonalization symptoms that
usually develop during adolescence or adulthood.
[46]
Due to the adaptive nature of dissociation, indivi-
duals with childhood-onset chronic DDs may experi-
ence more distress at the consequences of the
dissociation, not necessarily at the dissociative symp-
tom per se. For example, a teacher becomes angry at a
child with dissociative identity disorder (DID) who
cannot recall ever having known important academic
information that the teacher insists the child seemed to
know well previously.
[45]
On the other hand, the DID
person may experience more direct distress at intrusive
symptoms: e.g. dysphoric ‘‘made’’ feelings, disquieting
intrusions of painful body sensations without cognitive
referent or sense of subjective ownership, finding him/
herself in the midst of circumstances with no memory
of how he/she has arrived there, and so on.
[47]
It is hypothesized that dissociative symptoms reduce
subjective distress both in the immediate context of
stress or trauma, as well as later when the dissociative
processes protect the individual from full awareness of
stressful, disquieting, and/or traumatic information.
[23]
It is also hypothesized that dissociative symptoms (e.g.
such as DA, ongoing derealization and depersonaliza-
tion, sequestration of traumatic information from
ongoing awareness, and other dissociative processes)
may diminish distress for the dissociative child growing
up under conditions of continual threat, fear, and
helplessness in chronically dysfunctional, violent, and/
or traumatizing circumstances. In this instance, dis-
sociation may operate as a resiliency factor, allowing the
development of the capacity for attachment, even to
traumatizing and/or neglectful care-givers, as well as
permitting the development of more normal social,
cognitive, intellectual, and self-observation capaci-
ties.
[33,48,49]
This is especially true in circumstances
requiring conflicting roles in relation to a parent who is
both protective and traumatizing, referred to as
‘‘betrayal trauma.’
[33,49]
From a dimensional and psychodynamic viewpoint,
one can understand dissociation, particularly in the
childhood-onset forms, as a major aspect of organizing
psychological experience and of intra-psychic defense.
Accordingly, dissociative processes characterize major
aspects of many of these individuals’ psychological life.
An important consequence of childhood-onset DDs is
that dissociative symptoms may occur in everyday
contexts, in response to life stresses that are not
traumatic stress.
[22]
The notion that dissociative
processes exist to reduce at least some aspects of
subjective distress is consistent with the neurobiologi-
cal data that individuals with dissociative forms of the
PTSD show ‘‘emotional overmodulation’’ with in-
creased activation of the orbitofrontal cortex inhibiting
activation of the amygdala and insular cortex, as
discussed below.
[50]
Similarly, neurobiological data
from studies of individuals with global DA and normal
highly hypnotizable subjects with posthypnotic amne-
sia show frontal cortex inhibition of hippocampal areas,
as well as occipital cortex, an area also thought to be
associated with retrieval of episodic autobiographical
memory.
[51–53]
Metaphorically speaking, fundamental aspects of
dissociative responding can be conceptualized in terms
of ‘‘detachment’’ or ‘‘compartmentalization.’’
[54]
Detachment includes depersonalization/derealization
experiences; and compartmentalization includes dis-
sociative experiences such as amnesia or separation of
memory material from one’s ongoing sense of self, etc.
Unfortunately, dissociation generally interferes with
processing of traumatic experiences, leaving memory
material in nonverbal, emotionally overwhelming,
usually imagic and sensory form.
[55,56]
Episodic failures or breakdowns of dissociation may
result in dissociative flashbacks and other forms of
posttraumatic intrusive symptoms. At such times,
presumably, the frontal cortex can no longer inhibit
the hippocampus, amygdala, insula, and related struc-
tures. Executive functioning may also be problematic,
since the intrusive symptoms overwhelm the dissocia-
tive person’s psychological resources and/or the trau-
matic memories are subject to re-dissociation with a
return to impaired accessibility. These circumstances
may have significant implications for treating dissocia-
tive forms of posttraumatic disorders.
[50]
In particular,
dissociative patients frequently may have a poor
response to unmodified forms of exposure-based
treatments. Thus, major proponents of exposure treat-
ment for the PTSD consider viewing severe dissocia-
tion to be a contraindication for exposure-based
therapy.
[57]
Phasic treatment models with an emphasis
on symptom management skills, modulation of dis-
sociation, and development of safety as the primary
tasks of treatment, appear to have better outcomes for
dissociative forms of PTSD and severe DDs.
[35,58]
DIFFERENTIAL DIAGNOSTIC
CONSIDERATIONS BETWEEN DDs AND
PSYCHOTIC DISORDERS
Phenomenological studies show that psychotic and
dissociative processes may produce symptoms that
superficially resemble each other, but have differing
828 Spiegel et al.
Depression and Anxiety
etiologies, treatment response, and presumptive psy-
chobiology. For example, Kluft and Ross et al.
[47,59]
reported high rates of apparent First Rank Symptoms
(FRS)
[60]
in DID patients—even higher than in some
studies of patients with diagnosis of schizophrenia. In a
general population study, Ross and Joshi reported that
FRS were strongly correlated with reported childhood
trauma and dissociative symptoms.
[61]
Dell
[7]
reviews a
number of subsequent studies, as well as his own data,
that have replicated these findings.
A number of studies have shown that DDs are often
misdiagnosed as a psychotic disorder and such patients
may suffer iatrogenic worsening of their disorders due
to years of misdiagnosis and mistreatment.
[62,63]
In
addition, studies of both psychotic disorders and DDs
may be confounded by the inclusion of misdiagnosed
subjects. Indeed, if misdiagnosed dissociative subjects
were removed from research cohorts of presumptive
psychotic subjects, this could also enhance the study of
the diagnosis, treatment, and psychobiology of psy-
chotic disorders. The correct diagnosis of each
diagnostic group is vital for clinical work as well as
for research.
[35]
Some commentators have voiced concerning that a
broader definition of dissociation from those of the
DSM-IVTR and the ICD-10 will lead to overdiagnosis
of DDs in individuals who actually meet diagnostic
criteria for psychotic disorders or mood disorders with
psychotic features (Michael First, American Psychiatric
Association, San Diego, CA, May 23, 2007). However,
validation studies of the Dissociative Experiences Scale
(DES),
[26,64,65]
the DDs Interview Schedule (DDIS),
[66]
and the Structured Clinical Interview for DSM-IV
DDs
[67–69]
show that DDs can be distinguished from
psychotic disorders (and other disorders
[70]
) with
excellent discriminant validity.
[8]
Thus, there are a
variety of clinical and psychometric inventories that
robustly distinguish the DDs from the psychotic
disorders.
[58]
Psychological testing studies have also shown sig-
nificant differences in the extent of traumatic respond-
ing, personality organization, capacity for attachment,
reality testing, relationship to reality, self-observation
capacity, and capacity for logical, reality-based thinking
in severely dissociative as compared to psychotic
patients.
[48,71–73]
Also, from a treatment perspective,
hallucinations in DDs generally do not to respond to
very high-dose antipsychotic regimens, even with several
antipsychotic medications.
[74]
In general, dissociative
hallucinosis does respond to psychotherapeutic interven-
tions such as mobilizing the ‘‘hallucinations’’ in therapy,
with or without the formal use of hypnosis.
[35,75]
Posttraumatic content may manifest in complex
perceptual and somatosensory hallucinatory symptoms,
without the person consciously knowing to what those
hallucinations relate.
[76]
Dissociative patients may have
reexperiences or reenactments of trauma during which
they believe that they are actually in a different time/
place undergoing that traumatic experience.
[23]
Patients with this presentation, who also report multi-
modal dissociative hallucinosis, may fit the putative
diagnostic construct of dissociative (hysterical) psycho-
sis (see below)
[77–79]
that was presumably subsumed
under the DSM-III category of Brief Reactive Psycho-
sis.
[80]
From a reality-testing standpoint and due to
temporarily disorganized behavior, they may appear
functionally ‘‘psychotic,’’ but the etiology of the
process is posttraumatic and dissociative.
Beside constituting a separate disorder on its own (see
below the section on DDNOS-7), dissociative (hyster-
ical) psychosis may be superposed on a chronic complex
DD such as DID or DDNOS-1 in terms of a crisis
condition (207, 210). In a patient with DID who is
controlled by the host identity most of the time (with
the alter identities being suppressed), this equilibrium
may disappear when stressful events occur. This may
reactivate many suppressed alternate identities as the
host personality can no longer stay dominant, and
severe dissociative symptoms and flashbacks may cause
a ‘‘‘dissociative (hysterical) psychosis’’[
[81]
, pp. 165–175].
Internal conflicts may also lead to a struggle for control
and influence between alternate identities who have
frightening, fearful, aggressive, or delusional features,
and some of whom may have been long dormant.
[82]
This condition has been called a ‘‘revolving door’
[45]
or
‘‘coconsciousness’’ crisis.
[81]
The former refers to rapid
switching between alternate identities because of a
struggle for control, while the latter refers to a transient
collapse of dissociative barriers. So, dissociative (hys-
terical) psychosis may be a ‘‘diagnostic window’’ for
DID in some cases. As such, dissociative (hysterical)
psychosis may be a gateway leading to the discovery of
chronic DDs in countries where clinicians are more
familiar with acute presentations of DDs.
These cases should not be confused with patients
who not only have an underlying schizophrenic
disorder but also report dissociative symptoms as an
additional phenomenon. Some authors prefer to
describe this phenomenon as a dissociative subtype of
schizophrenia which is, unlike dissociative (hysterical)
psychosis, not limited to an acute episode.
[83,84]
Dissociative patients do not report delusional ex-
planations for hallucinations or FRS. Rather, they tend
to experience these symptoms as inexplicable and
frightening: indicators that they are ‘‘crazy.’’
[85]
Accord-
ingly, they usually attempt to hide/rationalize the
existence of the symptoms and may avoid disclosing
them in a clinical interview due to fear and shame.
[71]
In Kluft’s classic 1987 study,
[86]
the DID patients did
not endorse thought broadcasting, audible thoughts, or
delusional perception; i.e. they did not have a psychotic
boundary disturbance nor show true delusional
thinking. Further, dissociative/posttraumatic thought
disorders differ from psychotic thought disorders in
that the thought disturbances usually center on a sense
of subjective self-division (e.g. that alter identities do
not inhabit the same body), and misattribution of blame
and responsibility for traumatic experiences.
[71,87,88]
829Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
Dissociative auditory hallucinations tend to be com-
plex and personified. They have a range of subjective
qualities, from ‘‘free-lance thoughts’’ to multiple simul-
taneous inner conversations. These dissociative auditory
hallucinations have a variety of content: pejorative,
commanding self-harm or suicide
1
; supportive; childlike;
neutral (i.e. discussing everyday topics like the weather or
sports); joking; fearful and suspicious; protective and
supportive; persecutory, etc. DD subjects may also have
musical hallucinations and auditory hallucinations of a
variety of other sounds.
[43]
Visual hallucinations in DDs are best understood as
images of alternate identities, vivid partial flashbacks, or
attempts to transform or disguise distressing mental
contents.
[89]
Posttraumatic content may also be a part of
complex hallucinatory symptoms with perceptual and
somatosensory phenomena that occur without the
person consciously knowing what they relate to.
[76]
Reports of dissociative FRS may have a complex, often
almost poetic quality: ‘‘I feel like someone else wants to
cry with my eyes’y‘I get those ghost feelings,’’ etc..
[90]
Also, highly hypnotizable subjects can readily be
made to hallucinate in all sensory dimensions, as well as
to experience ‘‘negative’’ hallucinations (i.e. sensory
experiences are ablated from conscious perception).
[91]
Individuals with DID have been shown to have the
highest hypnotizability of any clinical group and PTSD
patients also have high hypnotizability.
[92,93]
Patients
with DID and related disorders commonly describe
hallucinations in all perceptual domains: auditory,
visual, olfactory, tactile, gustatory, and somatosensory,
as well as negative hallucinations.
[90]
Importantly,
psychotic patients have significantly lower hypnotiz-
ability compared to other clinical groups, again
suggesting that dissociative and psychotic hallucinatory
phenomena have different etiologies.
[91,93–95]
In summary, the above findings are consistent with
the hypothesis that dissociative FRS and hallucinations
have a different etiology from psychosis.
DPD AND DEREALIZATION
*Should DPD remain in the DSM-5 DDs section, or
should it be moved to another section of the DSM-5?
Or, should DPD be considered a symptom of
another disorder or disorders, such as anxiety
disorders, psychotic disorders, personality dis-
orders, etc.? If DPD continues as a distinct
disorder, what is the relationship of symptoms of
depersonalization to symptoms of derealization
in the proposed diagnostic criteria? In DSM-
IVTR, depersonalization is separated from de-
realization, with the latter placed in examples of
DDNOS. In ICD-10, although DPD is not
included in the DDs, the diagnostic criteria
include both depersonalization and derealization.
The diagnostic criteria for DPD from both
volumes are listed in Table 2. Support for the
continuing inclusion of DPD in the DDs has several
components. Depersonalization and derealization
are highly prevalent in other DDs ranging from
peritraumatic dissociation to DID, although they
also occur in mood, anxiety, obsessive–compulsive,
and schizophrenic disorders, among others.
[44]
RELATIONSHIP TO STRESS AND TRAUMA
Depersonalization and derealization are quintessen-
tial responses to acute trauma; they are highly prevalent
in those subjected to motor vehicle accidents, emo-
tional/verbal abuse, and imprisonment, among
others.
[31,96–100]
Clinical reports describe devastating
effects of verbal/emotional abuse on traumatized
individuals.
[101]
Sierra,
[102]
among others, has proposed
that depersonalization is a ‘‘hard-wired’’ inhibitory
response—part of the human psychobiological survival
system—that attenuates anxiety and fosters psychobio-
logical hyperarousal to help preserve adaptive behavior
and to conserve physical resources under conditions of
threat and danger. Disorders related to depersonaliza-
tion may represent generalization and persistence of
this response outside the context of immediate threat,
just as PTSD fear reactivity can be understood, in part,
to be as a generalization of the adaptive, conditioned
fear response beyond the immediate context where it
TABLE 2. DSM-IVTR and ICD-10 diagnostic criteria
for depersonalization disorder
Diagnostic Criteria for DSM-IVTR Depersonalization Disorder (300.6)
A. Persistent or recurrent experiences of feeling detached from, and
as if one is an outside observer of, one’s mental processes or body
(e.g. feeling like one is in a dream)
B. During the depersonalization experience, reality testing remains
intact
C. The depersonalization causes clinically significant distress or
impairment in social, occupational or other important areas of
functioning
D. The depersonalization experience does not occur exclusively
during the course of another mental disorder, such as
Schizophrenia, Panic Disorder, ASD, or another Dissociative
Disorder, and is not due to the direct physiological effects of a
substance (e.g. a drug of abuse, a medication) or a general medical
condition (e.g. tempoDral lobe epilepsy)
Diagnostic Criteria for ICD-10 Depersonalization Disorder (F48.1)
Either of both (a) and (b) plus (c) and (d)
a. Depersonalization symptoms, i.e. the individual feels that his or her
own feelings and/or experiences are detached, distant, not his or
her own, lost, etc
b. Derealization symptoms, i.e. objects, people, and/or surrounding
seem unreal, distant, artificial, colourless, lifeless, etc
c. An acceptance that this is a subjective and spontaneous change, not
imposed by outside forces or other people (i.e. insight)
d. A clear sensorium an absence of toxic confusional state or epilepsy
ASD, acute stress disorder.
1
These kinds of hallucinations may lead more to a diagnosis of a
psychotic depression than schizophrenia.
830 Spiegel et al.
Depression and Anxiety
was generated. Recent neurobiological studies have
shown that childhood verbal/emotional abuse can
be related to a variety of psychobiological alterations.
These include high dissociation scores on the DES,
limbic system abnormalities, alterations in gray matter
volume, and changes in fractional anisotropy of white
matter in the corpus callosum, corona radiata, and
other areas, comparable to those found in individuals
with histories of childhood sexual abuse.
[99,103,104]
NOSOLOGY
Studies of two large cohorts
[46,105]
have documented
a consistent nosology for DPD, including age of onset,
acute and remote antecedents, symptomatology, cog-
nitive organization, course, treatment response (pri-
marily lack of treatment response), and gender
ratio.
[106]
Factor analysis from these studies suggest
that DPD symptoms are characterized by either four or
five factors: numbing, unreality of self, unreality of
other, temporal disintegration, and perceptual altera-
tions (i.e. micropsia/macropsia, out of body experi-
ences, and feelings of unreality of objects and one’s own
body).
[106]
These studies did not find any distinction
between patients with predominant depersonalization
versus those with predominant derealization, belying
the DSM-IVTR’s separate categorization of DPD and
‘‘IVTR derealization without depersonalization’’ (an
example of DDNOS).
EPIDEMIOLOGY
Studies from countries including the United States,
Canada, UK, Turkey, and Germany have shown a
prevalence for DPD in the range of 0.8–2.8%,
[24,107–110]
comparable to that of other DSM-IVTR disorders such
as schizophrenia, bipolar disorder, and Obsessive
Compulsive Disorder (OCD).
COMORBIDITY
Due to the high rates of depersonalization as a
symptom in other disorders, some have asked whether
DPD is a distinct disorder.
[111]
The studies cited above
only included subjects in whom the onset and course of
DPD was clearly distinct from that of the comorbid
disorders, such as mood, anxiety, and personality
disorders. Chronic depersonalization has been reported
to begin in a variety of contexts, including over-
whelming and/or traumatic circumstances, during an
episode of substance abuse, an episode of a mood or
anxiety disorder, as well as spontaneously.
[106]
How-
ever, in DPD the depersonalization persists after the
comorbid conditions have remitted.
Like PTSD, DPD may become chronic early in life,
or may have a delayed onset, triggered by a stress later
in life. In some DPD patients, anxiety and mood
disorders develop secondary to (i.e. after the onset of)
DPD;
[44]
this is similar to some patients with OCD
who develop secondary mood disorders.
[112]
In short,
just as anxiety or depression, comorbidity with other
morbid psychiatric disorders does not preclude the
existence of anxiety or depression as separate diagnostic
entities, so too, the comorbity of depersonalization
with other psychiatric disorders does not preclude its
existence as a separate diagnostic entity.
NEUROBIOLOGY
Persons with DPD have similar neurobiological
patterns to those of persons with other DDs.
[50]
In
brief, neuroimaging studies of DPD have documented
a consistent tripartite pattern of altered activation:
(1)findings: activation in posterior cortical sensory
association areas, especially the inferior parietal lobule;
(2) prefrontal activation; and (3) limbic inhibition.
[46,50]
These findings are unlike those seen in mood and
anxiety disorders. They are consistent with the
replicated finding of inferior parietal lobule involve-
ment in simulated out-of-body experiences
[113]
and
altered experiences of agency in healthy volunteers.
[114]
Also, these findings are similar to imaging findings in
those PTSD patients displaying a unique pattern of
psychobiological responses to trauma scripts, thought
to characterize a distinct dissociative subtype of
PTSD.
[115–117]
In addition, these findings are consis-
tent with rCBF studies of DID patients with alternate
identities who do not report experiencing the persons
unique trauma scripts as autobiographical memory.
[118]
Individuals with DPD have a different pattern of
hypothalamic–pituitary–adrenal axis dysregulation
compared with patients with PTSD, as well as those
with other mood and anxiety disorders.
[119]
DPD is
characterized by HPA axis baseline hyperactivity and
diminished negative feedback inhibition
[119,120]
with
blunted reactivity to psychosocial stress. This pattern is
different from that found in major depressive disorder,
where baseline hypercortisolemia is accompanied by
heightened HPA axis response to stressors in someone
but not all
[121]
studies. Simeon et al.
[122]
found that, in
DPD patients, basal norepinephrine declined markedly
as dissociation increased in response to anxiety, despite
evidence of increased noradrenergic tone. Sierra
et al.
[123]
found that DPD patients showed a blunted
skin conduction response (SCR) to emotional stimuli,
compared with normal controls and those with anxiety
disorders. In summary, these findings are consistent
with the hypothesis that there is autonomic blunting in
DPD. In a review of the (limited) psychopharmacolo-
gical treatments for DPD, Sierra
[102]
suggested that
possible agents and neurobiological targets for DPD
might include CB1 cannabinoid agonists, kopioid
agonists, NMDA antagonists, and 5HT2C agonists.
CROSS-CULTURAL ASPECTS OF DPD
Castillo
[124]
has described a set of DPD symptoms that
potentially broadens the cross-cultural validity of DPD.
Castillo’s cluster of symptoms is similar to the more
recent data-derived factor analytic models in Western
831Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
samples: persistent or recurrent experiences
of depersonalization and/or derealization in which
familiar experiences of the self and environment become
distorted, potentially resulting in physical and emotional
numbing; alterations in body image; experiences of being
an outside observer of one’s mental processes or body;
feeling like an automaton; time disturbances; feeling as if
one’s body or environment is ‘‘unreal’’o dreamlike. Visual
distortions (including micropsia, macropsia, teleopsia,
pelopsia, metamorphopsia, and loss of stereoscopic depth
perception). Relevant to diagnosis, the depersonaliza-
tion/derealization experience does not occur exclusively
during a culturally approved religious or ritual activity,
and is not considered normal by the patient’s own
cultural standards.
PROPOSED DSM-5 DIAGNOSTIC
CRITERIA
In summary, we propose that DPD should continue
to be included in the DDs category in DSM-5. The
totality of the data support the notion that chronic
persistent depersonalization/derealization does com-
prise a distinct disorder, that this disorder more
resembles than differs from other DDs, and can be
understood in terms of the basic psychobiology of
human response to threat and danger.
DPD symptoms are validated for more than a single
symptom, and these symptom factors should be
addressed in the diagnostic criteria and described in
the text for the disorder. Recent research supports the
ICD-10 notion that both depersonalization and/or
derealization can characterize DPD and the diagnostic
criteria for DPD and the DDNOS examples should be
changed accordingly.
PROPOSED DSM-5 DIAGNOSTIC CRITERIA
FOR DEPERSONALIZATION
DEREALIZATION DISORDER (300.6)
A. The patient can have either A1, A2 or both:A1.
Persistent or recurrent experiences for at least
1 month of feeling detached from, or as if one
is an outside observer of, one’s mind or body
(e.g. feeling like one is in a dream; sense of
unreality of self, perceptual alterations; emo-
tional and/or physical numbing; distorted
sense of time)A2. Persistent or recurrent
experiences for at least 1 month of unreality
of surroundings (e.g. the world around the
person is experienced as unreal, dreamy,
detached, foggy, or visually distorted)
B. During the depersonalization or derealization
experiences, reality testing remains intact
C. Significant distress or dysfunction
D. The depersonalization or derealization experi-
ences do not occur exclusively as symptoms of
another mental disorder, such as Schizophrenia,
Panic Disorder, ASD, or another DD, and are
not due to the direct physiological effects of a
substance (e.g. a drug of abuse, a medication) or a
general medical condition (e.g. complex partial
seizures).
DISSOCIATIVE AMNESIA AND
DISSOCIATIVE FUGUE
1. Should DA continue to be conceptualized as a
DD, or should it be included in another section
of the DSM, emphasizing its relationship to
trauma, e.g. as part of the symptom clusters for
ASD or PTSD? We begin the discussion of
question 1 by discussing the definition, char-
acteristics, and phenomenology of DA.
DEFINITION OF DISSOCIATIVE AMNESIA
DA has been described in the literature in three
major ways
*A clinical symptom or phenomenon of reported or
displayed prior or current autobiographical mem-
ory deficits for aspects of the life history, primarily
related to reported traumatic, stressful, and/or
overwhelming experiences (e.g. childhood sexual
or physical abuse, combat, concentration camp
experiences, sexual assault, natural disaster, etc). In
many of these studies, the DA is only recognized
subsequent to recall of the memories that were
unavailable. This is often called ‘‘recovered
memory,’’ or, more neutrally and precisely, ‘‘de-
layed recall for traumatic experiences.’’
[125–131]
*A DSM-IVTR DD: DA.
*A diagnostic criterion symptom of other DSM-
IVTR disorders: ASD, PTSD, Somatization
Disorder, DF, Dissociative Identity Disorder,
and DDNOS example 1. The diverse definitions
of DA in the DSM-IVTR and the ICD-10,
respectively, are found in Table 3. Apropos of
their respective definitions of dissociation, DSM-
IVTR, and ICD-10 have somewhat differing
conceptualizations of DA. ICD-10 emphasizes
recent, acute stressful events as precipitants of
amnesia, whereas DSM-IVTR posits a broader
domain of personal information (i.e. beyond the
frankly traumatic) as precipitants of DA that may
involve ‘‘some or all of one’s past.’’ Moreover,
DSM-IVTR implies that DA may occur for
events throughout the life history, not just recent
events. Based on the above definitions, the
domain of DA is bordered on the one hand by
the Cognitive Disorders and, on the other, by
‘‘Ordinary Forgetfulness.’’ Differential diagnosis of
DA and Cognitive Disorders have been discussed
in several reviews.
[43,132,133]
Salient differences
832 Spiegel et al.
Depression and Anxiety
between DA and Cognitive Disorders are listed in
Table 4. DSM-IVTR Cognitive Disorders include
Delirium, the Dementias, and the Amnestic
Disorders. These can be related to closed-head
trauma, anoxia with interruption of blood flow to
the hippocampus, penetrating missile wounds,
cerebrovascular disease, etc.
[134]
In some cases,
DA and Cognitive Disorders may coexist (e.g. a
patient with DID who also has cognitive deficits
secondary to a severe head injury).
IS DISSOCIATIVE AMNESIA JUST A
ORDINARY OR NORMAL FORGETFULNESS?
There has been a considerable debate about whether
DA is really different from ordinary forget-
ting.
[33,125,135]
Some cognitive psychologists have
expressed skepticism about (1) the existence of DA,
particularly for early life trauma, and (2) the presence
of unique psychobiological processes that putatively
explain DA.
[125,135,136]
Briefly, many cognitive psychol-
ogists assert that clinicians underemphasize the role of
normative kinds of forgetting and propose ‘‘special’
mechanisms of dissociative forgetting that lie outside
the mainstream of academic research on memory. Both
of these criticisms are probably accurate, but both fail
to account for these kinds of forgetting that is routinely
reported by patients with DA.
While ordinary forgetting can and does occur among
people with DA, in DA, the person loses autobiogra-
phical information that ordinarily would be a routine
part of memory (i.e. what the person did, where he/she
went, what he/she thought at the time, what emotions
were experienced, who else was present, what they do
or say, what happened next, etc.). This differs from
ordinary forgetting when it involves events that
occurred 5 min ago (i.e. the classic microamnesias of
DID patient), one’s personal identity (i.e. ‘‘I do not
remember my name or who I am’’), or the last 3 years
(as often occurs in cases of DA). Thus, factors that
counter ordinary forgetting, such as recency and
intensity, are compatible with DA.
In this review, it is impossible to give a full discussion
of the complex nature of problems with memory
subsumed by the (inadequate) term ‘‘ordinary forget-
fulness.’’ In addition to description of memory
problems identified by researchers in cognitive
psychology,
[137]
researchers in autobiographical mem-
ory have described a variety of normal memory
problems, failings, and deficiencies that can occur
in autobiographical memory.
[138–140]
These problems
are summarized in Tables 4 and 5, respectively.
In particular, autobiographical memory problems
are most relevant to contrast with DA, although
individuals with DA can suffer from all of the more
‘‘ordinary’’ forms of ‘‘forgetfulness’’ identified in the
tables.
CLINICAL STUDIES OF DISSOCIATIVE
AMNESIA
Most of the modern data on memory in DA come
from in-depth case studies or small case series of
patients with generalized DA, severe selective DA, and
generalized or selective DA subsequent to an episode of
DF, and in the study of memory in case studies, or case
series of DID patients.
[141–155]
These studies are useful,
but studies of larger samples of DA subjects are needed
to make more definitive conclusions about DA. In
clinical samples, DA manifests itself in several recog-
nized forms. These are listed in Table 5.
[156]
Kritchevsky et al.
[144]
studied 10 patients with
persistent, severe DA for personal history and/or
identity using standard neuropsychological batteries.
In general, patients did well on tests of anterograde
memory. On tests of remote memory for public events
and famous faces, tests used in previous individual case
studies of memory in DA, patients showed variable,
idiosyncratic—but individually consistent—memory
deficits. However, one subject admitted to malingering
TABLE 3. Definition of DA in DSM-IVTR and ICD-10
DSM-IVTR
PTSD: An inability to recall an important aspect of the trauma (p 468)
ASD: [I]nability to recall an important aspect of the trauma (p 471)
Somatization disorder: No definition, in Criterion B4: Pseudoneurological symptoms: ydissociative symptoms such as amnesia (p 490)
DA: The essential feature of Dissociative Amnesia is an inability to recall important personal information, usually of a traumatic or stressful
nature, that is too extensive to be explained by normal forgetting.(p 520)
DF: The essential feature of Dissociative Fugue is sudden, unexpected travel away from home or one’s customary place of daily activities, with
inability to recall some or all of one’s past (p 523)
DID: Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. (p 529)
ICD-10
DA: The main feature is loss of memory, usually for important recent events, which is not due to organic mental disorder and is too extensive to
be explained by ordinary forgetfulness or fatigue. The amnesia is usually centered on traumatic events, such as accidents or unexpected
bereavements, and is usually partial and selectiveythe most extreme instances usually occurring in men subject to battle fatigue (p 153–154)
DF: DF has all the features of dissociative amnesia, plus purposeful travel from home or place of work (p 155)
DA, dissociative amnesia; DF, dissociative fugue; DID, dissociative identity disorder; PTSD, posttraumatic stress disorder; ASD, acute stress
disorder.
833Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
amnesia, and two others were reported to have
developed alternate identities with extensive, persistent
DA. This last finding is consistent with clinical reports
in the DID literature which have described incidents of
generalized DA that occurred in the context of
DIDDID or severe DDNOS with DID features.
[43,44]
Overall, the central phenomenon of DA is a deficit in
both episodic and semantic aspects of autobiographical
memory (i.e. dense amnesia for personal identity and a
substantial portion of one’s life history). In extreme
cases, even procedural memory can also be affected.
[157]
Unlike the subjective wearing-away quality of auto-
biographical memory, DA often presents with distinct
boundaries—i.e. a distinct onset and a distinct offset,
lack of memory for a specific age, or lack of recall for a
specific category of information.
[22]
Most reports of nonorganic amnesia in the literature
entail memory loss that is far more extensive than the
localized amnesia for aspects of traumatic experience)
that may occur in ASD and PTSD. Thus, DA typically
involves an inability to recall whole epochs of
autobiographical memory, not a specific traumatic
incident or traumatic period of time (e.g. during a
series of combat missions). Generally, memory for
public events is accessible, whereas memory for private
events is not.
[51,141,144,145,158]
EPIDEMIOLOGY OF DISSOCIATIVE
AMNESIA AND DISSOCIATIVE FUGUE
In epidemiological studies,
[109,159,160]
DA had a
prevalence of 1.8–7.3%. Sar’s study of Turkish women
reported the highest prevalence (7.3%). Ross’ Cana-
dian Ross study found DA to be the most prevalent DD
(6.0%). DA was the second most prevalent in the other
studies (after DDNOS). Xiao et al.
[161]
studied a
Chinese psychiatric patient and factory worker sample
with a Chinese version of the DDIS. Factory workers
showed a prevalence of DA of 0.2% compared with
0.2% of inpatients and 1.3% of outpatients (Note:
patients were selected in part based on a childhood
history of physical or sexual abuse). Foote et al.
[162]
found that 10% of 82 inner city patients at an
outpatient clinic met diagnostic criteria for DA; none
met diagnostic criteria for DF.
Prevalence of DF was 0% in Canada, 0% in the
United States, 0.2% among women in Turkey, and
TABLE 4. Differences between DA and amnesia in cognitive disorders
Differences DA Cognitive disorders
Due to known medical disorder or physical cause No Yes
Onset related to psychological trauma/extreme stress Yes No
Exacerbated by stress Yes Yes/No; anxiety can worsen memory
performance in Cognitive Disorders
Memory deficits primarily in autobiographical
information, personal identity
Yes No, but may have circumscribed retrograde
memory loss and/or general impairment in
autobiographical recall that worsens with
illness progression
Reversible with hypnosis Yes No
Improvement with sedative-hypnotics
(e.g. pharmacologically facilitated interviews)
Yes or no change No or may make worse
Varying extent and nature of the intrusion of the dissociated
mental elements to consciousness
Yes N o
Ability to learn new information is intact. Ability to
manipulate facts and neutral information is generally
normal (e.g. finances, current events, etc.)
Yes N o
Disorientation to personal identity generally only
occurs in late phases of illness
No Yes
DA, dissociative amnesia.
TABLE 5. Types of DA
Localized amnesia: Inability to remember a specific period of time, or a
specific event, such as a suicide attempt, or a circumscribed period
of time, such as before age 12, all of second and third grade, etc
Selective amnesia: Inability to remember some, but not all, of the
events during a circumscribed period of time, such as parts of a
combat experience, a sexual assault, etc
Systematized amnesia. Inability to remember certain categories of
memory, such as no recall of one’s home-life during third grade,
but recalling being at school; or inability to recall a particular
person, e.g. a reportedly abusive brother
Continuous amnesia: Inability to remember successive events as they
occur (i.e. ongoing anterograde dissociative amnesia); extremely
rare; may present as dissociative pseudo-delirium, pseudo-
dementia, or pseudo-amnestic-confabulatory syndrome
Generalized (global) amnesia: Forgetting one’s entire life, generally
including memory for personal identity
Thematic DA: In DID or DDNOS different identity states recall the
same time period(s), but do not recall the events and/or themes
recalled by other self states
DA, dissociative amnesia; DID, dissociative identity disorder;
DDNOS, DD not otherwise specified.
834 Spiegel et al.
Depression and Anxiety
1.3% among outpatients in China (no cases of DF were
diagnosed in Chinese inpatients or factory workers).
NEUROBIOLOGICAL DATA
As noted above, neurobiological data (from studies of
individuals with generalized DA, DF with subsequent
generalized DA, and normal highly hypnotizable
subjects with posthypnotic amnesia) show neuro-
circuitry patterns similar to those found in studies of
dissociation in PTSD. In general, these studies show
frontal cortex inhibition of temporal/hippocampal
areas, as well as occipital cortex, an area also thought
to be associated with retrieval of episodic autobiogra-
phical memory.
[51,53,153]
These data are similar to those
of Anderson et al.’s memory suppression studies
[163]
frontal inhibition of the hippocampus. Anderson et al.
hypothesized that the neural networks they describe
could serve as a basis for understanding the suppression
of unwanted memories.
DIMENSIONAL AND SUBJECTIVE
PHENOMENOLOGY OF DA
In DA, the ‘‘forgotten’’ autobiographical information
is understood to be present ‘‘within,’’ but unavailable to
the conscious mind. Although subject to the vagaries of
avoidance, resistance, and psychological ‘‘readiness,’
genuine DA can always, in principle, be reversed.
Memory is available, but it is not accessible. Dissociated
information may still influence the person’s emotional
reactions and behavior, even without access to conscious
recall: out of sight is not out of mind.
[164–166]
Similarly,
dissociated information may temporarily be available to
conscious recall and then re-dissociated, often with
amnesia for the period that the memory appeared to be
consciously available. This may occur during psy-
chotherapy, as well as in everyday interactions.
These phenomena have led some researchers and
clinicians to conclude that the person’s reported
amnesia is feigned or malingered. On the contrary,
indirect dissociative influences on emotion and beha-
vior are a routine accompaniment of DA.
[166]
More-
over, this same phenomenon characterizes some forms
of amnesia in cognitive disorders. For example, studies
have shown the presence of implicit learning in
amnestic individuals with hippocampal lesions,
[167,168]
and in ‘‘blindsight,’’ a phenomenon where individuals
with cortical blindness discriminate among visual
stimuli at levels greater than chance.
[169]
Thus, explicit memory retrieval failures in dissocia-
tion likely over represent the unavailability of the
information in question. For example, traumatic
experiences that are not fully available to explicit recall
may nonetheless exert an influence on the person: a
woman raped in an elevator may still avoid elevators,
despite difficulty retrieving recollections of the assault.
In cases where the DA involves distress over current life
conflicts or indiscretions, there may be a mixture of
dissociative and factitious/malingered elements that
make, making for a difficult differential diagnosis.
[154]
Finally, since DDs involve profound strategies for
avoidance of dissociated information, it is not uncom-
mon for a person with amnesia to hide the existence of
the amnesia even from him- or herself.
COMORBIDITY
Coons and Milstein
[170]
reported on 25 patients
meeting DSM-IIIR diagnostic criteria for Psychogenic
(Dissociative) Amnesia. Patients presented at a tertiary
care center for DDs. Subjects had acute, recent, and
remote DA, similar to the conceptualization of
Loewenstein that DA presents in both an acute, florid
form—usually as generalized DA or dense selective
amnesia for life history/identity—and in a covert form
with retrospective memory loss for discrete episodes of
the person’s life.
[132]
Subjects had many associated
symptoms including depersonalization, mood disor-
ders, substance abuse, somatoform symptoms, and
personality disorders, although these comorbidities
may have been associated with the severity of the
patients’ overall clinical course, requiring referral to a
tertiary center.
Study subjects reported high rates of childhood
sexual and physical abuse. However, patients differed
from DID patients in a variety of clinical dimensions,
including lower rates of childhood trauma, lower DES
scores, and lower rates of associated symptoms such as
auditory hallucinations, self-mutilation, and fugue
episodes. However, this study did not use structured
diagnostic interviews for diagnosis of DDs, and did not
report rates of comorbid PTSD.
Ross et al. assessed 201 consecutively admitted
psychiatric inpatients to a private psychiatric hospi-
tal
[171]
with the DDIS,
[66]
the Structured Clinical
Interview for DSM-IV DDs (SCID-D),
[68]
and a
clinical interview. Depending on the instrument,
7.3% (SCID-D) or 13.4% (DDIS) of the patients met
diagnostic criteria for DA. Reliability data for DA (and
for DPD) were problematic, however, between the two
interviews, and the clinician interview (prevalence:
11.5%). A subset of patients met diagnostic criteria
for both DPD and DA, and had to be classified as
DDNOS or with both disorders. Ross et al. suggest
that these patients may fit more readily into a broader
dissociative diagnostic construct, rather than being
forced into a residual category.
SUMMARY
In short, taking the data above as a whole, we
recommend that DA be retained as a diagnosis in the
DSM-5, and not subsumed under another diagnostic
category. DA has been shown to be a more complex
and multifaceted phenomenon than lack of recall for
parts of specific trauma memories, as in PTSD and
ASD. In addition, epidemiological, phenomenological,
psychometric, and neurobiological data support con-
tinuing DA as a diagnostic category.
835Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
Further research can help to clarify the relationship
of various presentations of DA to DID, and to
elucidate the boundaries between DA and DDNOS.
We may find that a subgroup of DA patients have
associated dissociative symptoms such as depersonali-
zation, spontaneous trance, and dissociative age-
regression. Finally, further research can help to
evaluate when a person with PTSD or ASD should
receive a comorbid diagnosis of DA. Alternately,
inclusion of a dissociative sub-type of PTSD in
DSM-5 might provide a more parsimonious way of
addressing these diagnostic quandaries.
[50]
However,
because dissociative symptoms and (most other) PTSD
symptoms appear to represent distinct dimensions of
psychopathology (albeit both related to trauma), we
recommend that all localized amnesias should be
accorded a diagnosis of DA.
NEW DEFINITION OF DISSOCIATIVE
AMNESIA FOR DSM-5
Based on the forgoing discussion, a conservative
reformulation of the definition of DA is the following:
DA is an inability to recall important personal information,
often trauma-related, which is inconsistent with ordinary
forgetting. The essential characteristic of DA is an inability
to consciously retrieve autobiographical information that
(1) should be successfully stored in memory and (2) would
ordinarily be readily accessible to recall.
Question 2: Does the totality of the data support DF
as a separate diagnostic category in the DSM? Or
should this diagnosis be eliminated? Or is DF better
conceptualized under the rubric of another DD such as
Dissociative Identity Disorder (DID), or DA (if DA is
retained as a DD), or as an example of DDNOS?
The current DSM-IVTR diagnostic criteria and
ICD-10 diagnostic ‘‘guidelines’’ for DA and DF,
respectively, are found in Table 6.
According to ICD-10, DA is a major component of
DF (DF guideline A). As noted above, ICD-10
emphasizes that DA and DF are acute responses to
recent stressors. According to DSM-IVTR, DA and
DF are linked, but hold that amnesia in DF is like
generalized DA or dense forms of localized DA, with
identity alteration as a diagnostic criterion.
There are limited systematic data about DF in the
literature. Data primarily come from small case series,
or individual case reports. The largest case series
remain those of Fisher from the 1940s.
[172,173]
Coons
described five male cases of DF in a recent publica-
tion.
[174]
Hacking has written a social-historical study
of an ‘‘epidemic’’ of DF in men in late 19th century
France, around the same time as there was intense
interest in women with hysteria and multiple person-
alities.
[175]
However, the relationship of these fugueurs
to modern conceptualization of the DDs is unclear.
Because DF as a symptom has been reported in
systematic studies of DID patients,
[176]
given how rare
DF is, clinical ascertainment of a fugue (current or past) is
more likely to indicate the presence of DID than a pure
case of DF. In keeping with this statistical likelihood,
experienced clinicians have observed that many patients
diagnosed with DF appear to have a complex DD, usually
DID (wherein an amnestic personality state was created
who flees the person’s current circumstances, as well as
fleeing his/her identity).
[43,177]
Although previous conceptions of DF have described
the assumption of a new identity, there are no
systematic data to support this. Even the classic fugue
case of Ansel Bourne—who left home and was found
months later, living under a new name without recall of
his past—was originally described as a case of ‘‘dual
consciousness,’’ not of DF.
[178]
Hennig-Fast et al.
[145]
report on a patient who
presented with a dense retrograde amnesia for personal
history after a 2-week fugue. Despite the case study
originating in a fugue episode, psychometric and
neurobiological data were comparable in many respects
to other cases of dense, retrograde DA (see above).
In summary, there is little systematic data on most
aspects of patients with DF. Existing data suggest that
many DF patients will prove to meet the diagnostic
criteria for DID, and, that most others do not differ
from patients with DA characterized by severe retro-
grade localized or generalized DA, at least once the
episode of fugue ends.
[132,177,179]
Accordingly, we recommend that DSM-IVTR DF be
removed as a separate diagnostic category among the
DDs, and that it be included as a subtype of DA.
TABLE 6. Definition of DA in DSM-IVTR and ICD-10
DSM-IVTR
PTSD: An inability to recall an important aspect of the trauma (p
468)
ASD: [I]nability to recall an important aspect of the trauma (p 471)
Somatization disorder: No definition, in Criterion B4:
Pseudoneurological symptoms: ydissociative symptoms such as
amnesia (p 490)
DA: The essential feature of DA is an inability to recall important
personal information, usually of a traumatic or stressful nature,
that is too extensive to be explained by normal forgetting.(p 520)
DF: The essential feature of DF is sudden, unexpected travel away
from home or one’s customary place of daily activities, with
inability to recall some or all of one’s past (p 523)
DID: Inability to recall important personal information that is too
extensive to be explained by ordinary forgetfulness (p 529)
ICD-10
DA: The main feature is loss of memory, usually for important
recent events, which is not due to organic mental disorder and is
too extensive to be explained by ordinary forgetfulness or fatigue.
The amnesia is usually centered on traumatic events, such as
accidents or unexpected bereavements, and is usually partial and
selectiveythe most extreme instances usually occurring in men
subject to battle fatigue (p 153–154)
DF: DF has all the features of dissociative amnesia, plus purposeful
travel from home or place of work (p 155)
DA, dissociative amnesia; DF, dissociative fugue; DID, dissociative
identity disorder; PTSD, posttraumatic stress disorder; ASD, acute
stress disorder.
836 Spiegel et al.
Depression and Anxiety
Further research will be helpful in clarifying questions
about the relationships between DA, DID, and certain
patients currently conceptualized as DDNOS. Further,
we recommend that the text of DSM-5 discuss the
different sub-types of DA in depth, including DF, as
listed in Table 7.
REVIEW AND REVISION OF
DISSOCIATIVE IDENTITY
DISORDER DIAGNOSTIC
CRITERIA
Should the diagnostic criteria for DID be changed?
If so, should the diagnostic criteria follow a polythetic
form, a mixed polythetic/monothetic form, or remain a
monothetic criteria set with modifications?
The DSM-IV-TR Diagnostic Criteria for DID are
the following:
DISSOCIATIVE IDENTITY DISORDER (300.14)
A. The presence of two or more distinct identities
or personality states (each with its own
relatively enduring pattern of perceiving, relat-
ing to, and thinking about the environment
and self).
B. At least two of these identities or personality
states recurrently take control of the person’s
behavior.
C. Inability to recall important personal informa-
tion that is too extensive to be explained by
ordinary forgetfulness.
D. The disturbance is not due to the direct
physiological effects of a substance (e.g. black-
outs or chaotic behavior during Alcohol
intoxication) or a general medical condition
(e.g. complex partial seizures). NOTE: In
children, the symptoms are not attributable
to imaginary playmates or other fantasy play.
ICD-10 does not specify diagnostic criteria for
DID, but states: ‘‘The essential feature is the
apparent existence of two or more distinct
personalities within an individual, with only
one of them being evident at a time. Each
personality is complete, with its own mem-
ories, behavior, and preferences; these may be in
marked contrast to the single premorbid per-
sonality’’ (p 160). The ICD-10 description of
DID is not based on an understanding of DID
as a childhood-onset, complex, posttraumatic
developmental disorder. Rather, this description
is based on the literature that pre-dates the body
of research on DDs since the publication of the
DSM-III. Accordingly, we will focus on the
DSM-IVTR diagnostic construct.
REVIEW OF THE DSM-IV-TR DIAGNOSTIC
CRITERIA FOR DISSOCIATIVE IDENTITY
DISORDERS
Researchers have raised five concerns about the
DSM-IV-TR criteria for DID. (1) They do not
adequately describe the complex clinical phenomena
of DID. (2) The criteria are not sufficiently specific for
clinical utility. (3) Readily observable switching beha-
vior from one alternate identity to another is relatively
uncommon in the clinical presentation of most DID
patients. (4) The result is relatively high rates of false-
negative diagnosis of DID, with an unacceptably high
rate of DDNOS diagnoses. (5) The exclusion from the
criteria of experiences of pathological possession, a very
common cross-cultural form of DID.
A number of clinicians and researchers have opined
that the DSM-IV-TR diagnostic criteria do not
adequately describe the domain of dissociative symp-
toms most characteristic of DID.
[7,180]
Research has
repeatedly documented the presence of eight dissocia-
tive symptoms in DID (Table 8), only two of which are
addressed by the DSM-IV-TR diagnostic criteria.
Several researchers have urged that these additional
dissociative symptoms be used to revise or augment the
DSM-IV-TR diagnostic criteria for DID in DSM-5.
Dell has suggested that these well-documented symp-
toms of DID comprise a pathognomonic pattern of
dissociative symptoms that is unique to DID.
[181]
Some researchers have voiced concern that the
DSM-IV-TR criteria for DID lack sufficient clinical
utility for diagnosing the disorder. For example,
following the publication of DSM-IV, Latz et al. said:
‘‘We are still uncertain as to what specific clinical criteria
should be used to make the diagnosis’’
[182]
(p 1,348,
italics added). In a similar vein, Coons and Chu have
argued that the diagnosis of DID would be consider-
ably helped by diagnostic criteria that adequately
TABLE 7. Proposed DSM-5 diagnostic criteria for DA
(300.12)
A. Inability to recall important personal information, usually of a
traumatic or stressful nature, that is inconsistent with ordinary
forgetting. The amnesia may be localized, selective, systematized,
continuous, thematic, or generalized. Note: There are two primary
forms of Dissociative Amnesia: (1) localized amnesia for a specific
event or events, and (2) generalized amnesia for identity and life
history. DF occurs when Generalized Dissociative Amnesia is
accompanied by purposeful travel
B. The disturbance does not occur exclusively during the course of
DID, PTSD, ASD, or Somatization disorder and is not due to the
direct physiological effects of a substance (e.g. a drug of abuse, a
medication) or a neurological or other general medical condition
(e.g. Amnestic disorder or other cognitive disorders)
C. The symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning
DA, dissociative amnesia; DF, dissociative fugue; DID, dissociative
identity disorder; PTSD, posttraumatic stress disorder; ASD, acute
stress disorder.
837Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
reflect DID’s typical polysymptomatic presentation.
[183]
The most recent overview of diagnosing DID empha-
sizes its polysymptomatic presentation and the very
subtle phenomena of ‘‘the dissociative surface’’ (p 637)
that experts use to detect the presence of alter
identities.
[184]
Finally, both Kluft
[185]
and Dell
[75]
have
noted that the DSM diagnostic criteria make the
diagnosis of DID entirely dependent on clinical phe-
nomena that occur infrequently and are often difficult to
discern when they do occur. Specifically, the diagnosis of
DID requires that the clinician determine the ‘‘presence’
of ‘‘two or more distinct identities or personality states’’
that ‘‘recurrently take control’’ (DSM-IV-TR criteria A
and B). However, it is believed that most persons with
DID infrequently ‘‘switch’ in a highly visible fashion
and, as Latz et al. noted, the DSM-IV-TR diagnostic
criteria provide few guidelines for determining when
‘‘two or more distinct identities’’ that ‘‘recurrently take
control’’ are actually present.
[182]
Both clinical research and epidemiological studies
have routinely reported that DDNOS is either the
most common or among the most common dissociative
diagnoses.
[9,160,162,186]
Spiegel and Carden
˜a
[164]
identi-
fied the disproportionate number of DDNOS diag-
noses as a major problem to be solved by DSM-5.
A review and analysis of DDNOS concluded that the
majority of DDNOS cases are actually undiagnosed (or
misdiagnosed) DID cases.
[7,181]
In this regard, Dutch
researchers, commenting on a large study of DDs in
the Netherlands
[187]
stated:
Finally we would like to comment on the patients
in this study with the diagnosis DDNOS. In a
majority of these cases the diagnosis MPD was
strongly suspected during the research interview
[but could not be confirmed]. In those cases we
assigned the diagnosis DDNOS, although it
might be better to speak of ‘‘covert MPD’’ to
differentiate these cases from true atypical cases.
From a follow-up one year later, we obtained
information on 20 of the 24 patients with
DDNOS; 19 of the 20 patients were given the
diagnosis MPD, instead of DDNOS, by the
treating clinician and a description of distinct
alter personalities could be given (pp. 120–121).
In addition, experiences of pathological possession
are very common expressions of DID in cultures
around the world, but are not included in the DSM-IV-
TR diagnostic criteria. The section on Dissociative
Trance Disorders below addresses this issue in detail.
Thus, the DSM-IV-TR diagnostic criteria refer to
clinical manifestations of DID that may be difficult to
discern, especially for the average clinician who may not
know the characteristic symptoms of DID. It is believed
that this leads to many false-negative diagnoses of DID
and a large proportion of false-positive diagnoses of
DDNOS, or failure to diagnose a DD at all.
SHOULD THE DIAGNOSTIC CRITERIA FOR
DID BE REVISED?
The diagnostic criteria for DID have evolved from
the original DSM-III diagnostic criteria, but the basic
tri-partite monothetic structure has remained. The
evolution from DSM-III to DSM-IIIR and DSM-
IVTR specifically involved three major changes.
First, the description of identities as ‘‘complex and
TABLE 8. Frequencies of eight common dissociative symptoms in DTD
Study NInstrument
b,c
Amnesia Self-alteration FRS
d
Voices Trance Somatof Deperson Derealiz
Bliss
[255]
14 Clinician 91 55 91 64 82 91 82 55
Kluft
[256]a
5 Clinician 100 100 100 100 100
Kluft
[257]
30 Clinician 100 100
Putnam et al.
[258]
100 Clinician 98 20 45 60 57
Bliss
[259]
70 Clinician 75 53 53
Coons et al.
[260]
50 Clinician 100 58 72 40 38
Ross et al.
[261]
236 Clinician 95 72 72 92
Ross et al.
[262]
102 DDIS 100 87 92 57
Dell et al.
[263]a
11 Clinician 82 100 91
Hornstein et al.
[264]a
44 Clinician 100 60 97 97
Boon et al.
[265]
71 SCID-D 100 94 90 83 100 74
Sar et al.
[266]
35 DDIS 100 94 60
Middleton et al.
[267]
62 DDIS 100 95 98 71 71 66
Dell
[268]
179 MID 91 98 98 95 88 83 95 93
Total/range 41 MID 93 94 98 95 87 83 95 92
Median percentage 1,020 75–100 94–100 20–100 64–100 45–100 40–92 38–100 53–93
100 98 94 92 91 83 77 63
a
Child/adolescent sample.
b
Instrument used to assess the eight symptoms: DDIS, Dissociative Disorders Interview Schedule; SCID-D, Structural Clinical Interview for
DSM-III (or 5IV) Dissociative Disorders; MID, Multidimensional Inventory of Dissociation.
c
Instrument used to diagnose DID, except for Dell
[268]
(sample of 179 was diagnosed by a clinican; sample of 41 was diagnosed with the SCID-D).
d
SFR 5first-ranks symptoms.
838 Spiegel et al.
Depression and Anxiety
integrated’’ with unique behaviors and ‘‘social relation-
ships’’ was shifted to a description that portrays the
identities as centers of information processing. Second,
the transition from DSM-IIIR to DSM-IVTR was
marked by a subtle shift in the portrayal of control;
instead of identities being ‘‘dominant’’ or in ‘‘full
control,’’ (DSM-III-R), the ‘‘word ‘‘full’’ (in ‘‘full
control’’) was deleted.’’ This deletion, implicitly
allowed for control through passive-influence. Third,
DSM-IVTR introduced an amnesia criterion, partly to
minimize misdiagnosis, but also because DID without
amnesia is thought to be very rare.
At this time, due to a much larger body of data on the
phenomenology of DID, the work group has to decide to
either (1) retain—perhaps with minor alterations—the
DSM-IV-TR criteria (see above) or (2) revise the criteria
by developing monothetic/polythetic symptom clusters
based on the research literature, primarily from struc-
tured interview data (DDIS, SCID-D), or data from
comprehensive diagnostic self-report inventories (MID).
Arguments in favor or major alteration of the
DSM-IV-TR diagnostic criteria. Two lines of
argument have been employed in support of a major
alteration of the DSM-IV-TR criteria for DID: (1) a
polythetic argument, and (2) a clinical utility argument.
The polythetic argument. In most of the common
mental disorders, DSM-III-R and DSM-IV-TR
stopped using monothetic diagnostic criteria. For most
disorders, polythetic diagnostic criteria or mixed
monothetic-polythetic criteria set (e.g. PTSD) have
been developed. Monothetic criteria (usually 2–4 in
number) require that all criteria be present in order to
make a diagnosis. In contrast, polythetic, or mixed
mono-polythetic criteria require that only some of
criteria be present in order to make a diagnosis—
typically five or more symptoms, often in several
subcategories, e.g. 3 of A, 2 of B, etc. Dell
[180]
believes
that monothetic criteria have many disadvantages. He
states that these are more difficult to use, and,
accordingly, are more likely to be ignored by clin-
icians.
[188]
Due to this, he argues that monothetic
criteria sets tend to create an artificially low base-rate
for the disorder, i.e. they will tend to generate a larger
number of false negative diagnoses than the alternative
typologies.
[189]
Accordingly, Dell has urged that
DSM-5 use a mixed monothetic/polythetic criteria set
for diagnosis of DID.
The clinical utility argument for major alteration
of the DSM-IV-TR criteria for DID. The essence of
this argument is that DSM-IV-TR Criteria A and B for
DID have limited clinical utility. They provide only a
definition of DID, the presence of two or more distinct
identities, rather than a description of how alternate
identities manifest in a clinical encounter. In addition,
the exclusive focus on two or more ‘‘distinct’’ identities
is thought to be problematic since, in many clinical
presentations of DID, distinct identities are not present
in the interview, and, if they are, in many cases the
‘‘distinctness’’ may be hard to assess.
[181,190]
According to Kluft and Dell,
[181,188]
only 15% of
DID cases regularly manifest easily observable alter-
nate identities during diagnostic interviews. The
remaining cases rarely manifest clearly detectable
identities, except when these patients are in crisis.
[89]
Kluft used the term "window of diagnosability" to
capture the latent nature of clear-cut switching
phenomena in DID patients.
[191]
The clinical utility
argument proposes that the diagnostic criteria for DID
should reflect two fundamental sets of phenomena: (1)
the pathognomonic symptom of DID (i.e. alters that
switch) and (2) the typical clinical presentation of DID.
What is the typical clinical presentation of DID? Two
data sets answer this question. A re-analysis of Dell’s
MID data on 220 persons with DID provides one view
of the typical clinical presentation of DID–DID
patients’ seven most common symptoms: (1) recurrent
incidents of amnesia; (2) subjective experiences of self-
alteration; (3) incidents of uncontrolled, dissociated
behavior or speech; (4) experiences of internal struggle
between two self states; (5) depersonalization; (6)
thought insertion/thought withdrawal; and (7) sponta-
neous trance. Of these symptoms, the DSM-IV-TR
criteria for DID include one: DA.
The typical clinical presentation of DID can also be
gleaned from a review of the modern empirical
literature on DID. A systematic review of that
literature produced findings similar to Dell’s MID-
based characterization of DID. Table 8 presents the
median percentage of eight dissociative symptoms in
DID patients as reported by post-DSM-III studies of
DID: amnesia (100%), self-alteration (98%), first-
ranked symptoms (94%), hearing voices (92%), trance
states (91%), somatoform symptoms (83%), deperso-
nalization (77%), and derealization (63%).
Both sets of DID phenomena (i.e. the pathognomonic
switching phenomena and the typical clinical presenta-
tion of DID) should be able to diagnose DID.
According to the clinical utility argument, however,
the typical clinical presentation of DID are preferable as
diagnostic criteria. Why? Because the overt switching
phenomena are so infrequent The only study that
has assessed the frequency of switching found that
self-reported switching was surprisingly frequent.
[192]
Unfortunately, both clinical experience and expert
commentary have shown that overt, easily discernable
switching is uncommon in about 85% of cases. Thus,
discernable switching occurs too infrequently to allow it
to serve as an adequate diagnostic criterion for DID.
Conversely, Dell correctly predicted that DID could be
accurately diagnosed solely on the basis of DID’s typical
clinical presentation (i.e. without observing a switch
from one personality to another).
[7,9,180]
Dell tested this hypothesis by developing the MID, a
self-administered, paper-and-pencil instrument that
assesses the subjective experiences of dissociation.
Using the MID, Dell
[7,9,180]
and others
[193]
have shown
that DID can be reliably diagnosed without observing
switching behaviors.
839Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
Arguments for minor alteration of the DSM-IV-
TR diagnostic criteria in DSM-5. Two previous
DDs work groups (DSM-III-R and DSM-IV) con-
sidered whether to develop new diagnostic criteria
based on research findings from the 1980s and early
1990s. Each time, however, the work groups chose to
retain (with minor adjustments) the simple diagnostic
criteria that DSM-III established for DID.
As shown in Table 8, most DID patients share a
common set of dissociative symptoms. Since the
presence of most of these symptoms is high, the
symptoms of the DID population are relatively uni-
form. This means that the simultaneous presence of
two symptoms (viz. subjective divisions of identity and
DA) would likely to identify most persons with DID.
When a population is more heterogeneous, polythetic
diagnostic criteria are needed because many members
of the population possess only a subset of the
diagnostic symptoms, thereby necessitating a poly-
thetic format.
The avoidance symptoms of PTSD provide a good
example of when polythetic criteria are needed. These
avoidance symptoms are not highly correlated with one
another; hence, different persons with PTSD can have
very different subsets of avoidance symptoms.
It would appear that the population of persons with
DID is sufficiently homogeneous that polythetic
diagnostic criteria would not improve the reliability
or validity of diagnoses of DID, which can be made
with simpler monothetic criteria. Such monothetic
criteria are inherently simpler than a longer list of
polythetic criteria, facilitating diagnosis for those who
make the diagnosis rarely. Thus, from this perspective,
only minor adjustments of the DSM-IV diagnostic
criteria are necessary. However, based on the research
data of Dell and others, these should also include
language to indicate that identity disturbance and
related switching behaviors need not be directly
observed, but may be reliably reported by the patient
or others.
In addition, the text of the DSM-5 should discuss in
depth the complex phenomenology of the DID patient
population, and ways to avoid unnecessary placement
of typical DID patients in the DDNOS category.
Further research may help clarify how to make the
simple monothetic criteria more user-friendly for
clinicians. In this regard, additional research may also
help to clarify the question of the frequency of
switching behaviors in DID. Dell’s MID, a self-report
designed to mostly assess specific dissociative symp-
toms other than DID switching, not surprisingly does
not show much evidence for frequent switching.
Neither the DDIS nor the SCID-D specifically code
for switching in the sections on dissociative symptoms,
although the interviewer observer section of the
SCID-D allows for coding of observed alternations in
identity (i.e. switching) in one item. Research studies
specifically designed to reliably detect switching beha-
viors may provide additional data on these questions.
SUMMARY
In conclusion, the work group recommends only
minor alterations of the diagnostic criteria for DID in
DSM-5. We include language that encompasses posses-
sion disorders, to assist diagnosis in cultures where the
‘‘diagnostic niche’’ of DDs related to identity alteration
is filled by possession-related symptoms. The latter
point will be discussed in depth in the next section.
Proposed diagnostic criteria for DSM-5
dissociative identity disorder (300.14)
A. Disruption of identity characterized by two or
more distinct personality states or an experi-
ence of possession, as evidenced by disconti-
nuities in sense of self, cognition, behavior,
affect, perceptions, and/or memories. This
disruption may be observed by others, or
reported by the patient.
B. Inability to recall important personal informa-
tion, for everyday events or traumatic events,
that is inconsistent with ordinary forgetfulness.
C. Causes clinically significant distress and im-
pairment in social, occupational, or other
important areas of functioning.
D. The disturbance is not a normal part of a
broadly accepted cultural or religious practice
and is not due to the direct physiological
effects of a substance (e.g. blackouts or chaotic
behavior during Alcohol intoxication) or a
general medical condition (e.g. complex partial
seizures). Note: In children, the symptoms are
not attributable to imaginary playmates or
other fantasy play. Specify if:
(a) With nonepileptic seizures or other con-
version symptoms
(b) With somatic symptoms that vary across
identities (excluding those in specifier a)
These specifiers are under consideration.
DISSOCIATIVE DISORDERS NOT
OTHERWISE SPECIFIED IN DSM-5
The work group identified several problematic
aspects of the DSM-IVTR diagnostic category of
DDNOS, as well as in the examples of clinical
presentations of DDNOS. The DSM-IVTR descrip-
tion of DDNOS and associated examples are shown in
Table 9.
The major problematic issues with the DDNOS
category are listed below:
A. The disproportionately high prevalence of
DDNOS.
B. The question of whether patients with only
derealization (i.e. DDNOS Example 2) differ
from those diagnosed with DSM-IV DPD.
840 Spiegel et al.
Depression and Anxiety
C. The question of whether to include DDNOS
examples of acute and somatoform DD pre-
sentations. Acute and somatoform dissociative
presentations are as emphasized by the
ICD-10. Psychiatrists who use ICD-10’s are
more familiar with conceptualizing DDs as
acute and/or somatoform.
WHAT IS THE RELATIONSHIP BETWEEN
DDNOS-1 (ESPECIALLY DDNOS-1A) AND
DISSOCIATIVE IDENTITY DISORDER?
The major difficulty with the DDNOS category
is its high prevalence—over 40%—in all kinds of
epidemiological studies. Several authors have discussed
this nosological/diagnostic problem
[164,181,194–198]
and concluded that the problem lies at the interface
between DDNOS Example 1 (DDNOS-1) and
DID. Because DDNOS is a more heterogeneous
category, choice of treatment may be more difficult
than for DID, so clarification of the criteria would be
helpful.
As noted above, it is difficult to make a diagnosis of
DID because switching is infrequent and because most
clinicians are unsure how to confirm ‘‘the presence of
two or more distinct identities. Accordingly, patients
with a complex dissociative presentation, but no
apparent alter identities, routinely receive a diagnosis
of DDNOS. Such diagnoses are in keeping with
DSM-IV’s description of DDNOS-1: ‘‘Clinical
presentations similar to Dissociative Identity Disordery
in whichythere are not two or more distinct personality
states’’ (p 490).
If the diagnostic criteria for DID were changed
to reflect the typical clinical presentation of DID
(i.e. a complex dissociative presentation with
no confirmed alter identities), these complex
DDNOS patients would meet diagnostic criteria
for DID. To be clear, these complex DDNOS-1
patients commonly report or demonstrate recurrent
chronic complex DA symptoms, fugue behaviors,
somatoform and conversion symptoms, depersona-
lization/derealization, spontaneous trances, and
intrusion symptoms such as ‘‘made’’ feelings, impulses,
and/or acts, thought insertion or withdrawal, and
a sense of subjective self-division. Nevertheless,
they fail to meet the DSM-IVTR diagnostic DID
criteria for DID because the clinician has been unable
to confirm the presence of ‘‘two or more distinct
identities.’’
[187,193,199–202]
If correct, this analysis indicates that the overly high
prevalence of DDNOS is not due to the diagnostic
criteria for DDNOS-1. Instead, the high prevalence of
DDNOS is due to the diagnostic criteria for DID—
specifically, the difficulty of confirming the presence of
two or more distinct identities in complex dissociative
patients.
As delineated in the section on DID above, the
Work Group has not endorsed any sweeping
changes in the diagnostic criteria for DID. Rather,
in both the DID and DDNOS categories, (1) the
new criteria explicitly state that direct observation
of alternate identities is not necessary for diagnosis
(i.e. inferential, historical, and/or collateral infor-
mation is sufficient); and (2) language has been
suggested that will help the clinician to understand
the spectrum of dissociative phenomena, including
the ‘‘distinctness’’ of DID identities. In addition, the
DSM-5 text will discuss at length the issue of
differential diagnosis of DID and DDNOS1. Field
trials may help to refine the diagnostic criteria and
associated features of DID, DDNOS1, as well as those
of the other DDs.
SHOULD PATIENTS WITH ONLY
DEREALIZATION (i.e. DDNOS EXAMPLE 2)
RECEIVE A DSM-5 DIAGNOSIS OF DPD?
As described above, current data sets find no salient
differences between DPD patients and patients with
TABLE 9. DSM-IVTR dissociative disorders DDNOS examples
1. Clinical presentations similar to DID that do not meet full criteria for this disorder. Examples include presentations in which (a) there are not
two or more distinct personality states, or (b) amnesia for important personal information does not occur
2. Derealization unaccompanied by depersonalization in adults
3. States of dissociation that occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion (e.g.
brainwashing, thought reform, or indoctrination while captive)
4. Dissociative trance disorder: single or episodic disturbances in the state of consciousness, identity, or memory that are indigenous to particular
locations and cultures. Dissociative trance involves narrowing of awareness of immediate surroundings or stereotyped behaviors or movements
that are experienced as being beyond one’s control. Possession trance involves replacement of the customary sense of personal identity by a new
identity, attributed to the influence of a spirit, power, deity, or other person, and associated with stereotyped ‘‘involuntary’’ movements or
amnesia and is perhaps the most common Dissociative Disorder in Asia. Examples include amok (Indonesia), bebainan (Indonesia), latah
(Malaysia), pibloktoq (Arctic), ataque de nervios (Latin America), and possession (India). The dissociative or trance disorder is not a normal part of
a broadly accepted collective cultural or religious practice. (See Research criteria for dissociative trance disorder for suggested research criteria.)
5. Loss of consciousness, stupor, or coma not attributable to a general medical condition
6. Ganser syndrome: the giving of approximate answers to questions (e.g. ‘‘2 plus 2 equals 5’’) when not associated with DA or DF
DA, dissociative amnesia; DF, dissociative fugue; DDNOS, DD not otherwise specified; DID, dissociative identity disorder.
841Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
chronic derealization only. Accordingly, the proposed
DSM-5 diagnostic criteria for DPD include deperso-
nalization, derealization, or both.
WHAT DDNOS EXAMPLES SHOULD BE
PROPOSED FOR DSM-5?
Dissociative conditions have traditionally been con-
sidered as solely acute and transient reactions in many
countries outside North America and the awareness of
chronic DDs lagged behind these observations. Accord-
ingly, European psychiatry and the ICD-10 emphasize
acute and reactive dissociative syndromes including
somatosensory (conversion) symptoms. Contrastingly,
while North American psychiatry and the DSM
emphasize chronic DDs, they failed in recognition of
worldwide presentations of partial, acute, and transient
dissociative manifestations, which are crucial in evoking
awareness about the entire spectrum of DDs among
clinicians globally. Thus, in order to cover the whole
spectrum of dissociation accurately and also to fit the
culturally diverse expectations, DSM-5 too should
adequately address acute dissociative presentations.
We propose two new DDNOS examples (]6 and 7).
While seemingly acute dissociative conditions may be
superposed on undetected chronic DDs such as
dissociative identity disorder or DDNOS-1, for a sizable
proportion of patients, acute presentations are limited to
short periods indeed constituting single or multiple
episodes over time (97). Acute dissociative conditions
fall along a broad spectrum of severity ranging from the
level of an adjustment disorder at the mildest pole to
quasi-psychotic phenomena at the most severe end.
While any combination of dissociative symptoms, such
as hallucinations, amnesia, depersonalization, or stupor,
may constitute an acute DD, the presence of alternate
identities are usually not part of the condition. Hence,
these presentations cannot be covered by DDNOS-1.
We propose two new DDNOS examples (]6 and 7).
Both conditions are transient states, less than 1 month
in duration, and characterized by mixed dissociative
symptoms. While the DDNOS-6 addresses relatively
mild and moderate parts of this spectrum, the
DDNOS-7 covers the most severe end.
Example ]6 is an acute reaction to a stressful event
that causes marked distress or impairment. These
transient presentations are common in epidemiological
studies;
[110]
they often show strong cultural patterning.
For example, many cases of ataque de nervios (attack of
nerves) in Caribbean Latinos present with mixed
dissociative symptoms.
[203]
Ataques are acute paroxysms
with loss of emotional and behavioral control, lasting
minutes to hours, that typically occur in response to
acute adversity.
[204]
The proposed DDNOS example
would provide a diagnostic home for this type of
presentation.
[205]
Example ]7 is an acute state, characterized by
psychotic and dissociative symptoms, that lasts
less than 1 month and causes marked distress or
impairment. In the past, this condition has been called
‘‘reactive dissociative psychosis’’ or ‘‘hysterical psycho-
sis.’’
[78,80,206,207]
Although it may mimic an acute
schizophrenic, manic, or delirious condition, the
disorder ceases abruptly without any sequellae (i.e. no
schizotypal or negative symptoms remain).
Helpful clues to diagnosis include dissociative
symptoms, preservation of affect, good premorbid
psychosocial functioning, and unexpected/sudden
onset. Predominant symptoms include visual and
auditory hallucinations and disorganized or grossly
unusual behavior. Thought form may appear discon-
tinuous and reality testing may be temporarily im-
paired. Child-like behavior, attempts to escape,
catatonia, disorganized, or animal-like behavior may
be observed. Other symptoms include: flashbacks,
conversion symptoms, and lability in behavior and
in level of cooperation.
[78,208–210]
Occasionally,
amnesia may remain for the period of acute disorder,
a finding that supports the dissociative nature of the
episode.
[78,208,211]
Proposed DDNOS examples 6 and 7.
A. Acute reactions to stressful events, lasting less
than 1 month, that are characterized by mixed
dissociative symptoms (e.g. depersonalization,
derealization, amnesia, disruptions of conscious-
ness, and/or stupor) that cause marked distress
orimpairmentandarenotrestrictedtothe
symptoms of another mental disorder, e.g. ASD,
Delirium, a Psychotic Disorder, or another DD.
B. Acute states, lasting less than 1 month, char-
acterized by mixed dissociative symptoms (e.g.
amnesia, dissociative flashbacks, disruptions of
consciousness) and psychotic symptoms (e.g.
catatonia, auditory, visual, and/or multi-modal
hallucinations, delusions, grossly disturbed be-
havior) that cause marked distress or impairment
and do not meet criteria for ASD, a Psychotic
Disorder, Delirium or other Cognitive Disorder,
or another DD.The proposed DSM-5 DDNOS
examples are found in Table 10.
SHOULD DISSOCIATIVE TRANCE
DISORDER CURRENTLY IN THE
APPENDIX OF DSM-IV, BE
INCLUDED IN THE DDs?
The DSM-IV-TR DTD criteria describe two related
dissociative conditions, pathological trance and patho-
logical possession trance (PPD). DTD is highly
prevalent around the world, but is only listed in DSM-
IV-TR as a form of DDNOS. The DTD criteria in the
Appendix of DSM-IV-TR are based on ICD-10’s TPD
It is very important to note that the PPTcomponent
of DTD has marked phenomenological similarities to
DID. It is a disorder of identity alteration that occurs
842 Spiegel et al.
Depression and Anxiety
during an altered state of consciousness. Of course,
unlike DID, the alternate identity or identities in PPT
are attributed to possession (by an external spirit, power,
deity, or other person) rather than to internal personality
states. Associated symptoms of PPT include stereotyped
or culturally determined behaviors or movements that
are experienced as being controlled by the possessing
agent and/or full or partial amnesia for the event.
Importantly, the possession trance state is not accepted as
a normal part of a collective cultural or religious practice.
Some have asked: ‘‘If PPT is a cultural variant of
DID and is included within DSM-5 DID, would that
inclusion artificially inflate the worldwide prevalence of
DID?’’ Alternately, others have asked a different
question: ‘‘whether the DSM-IV-TR criteria for DID
reflect a cultural blindness that describes only non-
possession variants of DID?’’
Inclusion of possession variants of DID (i.e. PTP)
within DSM-5 DID would necessitate only a minor
change in the criteria—addition of the words ‘‘or an
experience of possession.’’ Such a decision would sever
the two components of DTD.’’ It would also entail
separating the two components of DTD, relegating
pathological trance without possession to DDNOS.
Alternatively, DSM-5 could (a) retain all of DTD in
DDNOS (and an appendix), or (b) incorporate DTD
(or only PPT) as a new disorder.
‘‘Possession’’ is a broader construct than PPT because it
may be used as a nonspecific attribution for explaining
events (e.g. illness, misfortune) that go beyond patholo-
gical identity alteration
[212]
By contrast, in PPT we focus
only on the subset of possession experiences–(1) an
alteration of consciousness wherein the person experiences
his/her the identity as being replaced by an ancestor, spirit,
or other entity (i.e. possession trance), and (2) these
alterations are involuntary, distressing, uncontrollable,
often chronic, and involve conflict between the individual
and his/her surrounding social or work milieu (i.e. the
possession trance is a pathological one).
[213]
PPT explicitly excludes non-PPT ones that are
culturally sanctioned and nondistressing (e.g. occurring
only during a religious ritual and does not lead to
impairment). The distinction between normal and
PPT—in Lewis’s terms,
[214]
between ‘‘central’’ and
‘‘peripheral’’ possession—has been well characterized.
Compared with persons with DID, DDs, and other
psychiatric disorders, most participants in normal or
culturally sanctioned possession trance are significantly
less likely to evidence psychopathology, subjective
distress, poor social support, past psychiatric history,
and traumatic exposure.
[213,215–217]
DISTRIBUTION AND PREVALENCE OF
PATHOLOGICAL POSSESSION TRANCE
PPT has been reported in very diverse cultural
settings all over the world.
[212,218–223]
As cultural factors
in each setting influence the prevalence and local
specific characteristics of PPT (e.g. one possessing
agent rather than another), the widespread distribution
of PPT makes it a global disorder that is not ‘‘bound’’ to
any one cultural setting. Some DID patients in the
United States, for example, describe their illness as one
of recurrent unwanted possession states.
[224,225]
Typi-
cally, these are individuals whose DID phenomenology
is influenced by their participation in religious groups
that emphasize normative possession (e.g. Pentecostals
or Charismatics). The bottom line here is that, in
keeping with the ‘‘cultural pathoplasticity’’ of psychia-
tric disorders,
[226]
the specific phenomenology of DID
and PPT may be shaped by local cultural attributions.
With the exception of Turkey and India, there are no
data on the community prevalence of PPT in most
countries. An epidemiological study of a representative
sample from a town in central Turkey using the
DDIS,
[227]
found much higher rates of DSM-IV DID
(1.1%) and DDNOS-1 (4.1%) than DTD (.6%).
[228]
On the other hand, the period prevalence of PPT in
rural Indian communities has been estimated at.97%
(over 6 months) to 3.5% (over 1 year), depending on
the region, the sample, and the method of assess-
ment.
[229,230]
The reported prevalence of voluntary
TABLE 10. Proposed DSM-5 DDNOS examples
1. Clinical presentations similar to DID that fail to meet full criteria for this disorder. Examples include presentations in which (a) there are not
two or more distinct personality states, or (b) amnesia for important personal information does not occur
2. States of dissociation that occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion (e.g.
brainwashing, thought reform, or indoctrination while captive)
3. Dissociative trance, characterized by narrowing of awareness of immediate surroundings or stereotyped behaviors or movements that are
experienced as being beyond one’s control. The dissociative trance is not a normal part of a broadly accepted collective cultural or religious
practice
4. Loss of consciousness, stupor, or coma not attributable to a general medical condition
5. Ganser syndrome: the giving of approximate answers to questions (e.g. 2 plus 2 equals 5) when not associated with DA
6. Acute reactions to stressful events, lasting less than one month, that are characterized by mixed dissociative symptoms, such as
depersonalization, derealization, amnesia, disruptions of consciousness, and/or stupor that cause marked distress or impairment and are not
restricted to the symptoms of another mental disorder, e.g. ASD, Delirium, or another dissociative disorder.
7. Acute states, lasting less than one month, characterized by mixed dissociative symptoms (e.g. amnesia, dissociative flashbacks, disruptions of
consciousness) and psychotic symptoms (e.g. catatonia, auditory or visual hallucinations, delusions, grossly disturbed behavior) that cause
marked distress or impairment and do not meet criteria for ASD, a Psychotic Disorder, Delirium, or another dissociative disorder
DA, dissociative amnesia; DF, dissociative fugue; ASD, acute stress disorder.
843Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
(normal) possession trance contributed an additional
0.2–1.8% over 6–12 months in the same studies.
PPT is also common among dissociative outpatients
in India. Saxena et al. reviewed data on more than
4,000 Indian outpatients; 104 were diagnosed with a
DD.
[231]
Only 5–10% of these received a specified DD
diagnosis according to DSM-III or DSM-III-R (there
were no diagnoses of DID). By contrast, 85.5% of DD
cases were covered by the specified dissociative
diagnoses in ICD-10.
[231]
Seventy-four percent of
patients had dissociative convulsions, 9.5% TPD, and
2% dissociative movement disorder. Indian clinicians
have reported case series of DID,
[232]
but much more
rarely than PPT. The three cases in one series were of
dual personality, rather than more complex presenta-
tions. All had strong cultural features that were
attributed to particularities of the Indian setting (e.g.
use of English and a preference for Western clothes by
the alter, to indicate higher social standing).
These findings indicate the regional diversity of
prevalence and cultural characteristics in complex
dissociative conditions that involve pathological iden-
tity alteration. This corresponds to the secondary
structuring of the DID identities in the Western DID
literature (i.e. names, genders, and other descriptive
characteristics). This secondary structuring of alter
identities reflects a variety of factors (e.g. intrapsychic,
developmental, posttraumatic, intrafamilial, socio-cul-
tural, auto-hypnotic, artistic, etc.).
[233]
RELATIONSHIP OF PPT TO DISSOCIATION
Empirical support for the dissociative origin of PPT
has been provided in a number of case reports and case
series of persons with PPT.
[213]
Gaw et al.
[222]
studied a
Chinese sample of possession inpatients, observing loss
of control of actions, loss of awareness of surroundings,
and loss of personal identity, insensitivity to pain,
changes in tone of voice, and problems with distin-
guishing reality from fantasy. In a sample of Singapor-
ean inpatients, Ng
[234]
encountered similar
manifestations: unusual vocalizations and movements
including shaking, insensitivity to pain, unfocused or
fixed gaze, and assumption of another identity.
Kianpoor and Rhoades
[221]
described Djinnati,a
possession state indigenous to Iran, that involves
unresponsiveness to external stimuli, glossolalia, iden-
tity alteration, and subsequent amnesia. Martinez-
Taboas
[235,236]
reported two cases of identity alteration
in cases of possession in Puerto Rico, that were
strongly influenced by local espiritista (spiritist) beliefs
of ongoing contact with the spirits of the dead. The
two patients variously experienced glossolalia, halluci-
nations, nonepileptic seizures, trance, verbalizations
against the host identity, and/or amnesia.
Case descriptions from India and other settings are
very similar.
[237,238]
Among 119 possessed patients who
had visited traditional healers in Uganda, Van Duijl
et al.
[239]
observed involuntary shaking of the head or
parts of the body (attributed to spirits), talking in a
different voice—which others recognized as the voice
of a specific spirit—and feeling influenced by uni-
dentified forces that cause unusual behavior. Nearly,
half of the possessed patients mentioned something
holding the body so they were unable to move or speak.
Among traditional healers and local health workers in
these villages, case vignettes of DID were always
attributed to spirit possession.
[219]
Systematic evidence supports these case reports. Van
Duijl et al. obtained DES and Somatoform Dissocia-
tion Questionnaire (SDQ-20)
[240]
scores on 119 PPT
cases in Uganda and compared these to the scores of 71
randomly selected mentally healthy inhabitants of the
same villages.
[239]
PPT patients scored significantly
higher than controls on the DES (35.3 versus 21.2,
Po.0001) and the SDQ-20 (39.4 versus 29.9,
Po.0001). Moreover, strong correlations were found
between culturally defined features of PPT and both
scales, confirming the dissociative character of PPT.
RELATIONSHIP WITH TRAUMA
Case reports of PPT describe a range of stressful
precipitants, not all of them traumatic. At the
nontraumatic pole were romantic disappointments,
work, and/or religious conflicts. At the traumatic pole
were obvious traumatic stressors such as rape, the
deaths of children, and the murder of one’s hus-
band.
[124,223,241]
However, the absence of systematic
assessment of childhood trauma in these studies makes
it impossible to exclude childhood trauma from the
genesis of DDs in these populations. For example, in
an Indian sample, Castillo
[124]
noted that PPT occurs
against a backdrop of remarkable violence against
women, including selective abortion and infanticide,
murder due to discovered premarital relations, rape,
sale into prostitution, ‘‘dowry death’’ (new bride is
killed if dowry is considered insufficient), marital
abuse, witch killings, and sati (widow burning).
In the most comprehensive study to date, Van Duijl
et al. systematically addressed this issue
[239]
and found a
significant association between PPT and earlier life
trauma. These Ugandan villagers with PPT obtained
significantly higher scores than did matched healthy
controls on the Harvard Trauma Questionnaire
[242]
and
the Traumatic Experiences Checklist.
[243]
Scores on
both scales were strongly correlated with dissociation
and symptoms of with PPT. Mass psychogenic illness
among Bhutanese refugees was attributed to spirit
possession (without identity alteration). Systematic
assessment of these refugees found higher rates of
recent and early trauma than in a comparison group.
[244]
RELATIONSHIP OF PPT TO DSM-IV-TR DID
The proposed relationship between DID and PPT is
based on their phenomenological similarity, shared
dissociative origin, and association with associated
trauma and other stressors. Both DID and PPT
844 Spiegel et al.
Depression and Anxiety
manifest incompatible identities that are separated by
an amnestic barrier; these identities occur during an
altered state of consciousness and display distinct
cognitions, affects, and behaviors.
Perhaps the primary distinction between DID and
PPT involves the attributed origin and features of the
alternate identities.
[211]
DID is hypothesized to evolve
during a traumatic, neglectful, and/or abusive early
childhood. These developmental disturbances prevent
the dissociative child from developing a unified sense of
self; instead, the child develops multiple senses of self
that continue to evolve over developmental time.
These alter identities, as already noted, are shaped by
posttraumatic, developmental, intrafamilial, psychoso-
cial, interpersonal, and cultural substrates.
[22,233]
Alternate identities in PPT tend to represent super-
natural agents, typically the spirit of a dead person, or a
culturally accepted spirit, demon, god, animal, or
mythical figure. Unlike DID alters, possessing entities
display a collective existence. For example, the same
spirit may possess different family members down the
generations (or different villagers in the same genera-
tion).
[218]
The different origin of the alternate identities
may correspond more to cultural factors—such as how
individual or porous (‘‘dividual’’) the social conception
of the self is
[124,245]
—that pattern a common dissocia-
tive diathesis rather than to the influence of distinct
pathological processes.
Both DID alternate identities and/or PPT possessing
entities share stereotypical features (‘‘child alters,’’
‘‘protectors,’’ ‘‘introjects,’’ ‘‘vengeful ghosts,’’ ‘‘angry
gods’’) that pattern their behaviors, affects, and
cognitions into stable alternate roles with whom the
sufferer’s social network can interact. In addition,
multigenerational DID has been described in families
where similar identities occur across generations, or
identities that are reciprocal occur, i.e. an angry, violent
parent identity who only corresponds to a cowering,
frightened child identity, with mutual amnesia after a
violent interaction.
[246,247]
It is of interest that in the
more sociocentric Eastern cultures, dissociative iden-
tities take the form of a member of the community,
while in the more individually focused Western
cultures, the dissociation involves a variety of internal
individual identities.
PPT tends to be described in case series as more
transient and episodic than DID, which is typically
chronic. It is possible that the emergence of PPT is
facilitated by the same porosity of the self that patterns
the external attribution of alternate identities, leading
to more transient states after a wider range of
stressors.
[238]
However, it is also possible that PPT
cases only seem transient and episodic, but that this is
just the overt presentation of phenomena that persist in
more subtle form over time. Support for this possibility
comes from data on relapse of PPT. In India, for
example, relapse within 15 years was not infrequent,
and was also recorded after two to three decades.
[223]
Four of 15 subjects in one study were found to have
suffered previous episodes,
[248]
and one subject in
another series reported three consecutive postpartum
attacks.
[249]
In China, individuals with chronic PPT
may be hospitalized after a history of recurrent
episodes.
[222]
As in the case of the traumatic precipi-
tants of PPT, systematic research with larger samples of
PPT over time is required to clarify this issue.
Therapists of DID and PPT patients usually
negotiate directly with these alternate identities—
whatever their form—in order to ‘‘give voice’’ to their
complaints, clarify the circumstances of the distress,
and possibly redress them. The evolution of the
identities over time, and their eventual change to a
more adaptive configuration or unification into a single
self-state constitutes one major basis of improvement.
Finally, some early neuroimaging data link the two
conditions, although there is no data specifically on
PPT.
[213]
A SPECT perfusion study of persons
experiencing normal possession trance—Christian
glossolalists, who report involuntariness when ‘‘speak-
ing in tongues,’’ attributed to possession by the Holy
Spirit—found decreased blood flow in the dorsolateral
prefrontal cortices after glossolalia as compared to
regular singing.
[250]
This finding is consistent with
hypoperfusion of orbitofrontal regions in DID.
[251,252]
This finding does not suggest that PPT is associated
with frontal lobe dysfunction. Rather, these experiences
may be related to enhanced connections between
frontal structures implicated in the experience of
involuntariness, as has been found with highly hypno-
tizable individuals.
[253,254]
Research on the experience
of not feeling in control suggests that attenuation of
activity in the inferior parietal cortex, modulated by the
anterior cingulate and the dorsolateral prefrontal
cortex, may also be relevant to the experience of
possession.
[213]
RECOMMENDATIONS FOR DSM-5
In light of the above, we recommend that DSM-IV
DID and PPT be considered as exemplars of a revised
umbrella category of DID in DSM-5. This umbrella
category would include the experience of possession as
an expression of identity alteration in the general
definition of the disorder. This change would be
reflected in the following:
(a) Addition of the phrase ‘‘an experience of
possession’’ to Criterion A of DID, as shown
in the revised DID criteria.
(b) Description of Western and non-Western
symptomatology of PPT in the textual clar-
ification of the prevalence and worldwide
phenomenological variation in PPT (e.g.
possession versus non-possession) The full
proposed DSM-5 diagnostic criteria for
DID, incorporating these suggestions, are
found in a prior section. The literature
reviewed suggests modest changes for the
845Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
DSM-5 description of DDs, including adding
derealization to DPD, making DF a subtype of
DA, and adding pathological possession to
dissociative identity disorder. There is a
growing body of evidence linking DDs to a
history of trauma, and greater understanding
of specific neural mechanisms underlying
dissociation.
Acknowledgments. This article was commissioned
by the DSM-5 Anxiety, Obsessive-Compulsive Spectrum,
Post-Traumatic, and Dissociative Disorders Work Group.
It represents the work of the authors for consideration by
the work group. Recommendations provided in this article
should be considered preliminary at this time; they do not
necessarily reflect the final recommendations or decisions that will
be made for DSM-5, as the DSM-5 development process is still
ongoing. It is possible that this article recommendations will
be revised as an additional data and input from experts and
the field are obtained. In addition, the categorization of
disorders discussed in this review needs to be harmonized
with recommendations from other DSM-5 workgroups
and the DSM-5 Task Force for the overall structure of
DSM-5.
Many of the ideas and recommendations in this
article were strongly influenced by discussions at the
Dissociative Disorders Research Planning Conferences
that were sponsored by the International Society for
the Study of Trauma and Dissociation from 2005 to
2009. We also thank Jacqueline Worden for her
valuable assistance in integrating revisions of the
manuscript.
REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders (Revised). 3rd ed. Washington,
DC: American Psychiatric Press; 1987.
2. American Psychiatric Association. Diagnostic And Statistical
Manual of Mental Disorders. 3rd ed. Washington, DC: American
Psychiatric Press; 1980.
3. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders DSM-IV-TR (Text Revision). 4th
editor. Washington, DC: American Psychiatric Press; 2000.
4. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision.
4th ed. Washington, DC: American Psychiatric Press; 2000.
5. Organization WH. The ICD-10 Classification of Mental and
Behavioural Disorders: Clinical Descriptions and Diagnostic
Guidelines. Geneva, Switzerland: WHO; 1992.
6. Butler LD, Duran RE, Jasiukaitis P, et al. Hypnotizability and
traumatic experience: a diathesis-stress model of dissociative
symptomatology. Am J Psychiatry 1996;153:42–63.
7. Dell PF. A new model of dissociative identity disorder. Psychiatr
Clin North Am 2006;29:1–26.
8. Gleaves DH, May MC, Cardena E. An examination of the
diagnostic validity of dissociative identity disorder. Clin Psychol
Rev 2001;21:577–608.
9. Dell PF. The multidimensional inventory of dissociation (MID):
a comprehensive measure of pathological dissociation. J Trauma
Dissociation 2006;7:77–106.
10. Dell PF. The phenomena of pathological dissociation. In:
Dell PF, O’Neil JA, editors. Dissociation and the Dissociative
Disorders: DSM-V and Beyond. New York: Routledge; 2009.
11. Kihlstrom JF, Barnhardt TM, Tataryn DJ. The psychological
unconscious. Found, lost, and regained. Am Psychol 1992;47:
788–791.
12. Cardena E. The domain of dissociation. In: Lynn SJ, Rhue JW,
editors. Dissociation: Clinical and Theoretical Perspectives.
New York: Guilford; 1994:15–31.
13. van der Hart O, Dorahy MJs. History of the concept of
dissociation. In: Dell PF, O’Neil JA, editors. Dissociation and
the Dissociative Disorders: DSM-V and Beyond. New York:
Routledge; 2009:3–26.
14. Braude SE. The coneptual unity of dissociation: a philosophical
argument. In: Dell PF, O’Neil JA, editors. Dissociation and
the Dissociative Disorders: DSM-V and Beyond. New York:
Routledge; 2009:27–36.
15. Dell PF. Understanding dissociation. In: Dell PF, O’Neil JA,
editors. Dissociation and the Dissociative Disorders: DSM-V and
Beyond. New York: Routledge; 2009:709–825.
16. Faust D, Miner RA. The empiricist and his new clothes:
DSM-III in perspective. Am J Psychiatry 1986;143:962–967.
17. Brown RJ, Cardena E, Nijenhuis ERS, et al. Should conversion
disorder be reclassified as a dissociative disorder in DSM V?
Psychosomatics 2007;48:369–378.
18. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, 2nd ed. Washington, DC:
American Psychiatric Press; 1968.
19. West LJ. The dissociative reactions. In: Freeman AM,
Kaplan HI, editors. Comprehensive Textbook of Psychiatry.
Baltimore: Williams and Wilkins; 1967.
20. Dalenberg CJ. The case for the study of ‘‘normal’’ dissociation.
In: Dell PF, O’Neil JA, editors. Dissociation and the Dissociative
Disorders: DSM-V and Beyond. New York: Routledge;
2009:145–154.
21. Hilgard ER. Divided Consciousness: Multiple Controls in
Human Thought and Action. Expanded Edition. New York:
Wiley; 1986.
22. Putnam FW. Dissociation in Children and Adolescents:
A Developmental Model. New York: Guilford; 1997.
23. Spiegel D. Dissociation, double binds, and posttraumatic stress.
In: Braun BG, editor. The Treatment of Multiple Personality
Disorder. Washington, DC: American Psychiatric Association;
1986:61–77.
24. Ross CA, Joshi S, Currie R. Dissociative experiences
in the general population. Am J Psychiatry 1990;147:
1547–1552.
25. Butler LD. Normative dissociation. Psychiat Clin N Am 2006;
29:45–62.
26. Waller NG, Putnam FW, Carlson EB. Types of dissociation and
dissociative types: a taxonometric analysis of dissociative
experiences. Psychol Methods 1996;1:300–321.
27. Waller NG, Ross CA. The prevalence and biometric structure of
pathological dissociation in the general population: taxonmetric
and behavioral genetic findings. J Abnorm Psychol 1997;106:
499–510.
28. Loewenstein RJ, Ross D. Multiple personality and psycho-
analysis: an introduction. Psychoanal Inq 1992;12:3–48.
29. Rapaport D. Emotions and Memory. Baltimore: Williams and
Wilkins; 1942.
30. Herman JL. Trauma and Recovery. New York: Basic Books;
1992.
31. Jacobson E. Depersonalization. J Am Psychoanal Assoc 1959;7:
581–610.
846 Spiegel et al.
Depression and Anxiety
32. van der Hart O, Brom D. When the victim forgets: trauma-
induced amnesia and its assessment in Holocaust survivors. In:
Shalev AY, Yehuda R, McFarlane AC, editors. International
Handbook of Human Response to Trauma. New York: Plenum;
1999;233–248.
33. Freyd JJ. Betrayal Trauma: The Logic of Forgetting Childhood
Abuse. Cambridge: Harvard; 1996.
34. Brand B, Armstrong JA, Loewenstein RJ. Psychological assess-
ment of patients with dissociative identity disorder. Psychiatr
Clin N Am 2006;29:145–168.
35. Brand BL, Classen CC, Lanius R, et al. A naturalistic study of
dissociative identity disorder and dissociative disorder not
otherwise specified patients treated by community clinicians.
Psychol Trauma Theory Res Pract Policy 2009;1:153–171.
36. Putnam FW, Helmers K, Horowitz LA, et al. Hypnotizability
and dissociativity in sexually abused girls. Child Abuse Neglect
1994;14:615–625.
37. Becker-Blease KA, Deater-Deckard K, Eley T, et al. A genetic
analysis of individual differences in dissociative behaviors in
childhood and adolescence. J Child Psychol Psychiatry 2004;45:
522–532.
38. Butler LD, Duran RE, Jasiukaitis P, et al. Hypnotizability and
traumatic experience: a diathesis-stress model of dissociative
symptomatology. Am J Psychiatry 1996;153:42–63.
39. Janet P. L’Automatisme psychologique. Paris: Alcan; 1889.
40. McClelland JL, Rumelhart DE. A distributed model of human
learning and memory. In: Clelland JL, Rumelhart DE, editors.
Parallel Distributed Processing. Cambridge, MA: MIT Press;
1986.
41. Kruschke JK. ALCOVE: an exemplar-based connectionist model
of category learning. Psychol Rev 1992;99:22–44.
42. Li D, Spiegel D. A neural network model of dissociative
disorders. Psychiatr Ann 1992;22:144-147.
43. Loewenstein RJ, Putnam FW. The dissociative disorders. In:
Sadock BJ, Sadock VA, editors. Comprehensive Textbook of
Psychiatry VIII. Vol. 1. 8th ed. Baltimore: Williams & Wilkins;
2004:1844–1901.
44. Simeon D, Loewenstein RJ. Dissociative disorders. In:
Sadock BJ, Sadock VA, Ruiz P, editors. Comprehensive Textbook
of Psychiatry. Vol. 1. 9th ed. Philadelphia, PA: Wolters
Kluwer/Lippinoctt Williams & Wilkens; 2009:1965–2026.
45. Putnam FW. Diagnosis and Treatment of Multiple Personality
Disorder. New York: Guilford; 1989.
46. Simeon D, Knutelska M, Nelson D, et al. Feeling unreal:
a depersonalization disorder update of 117 cases. J Clin
Psychiatry 2003;64:990–997.
47. Kluft RP. First rank symptoms as a diagnostic clue to multiple
personality disorder. Am J Psychiatry 1987;144:293–298.
48. Brand B, Armstrong JA, Loewenstein RJ, et al. Personality
differences on the Rorschach of dissociative identity disorder,
borderline personality disorder, and psychotic Inpatients. Psy-
chol Trauma Theory Res Pract Policy 2009;1:188–205.
49. Freyd JJ, DePrince AP, Zurbriggen EL. Self-reported memory
for abuse depends upon victim-perpetrator relationship.
J Trauma Dissociation 2001;2:5–16.
50. Lanius RA, Vermetten E, Loewenstein RJ, et al. Emotion
modulation in PTSD: clinical and neurobiological evidence for a
dissociative subtype. Am J Psychiatry 2010;167:640–647.
51. Kikuchi H, Toshikatsu F, Nobuhito A, et al. Memory repression:
brain mechanisms underlying dissociative amnesia. J Cogn
Neurosci 2009;X:1–12.
52. Hennig-Fast K, Meister F, Frodl T, et al. A case of
persistent retrograde amnesia following a dissociative fugue:
neuropsychological and neurofunctional underpinnings of loss of
autobiographical memory and self-awareness. Neuropsychologia
2008;46:2993–3005.
53. Mendelson A, Chalamish Y, Solomonovich A, et al. Mesmerizing
memory: brain substrates of episodic memory suppression and
posthypnotic amnesia. Neuron 2008;57:159–170.
54. Holmes EA, Browne RJ, Mansell W, et al. Are there two
qualitatively distinct forms of dissociation? A review and some
clinical implications. Clin Psychol Rev 2005;25:1–23.
55. Rauch SL, van der Kolk BA, Fisler RE, et al. A symptom
provocation study of posttraumatic stress disorder using positron
emission tomography and script-driven imagery. Arch Gen
Psychiatry 1996;53:380–387.
56. Lanius RA, Williamson PC, Densmore M, et al. The nature of
traumatic memories: a 4-T fMRI functional connectivity
analysis. Am J Psychiatry 2004;161:36–44.
57. Foa EB. Treating the Trauma of Rape. New York: Guilford;
1998.
58. Cloitre M, Stovall-McClough K, Nooner K, et al. Treatment for
PTSD related to childhood abuse: a randomized controlled trial.
Am J Psychiatry. July 1, 2010 2010:appi.ajp.2010.09081247.
59. Ross CA, Miller SD, Reagor P, et al. Schneiderian symptoms
in multiple personality disorder and schizophrenia. Compr
Psychiatry 1990;31:111–118.
60. Schneider K. Clinical Psychopathology. 5th ed. New York:
Grune and Stratton; 1959.
61. Ross C, Joshi S. Schneiderian symptoms and childhood trauma
in the general population. Compr Psychiatry 1992;33:269–273.
62. Putnam FW, Guroff JJ, Silberman EK, et al. The clinical
phenomenology of multiple personality disorder: a review of 100
recent cases. J Clin Psychiatry 1986;47:285–293.
63. Boon S, Draijer N. Multiple personality disorder in the
Netherlands: a clinical investigation of 71 patients. Am J
Psychiatry 1993;150:489–494.
64. Bernstein EM, Putnam FW. Development, reliability, and
validity of a dissociation scale. J Nerv Ment Dis 1986;174:
727–735.
65. Carlson EB, Putnam FW, Ross C, et al. A discriminant validity
analysis of the Dissociative Experiences Scale: a multicenter
study. Paper presented at 7th International Conference on
Multiple Personality and Dissociative States, Chicago; 1990.
66. Ross C, Heber S, Norton G, et al. The dissociative disorders
interview schedule. Dissociation 1989;2:169–188.
67. Steinberg M. The Structured Clinical Interview for DSM-III-R
Dissociative Disorders (SCID-D). Washington, DC: American
Psychiatric Press; 1993.
68. Steinberg M. The Structured Clinical Interview for DSM-IV
Dissociative Disorders-revised (SCID-D-R). Washington, DC:
American Psychiatric Press; 1994.
69. Steinberg M. Advances in the clinical assessment of dissociation:
the SCID-D-R. Bull Menninger Clin 2000;64:146–163.
70. Boon S, Draijer N. The differentiation of patients with MPD or
DDNOS from patients with Cluster B personality disorder.
Dissociation 1993;6:126–135.
71. Armstrong JG, Loewenstein RJ. Characteristics of patients with
multiple personality and dissociative disorders on psychological
testing. J Nerv Ment Dis 1990;178:448–454.
72. Armstrong JG. The psychological organization of multiple
personality disordered patients as revealed in psychological
testing. Psychiatr Clin North Am 1991;14:533–546.
73. Armstrong JG. Reflections on multiple personality disorder as
a developmentally complex adaptation. Psychoanal Study Child
1995;50:349–364.
74. Loewenstein RJ. Psychopharmacologic treatments for dissocia-
tive identity disorder. Psychiatric Ann 2005;35:666–673.
847Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
75. Chu JA, Loewenstein RJ, Dell PF, et al. Guidelines for treating
dissociative identity disorder in adults. J Trauma Dissociation
1994 2005;6:69–6149.
76. Braun BG. The BASK (behavior, affect, sensation, knowledge)
model of dissociation. Dissociation 1988;1:4–23.
77. Sar V. The scope of dissociative disorders: an international
perspective. Psychiatr Clin North Am 2006;29:227–244.
78. van der Hart O, Witztum E, Friedman B. From hysterical
psychosis to reactive dissociative psychosis. J Traum Stress 1993;
6:43–64.
79. van der Kolk B, Kadisch W. Amnesia, dissociation and the return of
the repressed. In: van der Kolk B, editor. Psychological Trauma.
Washington, DC: American Psychiatric Press; 1987:173–192.
80. Spiegel D, Fink R. Hysterical psychosis and hypnotizability. Am J
Psychiatry 1979;136:777–781.
81. Sar V, Ozturk E. Psychotic symptoms in complex dissociative
disorders. In: Moskowitz IS, Dorahy M, editors. Psychosis,
Trauma and Dissociation: Emerging Perspectives on Severe
Psychopathology. New York: Wiley; 2008:165–175.
82. Moskowitz A, Schaefer I, Dorahy ME. Psychosis, Trauma and
Dissociation: Emerging Perspectives on Severe Psychopathology.
New York: Wiley; 2009:165–175.
83. Ross CA. Dissociative schizophrenia. In: Moskowitz IS,
Dorahy M, editors. Psychosis, Trauma and Dissociation:
Emerging Perspectives on Severe Psychopathology. New York:
Wiley Press; 2008:229–283.
84. Sar V, Taycan O, Bolat N, et al. Childhood trauma and
dissociation in schizophrenia. Psychopathology 2010;3:33–40.
85. Bremner JD, Vermetten E, Afzal N, et al. Deficits in verbal
declarative memory function in women with childhood sexual
abuse-related posttraumatic stress disorder. J Nerv Ment Dis
2004;192.
86. Kluft RP. First-rank symptoms as a diagnostic clue to multiple
personality disorder. Am J Psychiatry 1987;144:293–298.
87. Fine CG. Thoughts on the cognitive perceptual substrates of
multiple personality disorder. Dissociation 1988;1:5–9.
88. Fine CG. The cognitive sequelae of incest. In: Kluft RP, editor.
Incest-Related Disorders of Adult Psychopathology. Washington,
DC: American Psychiatric Press; 1990:161–182.
89. Kluft RP. Clinical presentations of multiple personality disorder.
Psychiatr Clin North Am 1991;14:605–629.
90. Loewenstein RJ. An office mental status examination for chronic
complex dissociative symptoms and multiple personality dis-
order. Psychiatr Clin North Am 1991;14:567–604.
91. Spiegel H, Spiegel D. Trance and Treatment. 2nd ed. Washington:
American Psychiatric Press; 2004.
92. Frischholz EJ, Lipman LS, Braun BG, et al. Psychopathology,
hypnotizability, and dissociation. Am J Psychiatry 1992;149:
1521–1525.
93. Spiegel D, Hunt T, Dondershine H. Dissociation and hypnotiz-
ability in posttraumatic stress disorder. Am J Psychiatry 1988;
145:301–305.
94. Spiegel D. Dissociation and hypnosis in posttraumatic stress
disorders. J Traumatic Stress Studies 1988;1:17–33.
95. Pettinati HM, Kogan LG, Evans FJ, et al. Hypnotizability of
psychiatric inpatients according to two different scales. Am J
Psychiatry 1990;147:69–75.
96. Noyes R, Hoenk PR, Kuperman S, et al. Depersonalization in
accident victims and psychiatric patients. J Nerv Ment Dis 1977;
164:401–407.
97. Noyes R, Kletti R. Depersonalization in response to life
threatening danger. Compr Psychiatry 1977;8:375–384.
98. Putnam FW. Dissociative phenomena. In: Spiegel D,
editor. American Psychiatric Press Annual Review of Psychiatry.
Vol. 10. Washington, DC: American Psychiatric Press; 1991;
145–160.
99. Teicher MH, Samson JA, Polcari A, et al. Sticks, stones, and
hurtful words: relative effects of various forms of childhood
maltreatment. Am J Psychiatry 2006;163:993–1000.
100. Simeon D, Guralnik O, Schmeidler J, et al. The role of
childhood interpersonal trauma in depersonalization disorder.
Am J Psychiatry 2001;158:1027–1033.
101. Mullen PE, Martin JL, Anderson JC, et al. The long–term
impact of the physical, emotional, and sexual abuse of children:
a community study. Child Abuse Negl 1996;20:7–21.
102. Sierra M. Depersonalization disorder: pharmacological
approaches. Expert Rev Neurotherapy 2008;8:19–26.
103. Teicher MH, Rabi K, Sheu Y-S, et al. Neurobiology of
childhood trauma and adversity. In: Lanius RA, Vermetten E,
Pain C, editors. The Impact of Early Life Trauma on Health
and Disease: The Hidden Epidemic. Cambridge: Cambridge
University Press; 2010:112–122.
104. Teicher MH, Samson JA, Sheu Y-S, et al. Hurtful words:
association of exposure to peer verbal abuse with elevated
psychiatric symptom scores and corpus callosum abnormalities.
Am J Psychiatry 2010;167:1464–1471.
105. Simeon D, Knutelska M, Nelson D, et al. Examination of the
pathological dissociation taxon in depersonalization disorder.
J Nerv Ment Dis 2003;191:738–744.
106. Simeon D. Depersonalization disorder. In: Dell PF, O’Neil JA,
editors. Dissociation and Dissociative DisordersDSM-V and
Beyond. New York: Routledge; 2009:441–442.
107. Foote B, Smolin Y, Neft DI, et al. Dissociative disorders and
suicidality in psychiatric outpatients. J Nerv Ment Dis 2008;
196:29–36.
108. Hunter EC, Sierra M, David AS. The epidemiology of
depersonalisation and derealisation. A systematic review. Soc
Psychiatry Psychiatr Epidemiol 2004;39:9–18.
109. Johnson JG, Cohena P, Kasena K, et al. Dissociative disorders
among adults in the community, impaired functioning, and axis
I and II comorbidity. J Psychiatr Res 2006;40:131–140.
110. Sar V, Akyuz G, Dogan O. Prevalence of dissociative disorders
among women in the general population. Psychiatry Res 2007;
149:169–176.
111. Simeon D, Abugel J. Feeling Unreal: Depersonalization
Disorder and the Loss of Self. New York: Oxford; 2006.
112. Zohar J, Insel TR. Obsessive-compulsive disorder: psycho-
biological approaches to diagnosis, treatment, and patho-
physiology. Biol Psychiatry 1987;22:667–687.
113. Arzy S, Thut G, Mohr C, et al. Neural basis of embodiment:
distinct contributions of temporoparietal junction and extra-
striate body area. J Neurosci 2006;26:8074–8081.
114. Dell PF. Involuntariness in hypnotic responding and dissocia-
tive symptoms. J Trauma Dissociation 11:1–18.
115. Lanius RA, Williamson PC, Boksman K, et al. Brain activation
during script-driven imagery induced dissociative responses in
PTSD: a functional magnetic resonance imaging investigation.
Biol Psychiatry 2002;52:305–311.
116. Lanius RA, Hopper JW, Menon RS. Individual differences in a
husband and wife who developed PTSD after a motor vehicle
accident: a functional MRI case study. Am J Psychiatry 2003;
160:667–669.
117. Lanius RA, Williamson PC, Bluhm RL, et al. Functional
connectivity of dissociative responses in posttraumatic stress
disorder: a functional magnetic resonance imaging investiga-
tion. Biol Psychiatry 2005;57:873–884.
118. Reinders AA, Nijenhuis ER, Quak J, et al. Psychobiological
characteristics of dissociative identity disorder: a symptom
848 Spiegel et al.
Depression and Anxiety
provocation study. Department of Biological Psychiatry,
University Medical Center Groningen, University of
Groningen, Groningen. Department of Cardiology, University
Medical Center Groningen, University of Groningen,
Groningen. The Thorax Center and Nuclear Medicine and
Molecular Imaging, University Medical Center Groningen,
University of Groningen, Groningen. Mental Health Care
Drenthe, Assen, The Netherlands; 2006.
119. Simeon D, Guralnik O, Knutelska M, et al. Hypothalamic-
pituitary-adrenal axis dysregulation in depersonalization dis-
order. Neuropsychopharmacology 2001;25:793–795.
120. Giesbrecht T, Smeets T, Merckelbach H, et al. Depersonaliza-
tion experiences in undergraduates are related to heightened
stress cortisol responses. J Nerv Ment Dis 2007;195:282–287.
121. Giese-Davis J, Wilhelm FH, Conrad A, et al. Depression and
stress reactivity in metastatic breast cancer. Psychosom Med
2006;68:675–683.
122. Simeon D, Guralnik O, Knutelska M, et al. Basal norepinephr-
ine in depersonalization disorder. Psychiatry Res 2003;121:
93–97.
123. Sierra M, Senior C, Dalton J, et al. Autonomic response in
depersonalization disorder. Arch Gen Psychiatry 2002;59:
833–838.
124. Castillo RJ. Spirit possession in South Asia, dissociation or
hysteria? Part 1: Theoretical background. Cult Med Psychiatry
1994;18:1–21.
125. Brown D, Scheflin AW, Hammond DC. Memory, Trauma,
Treatment, and the Law. New York: Norton; 1998.
126. Williams LM. Recall of childhood trauma: a prospective study
of women’s memories of child sexual abuse. J Consult Clin
Psychol 1994;6:1167–1176.
127. Edwards VJ, Fivush R, Anda RF, et al. Autobiographical
memory disturbances in childhood abuse survivors. In:
Freyd JJ, DePrince AP, editors. Trauma and Cognitive Science:
A Meeting of Minds, Science, and Human Experience.
Binghamton, NY: Howarth; 2001.
128. Elliott DM, Briere J. Posttruamtic stress associated with
delayed recall of sexual abuse: a general population study.
J Interpers Violence 1995;8:628–647.
129. Elliott DM. Traumatic events: prevalence and delayed recall in
the general population. Journal of Consulting and Clinical
Psychology 1997;65:811–820.
130. Briere J, Elliott DM. Prevalence and psychological sequelae of
self-reported childhood physical and sexual abuse in a general
population sample of men and women. Child Abuse Negl 2003;
27:1205–1222.
131. Courtois CA. Recollections of Sexual Abuse: Treatment
Principles and Guidelines. New York: Norton; 1999.
132. Loewenstein RJ. Psychogenic amnesia and psychogenic fugue: a
comprehensive review. In: Tasman A, Goldfinger S, editors.
American Psychiatric Press Annual Review of Psychiatry,
Vol. 10. Washington, DC: American Psychiatric Press; 1991;
189–222.
133. Lishman WA. Organic Psychiatry. 2nd ed. Oxford: Blackwell;
1987.
134. Cummings JL. Frontal-subcortical circuits and human
behavior. Arch Neurol 1993;50:873–880.
135. Loftus EF. The reality of repressed memories. Am Psychol
1993;48:518–537.
136. Conway MA, editor. Recovered Memories and False Memories.
Oxford: Oxford University Press; 1997.
137. Schacter DL. The seven sins of memory: insights from
psychology and cognitive neuroscience. Am Psychol 1999;54:
182–203.
138. Conway MA, Rubin DC. The structure of autobiographical
memory. In: Collins AF, Gaterhcole SE, Conway MA,
Morris PE, editors. Theories of Memory. Hillsdale, NJ:
Erlbaum; 1993:103–139.
139. Conway MA, Pleydell-Pierce CW. The construction of auto-
biographical memories in the self memory system. Psychol Rev
2000;107:261–288.
140. Kihlstrom JF. ‘‘So that we might have roses in December’’: the
functions of autobiographical memory. Appl Cogn Psychol
2009;23:1179–1192.
141. Schacter DL, Wang PL, Tulving E. Functional retrograde
amnesia: a quantitative study. Neuropsychologia 1982;20:
523–532.
142. Schacter DL, Kihlstrom JF, Kihlstrom LC. Autobiobraphical
memory in a case of multiple personality. J Abnorm Psychol
1989;98:508–514.
143. Bryant RA. Autobiographical memory across personalities in
dissociative identity disorder: a case report. J Abnorm Psychol
1995;114:625–631.
144. Kritchevsky M, Chang J, Squire LR. Functional amnesia:
clinical descripton and neuropsychological profile of 10 cases.
Learn Membr 2004;11:213–226.
145. Hennig-Fast K, Meister F, Frodl T, et al. A case of persistent
retrograde amnesia following a dissociative fugue: neuro-
psychological and neurofunctional underpinnings of loss of auto-
biographical memory and self-awareness. Neuropsychologia
2008;46:2993–3005.
146. Kikuchi H, Fujii T, Abe N, et al. Memory repression: brain
mechanisms underlying dissociative amnesia. J Cogn Neurosci
2010;22:602–613.
147. Markowitsch HJ. Retrograde amnesia: similarities between
organic and psychogenic forms. Neurol Psychiatry Brain Res
1996;4:108.
148. Markowitsch HJ. Psychogenic amnesia. NeuroImage 2003;20:
S132–S138.
149. Markowitsch HJ. Functional neuroimaging correlates of func-
tional amnesia. Memory 1999;7:561–583.
150. Markowitsch HJ, Fink GR, Thone A, et al. Persistent
psychogenic amnesia with a PET-proven organic basis. Cogn
Neuropsychiatry 1997;2:135–158.
151. Markowitsch HJ, Fink GR, Thone A, et al. A PET study of
persistent psychogenic amnesia covering the whole life span.
Cogn Neuropsychiatry 1997;2:135–158.
152. Markowitsch HJ, Kessler J, Russ MO, et al. Mnestic block
syndrome. Cortex 1999;35:219–230.
153. Markowitsch HJ, Kessler J, Weber-Luxenburger G, et al.
Neuroimaging and behavioral correlates of recovery from
mnestic block syndrome and other cognitive deteriorations.
Neuropsychiatry Neuropsychol Behav Neurol 2000;13:
60–66.
154. Kopelman MD, Christensen H, Puffett A, et al. The great
escape: a neuropsychological study of psychogenic amnesia.
Neuropsychologia 1994;32:675–691.
155. Huntjens RJC. Apparent Amnesia: Interidentity Memory
Functioning in Dissociative Identity Disorder. Ridderkirk, the
Netherlands: Ridderprint; 2003.
156. Janet P. The Mental State of Hystericals. New York: G.P.
Putnam’s Sons; 1901.
157. van der Hart O, Nijenhuis ERS. Generalized dissociative
amnesia: episodic, semantic, and procedural memories lost and
found. Aust N Z J Psychiatry 2001;35:589–600.
158. Kapur N. Amnesia in relation to fugue states—distinguishing a
neurological from a psychogenic basis. Br J Psychiatry 1991;
159:872–877.
849Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
159. Ross C. The epidemiology of multiple personality disorder and
dissociation. Psychiatr Clin North Am 1991;14:503–517.
160. S¸ar V, Akyu
¨z G, Dog
ˇan O. Prevalence of dissociative disorders
among women in the general population. Psychiatry Res 2007;
149:169–176.
161. Xiao Z, Yan H, Wang Z, et al. Trauma and dissociation in
China. Am J Psychiatry 2006;163:1388–1391.
162. Foote B, Smolin Y, Kaplan M, et al. Prevalence of dissociative
disorders in psychiatric outpatients. Am J Psychiatry 2006;163:
623–629.
163. Anderson MC, Ochsner KN, Kuhl B, et al. Neural systems
underlying the suppression of unwanted memories. Science
2004;303:232–235.
164. Spiegel D, Cardena E. Disintegrated experience: the dissocia-
tive disorders revisited. J Abnorm Psychol 1991;100:366–378.
165. Spiegel D. Recognizing traumatic dissociation. Am J Psychiatry
2006;163:566–568.
166. Christianson S-A, Engelberg E. Remembering and forgetting
traumatic experiences: a matter of survival. In: Conway MA,
editor. Recovered Memories and False Memories. Oxford:
Oxford University Press; 1997:230–250.
167. Milner B, Squire LR, Kandel ER. Cognitive neuroscience and
the study of memory. Neuron 1999;20:445–468.
168. Eichenbaum H. A cortical-hippocampal system for declarative
memory. Nat Rev Neurosci 2005;1:41–50.
169. Lamme VA. Blindsight: the role of feedforward and feedback
corticocortical connections. Acta Psychol (Amst) 2001;107:
209–228.
170. Coons PM, Millstein V. Psychogenic amnesia: a clinical
investigation of 25 cases. Dissociation 1992;5:73–79.
171. Ross C, Duffy C, Ellason JW. Prevalence, reliability and validity
of dissociative disorders in an inpatient setting. J Trauma
Dissociation 2002;3:7–17.
172. Fisher C. Amnesic states in war neurosis: the psychogenesis of
fugue. Psychoanal Q 1945;14:437–468.
173. Fisher C, Joseph ED. Fugue with awareness of loss of personal
identity. Psychoanal Q 1949;18:480–493.
174. Coons PM. Psychogenic or dissociative fugue: a clinical
investigation of five cases. Psychol Rep 1999;84:881–886.
175. Hacking I. Mad Travelers: Reflections on the Reality of
Transient Mental Illnesses. Charlottesville: University of
Virginia Press; 1998.
176. Ross CA, Miller SD, Reagor P, et al. Structured interview data
on 102 cases of multiple personality disorder. Am J Psychiatry
1990;147:596–601.
177. Ross CA. Dissociative amnesia and dissociative fugue. In:
Dell PF, O’Neil JA, editors. Dissociation and the Dissociative
Disorders: DSM-V and Beyond. New York: Routledge;
2009:429–434.
178. Sidis B, Goodhart SP. Multiple Personality: An Experimental
Investigation Into the Nature of Human Individuality.
New York: D. Appleton & Co.; 1905.
179. Howley J, Ross CA. The structure of dissociative fugue: a case
report. J Trauma Dissociation 2003;4:109–124.
180. Dell PF. Why the diagnostic criteria for dissociative identity
disorder should be changed. J Trauma Dissociation 2001;2:
7–37.
181. Dell PF. The long struggle to diagnose Multiple Personality
Disroder (MPD); Partial MPD. In: Dell PF, O’Neil JA, editors.
Dissociation and the Dissociative Disorders: DSM-V and
Beyond. New York: Routledge; 2009:403–428.
182. Latz TT, Kramer SI, Hughes DL. Multiple personality disorder
among female inpatients in a state hospital. Am J Psychiatry
1995;152:1343–1348.
183. Coons PM, Chu J. Psychiatrists’ attitudes toward DDs
diagnoses. American Journal of Psychiatry 2000;157:
1179–1180.
184. Kluft RP. Diagnosing dissociative identity disorder. Psychiatric
Annals 2005;35:633–643.
185. Kluft RP. Making the diagnosis of multiple personality disorder.
In: Flach F, editors. Directions in Psychiatry. New York:
Hatherleigh; 1985:1–10.
186. Johnson JG, Cohen P, Kasen S, et al. Dissociative disorders
among adults in the community, impaired functioning, and axis
I and II comorbidity. J Psychiatr Res 2006;40:131–140.
187. Boon S, Draijer N. Multiple Personality Disorder in the
Netherlands: A Study on Reliability and Validity of the
Diagnosis. Amsterdam: Swets & Zeitlinger B.V.; 1993.
188. Blashfield RK. Contemporary directions in psychopathology:
toward the DSM-IV. In: Millon TEK, Gerald L, editors.
Structural Approaches to Classification. Contemporary Direc-
tions in Psychopathology: Toward the DSM-IV. Vol. xiv.
New York, NY: Guilford Press; 1986:363–380.
189. Morey LC. Personality disorders in DSM-III and DSM-III-R:
convergence, coverage, and internal consistency. Am J Psychiatry
1988;145:573–577.
190. Dell PF. The long struggle to diagnose Multiple Personality
Disroder (MPD); MPD. In: Dell PF, O’Neil JA, editors.
Dissociation and the Dissociative Disorders: DSM-V and
Beyond. New York: Routledge; 2009:383–402.
191. Kluft RP. Multiple personality disorder. In: Tasman A,
Goldfinger S, editors. American Psychiatric Press Annual
Review of Psychiatry, Vol. 10. Washington, DC: American
Psychiatric Press; 1991:161–188.
192. Loewenstein RJ, Hamilton J, Alagna S, et al. Experiential
sampling in the study of multiple personality disorder. Am J
Psychiatry 1987;144:19–24.
193. Gast U, Rodenwald F, Dehner-Rau C, et al. Validation of the
German version of the Multidimensional Inventory of Dis-
sociation (MID-d). Annual meeting of the International Society
for the Study of Dissociation Vol, Chicago, IL, 2003.
194. Lipsanen T, Korkeila J, Peltola P, et al. Dissociative disorders
among psychiatric patients. Eur Psychiatry 2004;19:53–55.
195. Ross C. DSM-111 problems in diagnosing partial forms of
multiple personality disorder: discussion paper. J R Soc Med
1985;78:933–936.
196. Ross CA. Dissociative Identity Disorder: Diagnosis, Clinical
Features, and Treatment of Multiple Personality. New York:
Wiley; 1997.
197. Steinberg M. Updating diagnostic criteria for dissociative
disorders: learning from scientific advances. J Trauma Dissocia-
tion 2001;2:59–63.
198. Cardena E, Spiegel D. Diagnostic issues, criteria and comor-
bidity of dissociative disorders. In: Michelson LK, Ray WJ,
editors. Handbook of Dissociation: Theoretical, Empirical and
Clinical Perspectives. New York: Plenum Press; 1996.
199. Akyuz G, Dogan O, Sar V, et al. Frequency of dissociative
identity disorder in the general population in Turkey. Compr
Psychiatry 1999;40:151–159.
200. Graves SM. Dissociative disorders and dissociative symptoms at
a community mental health center. Dissocation 1989;2:
119–127.
201. Saxe GN, van der Kolk BA, Berkowitz R, et al. Dissociative
disorders in psychiatric inpatients. Am J Psychiatry 1993;150:
1037–1042.
202. Tutkun H, Sar V, Yargic LI, et al. Frequency of dissociative
disorders among psychiatric inpatients in a Turkish University
Clinic. Am J Psychiatry 1998;155:800–805.
850 Spiegel et al.
Depression and Anxiety
203. Lewis-Fernndez R, Gorritz M, Raggio GA, et al. Association of
trauma-related disorders and dissociation with four idioms of
distress among Latino psychiatric outpatients. Cult Med
Psychiatry 2010;34:219–243.
204. Guarnaccia PJ, Canino G, Rubio-Stipec M, et al. The
prevalence of ataques de nervios in the Puerto Rico Disaster
Study: the role of culture in psychiatric epidemiology. J Nerv
Ment Dis 1993;181:157–165.
205. Lewis-Ferna
´ndez R, Garrido-Castillo P, Bennasar MC, et al.
Dissociation, childhood trauma, and ataque de nervios among
Puerto Rican psychiatric outpatients. Am J Psychiatry 2002;159:
1603–1605.
206. Van der Hart O, Witztum E. Dissociative psychosis: clinical and
theoretical aspects. In: Moskowitz A, Scha
¨fer I, Dorahy M,
editors. Trauma, Psychosis, and Dissociation: Emerging Per-
spectives on Severe Psychopathology. London: Wiley; 2008.
207. Graham C, Thavasotby R. Dissociative psychosis: an atypical
presentation and response to cognitive-analytic therapy. Irish J
Psychol Med 1995;12:109–111.
208. Tutkun H, Yargic LI, Sar V. Dissociative identity disorder
presenting as hysterical psychosis. Dissocation 1996;9:241–249.
209. Van der Hart O, Spiegel D. Hypnotic assessment and treatment
of trauma-induce dpsychoses:the early psychotherapy of H.
Breukink and modern views. Int J Clin Exp Hypn 1993;41:
191–209.
210. Sar V, Ozturk E. Psychotic presentations of dissociative identity
disorder. In: Dell PF, O’Neil JA, editors. Dissociation and the
Dissociative Disorders: DSM-V and Beyond. New York:
Routledge; 2009:535–545.
211. Lewis-Fernandez R, Martinez-Taboas A, Sar V, et al. The cross
cultural assessment of dissociaton. In: Wilson JP, Tang C,
editors. The Cross-Cultural Assessment of Psychological
Trauma and PTSD. New York: Springer; 2007:279–317.
212. Bourguignon E. Possession. San Francisco: Chandler & Sharp;
1976.
213. Cardena E, Van Duijil M, Weiner L, et al. Possession/trance
phenomena. In: Dell PF, O’Neil JA, editors. Dissociation and
the Dissociative Disorders: DSM-V and Beyond. New York:
Routledge; 2009.
214. Lewis IM. Ecstatic Religion. 2nd ed. London: Routledge; 1989.
215. Moreira-Almeida A, Neto FL, Cardena E. Comparison of
brazilian spiritist mediumship and dissociative identity disorder.
J Nerv Ment Dis 2008;196:420–424.
216. Negro PJ, Palladino, N-P, Louza MR. Do religos mediumship
dissociative experiences conform to the sociocognitive theory of
dissociation? J Trauma Dissociation 2002;3:573.
217. Laria AJ. Dissociative Experiences Among Cuban Mental
Health Patients and Spiritist Mediums. Psychology. Boston:
University of Massachusetts; 1998.
218. Freed RS, Freed SA. Ghost illness in a north Indian village. Soc
Sci Med 1990;30:617–623.
219. Van Duijl M, Cardena E, De Jong JTMV. The validity of
DSM-IV dissociative disorders categories in South-West
Uganda. Transcult Psychiatry 2005;42:219–241.
220. Eguchi S. Between folk concepts of illness and psychiatric
diagnosis. Cult Med Psychiatry 1991;15:415–421.
221. Kianpoor M, Rhoades GFJ. ‘‘Djinnati,’’ a possession state in
Ballooshistan, Iran. J Trauma Pract 2005;4:147–155.
222. Gaw AC, Qin-Zhang D, Levine RE, et al. The clinical
characteristics of possession disorder among 20 Chinese
patients in Hebei Province of China. Psychiatr Serv 1998;49:
360–365.
223. Lewis-Fernandez R, Guarnaccia PJ, Ruiz P. Culture bound
syndromes. In: Kaplan H, Sadock B, editors. Comprehensive
Textbook of Psychiatry. New York: Lippincott, Williams &
Wilkins; 2009:2519–2538.
224. Ross CA, Ness L. Symptom patterns in dissociative identity
disorder patients and the general population. J Trauma
Dissociation 2011 (in press).
225. Bull DL, Ellason JW, Ross CA. Exorcism revisited: positive
outcomes with dissociative identity disorder. J Pyschol Theol
1998;26:188–196.
226. Alarcon RD, Bell CC, Kirmayer LJ, et al. Beyond the fun house
mirrors: research agenda on culture and psychiatric diagnosis.
In: Kupfer DJ, First MB, Regier DA, editors. A Research
Agenda for DSM-V. Washington, DC: American Psychiatric
Press; 2002:219–289.
227. Sar V, Koyuncu A, Ozturk E, et al. Dissociative disorders in the
psychiatric emergency ward. Gen Hosp Psychiatry 2007;29:
45–50.
228. Ross CA, Heber S, Norton GR, et al. The dissociative disorders
interview schedule: a structrured interview. Dissociation 1989;
169–178.
229. Carstairs GM, Kapur RL. The Great Universe of Kota: Social
Change and Mental Disorder in an Indian Village. Berkeley:
University of California Press; 1976.
230. Venkataramaiah V, Mallikarjunaiah M, Chandrasekhar CR,
et al. Possession syndrome: an epidemiological study in West
Karnataka. Indian J Psychiatry 1981;23:213–218.
231. Das PS, Saxena S. Classification of dissociative states in DSM-111-R
and ICD-10 1989 (draft). Br J Psychiatry 1991;425–427.
232. Adityanjee, Raju GS, Khandelwal SK. Current status of
multiple personality disorder in India. Am J Psychiatry 1989;
146:1607–1610.
233. Kluft RP. The natural history of multiple personality disorder.
In: Kluft RP, editor. Childhood Antecedents of Multiple
Personality. Washington, DC: American Psychiatric Press;
1985:197–238.
234. Ng B-Y. Phenomenology of trance states seen at a pyschiatric
hospital in Singapore: a cross-cultural perspective. Transcult
Psychiatry 2000;37:560–579.
235. Martinez-Taboas A. A Case of spirit possession and Glossolalia.
Cult Med Psychiatry 1999;23:333–348.
236. Martinez-Taboas A. Psychogenic seizures in an Espiritismo
context: the role of culturally sensistive psychotherapy.
Psychother Theory Res Pract Train 2005;42:6–13.
237. Carden
˜a E, Lewis-Ferna
´ndez R, Beahr D, et al. Dissociative
disorders. In: Widiger TA, Frances AJ, Pincus HJ, Ross R,
First MB, Davis WW, editors. Sourcebook for the DSM-IV.
Vol. II. Washington, DC: American Psychiatric Press;
1996:973–1005.
238. Lewis-Fernandez R. Culture and dissociation: a comparison of
ataque de nervios among Puerto Ricans and possession
syndrome in India. In: Spiegel D, editor. Dissociation: Culture,
Mind and Body. Washington, DC: American Psychiatric Press;
1994:123–167.
239. Van Duijl M, Nijenhuis E, Komproe IH, et al. Dissociative
symptoms and reported trauma among patients with spirit
possession and matched healthy controls in Uganda. Cult Med
Psychiatry 2010;34:380–400.
240. Nijenhuis ER, Spinhoven P, vanDyck R, et al. The development
and psychometric characterstics of the somatoform dissociation
questionnaire (SDQ-20). J Nerv Ment Dis 1996;688–694.
241. Ng B-Y, Chan Y-H. Psychosocial stressors that precipitate
dissociative trance disorder in Singapore. Aust N Z J Psychiatry
2004;38:426–432.
242. Mollica RF, Caspi-Yavin Y, Bollini P, et al. The Harvard Trauma
Questionnaire. Validating a cross-cultural instrument for
851Research Article: Dissociative Disorders in DSM-5
Depression and Anxiety
measuring torture, trauma, and posttraumatic stress disorder in
Indochinese refugees. J Nerv Ment Dis 1992;180:111–116.
243. Nijenhuis ER, van der Hart O, Krueger K. The psychometric
characteristics of the Traumatic Experiences Questionnaire
(TEC): first findings among psychiatric outpatients. Clin
Psychol Psychother 2002;9:200–210.
244. Van Ommeren M, Sharma B, Komproe I, et al. Trauma and loss
as determinant of medically unexplained epidemic illness in a
Bhutanese refugee camp. Psychol Med 2001;31:1259–1267.
245. Umesue M, Matsuo T, Iwata N, et al. Dissociative Disorders in
Japan: a pilot study with the dissociative experiences scale and
a semi-structured interview. Dissociation 1996;9:182–189.
246. Kluft RP. Childhood multiple personality disorder: predictors,
clinical findings, and treatment results. In: Kluft RP, editor.
Childhood Antecedents of Multiple Personality. Washington,
DC: American Psychiatric Press; 1985:167–196.
247. Braun BG. The transgenerational incidence of dissociation and
multiple personality disorder: a preliminary report. In:
Kluft RP, editor. Childhood antecedants of multiple
personality. Washington, DC: American Psychiatric Press;
1985:127–150.
248. Teja JS, Khanna BS, Subrahmanyam TB. Possession states in
Indian Patients. Indian J Psychiatry 1970;12:71–87.
249. FreedSAF RS. Spirit possession as illness in a North Indian
village. Ethnology 1964;3:152–171.
250. Newberg AB, Wintering NA, Morgan D, et al. The measure-
ment of regional cerebral blood flow during glossolalia: a
preliminary SPECT study. Psychiatry Res 2006;148:67–71.
251. Sar V, Unal SN, Kiziltan E, et al. HMPAO SPECT study of
cerebral perfusion in dissociative indentity disorder. J Trauma
Dissociation 2001;2:5–25.
252. Sar V, Unal SN, Ozturk E. Frontal and occipital perfusion
changes in dissociative identity disorder. Psychiatry Res 2007;
156:217–223.
253. Gruzelier J. Frontal functions, connectivity andnerual efficiency
underpinning hypnosis and hypnotic suscepticibility. Contemp
Hypn 2006;23:15–32.
254. Horton JE, Crawford HJ, Harrington G, et al. Increased
anterior corpus callosum size associated positively with
hypnotizability and the ability to control pain. Brain 2004;
127:1741–1747.
255. Bliss EL. Multiple personalities: a report of 14 cases with
implications for schizophrenia and hysteria. Arch General
Psychiatry 1980;37:1388–1397.
256. Kluft RP. Childhood multiple personality disorder predictors,
clinical findings, and treatment results. In: Kluft RP, editor.
Childhood Antecedents of Multiple Personality Disorder.
Washington, DC: American Psychiatric Press; 1985:168–196.
257. Kluft RP. First-rank symptoms as a diagnostic clue to multiple
personality disorder. Am J Psychiatry 1987;144:293–298.
258. Putnam FW, Guroff JJ, Silberman EK, Barban L, Post RM.
The clinical phenomenology of multiple personality disorder:
review of 100 recent cases. J Clin Psychiatry 1986;47:285–293.
259. Bliss EL. 1986. Multiple Personalities, Allied Disorders and
Hypnosis. New York: Oxford University Press.
260. Coons PM, Bowman ES, Milstein V. Multiple personality
disorder: a clinical investigation of 50 cases. J Nervous Mental
Disease 1988;176:519–527.
261. Ross CA, Norton GR, Wozney K. Multiple personality
disorder: an analysis of 236 cases. Canadian J Psychiatry 1989;
34:413–417.
262. Ross CA, Miller SD, Reagor P, Bjornson L, Fraser GA,
Anderson G. Structured interview data on 102 cases of multiple
personality disorder from four centers. Am J Psychiatry 1990b;
147:596–601.
263. Dell PF, Eisenhower JW. Adolescent multiple personality
disorder. J Am Academy Child Adoles Psychiatry 1990;29:
359–366.
264. Hornstein NL, Putnam FW. Clinical phenomenology of child
and adolescent dissociative disorders. J Am Academy Child
Adoles Psychiatry 1992;31:1077–1085.
265. Boon S, Draper N. Multiple personality disorder in
The Netherlands: a study on reliability and validity of the
diagnosis. Amsterdam/Lisse: Swets & Zeitlinger; 1993.
266. S¸ar V, Yargic I, Tutkun H. Structured interview data on 35 cases
of dissociative identity disorder in Turkey. Am J Psychiatry
1996;153:1329–1333.
267. Middleton W, Butter J. Dissociative identity disorder: an
Australian series. Australian & New Zealand J Psychiatry
1998;32:794–804.
268. Dell PF. A new model of dissociative identity disorder.
Psychiatric Clin North America 2006b;29:1–26.
852 Spiegel et al.
Depression and Anxiety
ResearchGate has not been able to resolve any citations for this publication.
Chapter
Psychotic symptoms may occur in dissociative identity disorder (DID), in its partial presentations, and in acute dissociative conditions. This chapter summarizes clinical observations and the existing empirical data on the prevalence and significance of psychotic symptoms in dissociative disorders. Formal thought disorder is related to the disturbances in thought flow as observed in conversation with the patient. Impaired reality testing is one of the major hallmarks of psychosis. Reality testing is intact in patients with dissociative disorders except during dissociative psychotic episodes, which may constitute crisis states superimposed on the ongoing dissociative pathology. Certain kinds of hallucinations and delusions are called Schneiderian symptoms, and have been considered typical of schizophrenia. The chapter presents an alternative hypothesis, namely an interaction model, to explain the complex comorbidity between two distinct but concurrent or subsequent disorders.
Chapter
In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association), the first example of Dissociative Disorder Not Otherwise Specified (i.e., DDNOS-1) is “clinical presentations similar to Dissociative Identity Disorder that fail to meet full criteria for this disorder” (p. 490). This definition of DDNOS-1 has a necessary implication. As the criteria for DID change, so, too, must the nature of DDNOS-1 change. Before discussing DDNOS-1, a few prefatory comments are necessary regarding the Not Otherwise Specified (NOS) category of the modern DSM (American Psychiatric Association, 1980, 1987, 1994). The examples that are listed in an NOS category do not have the same DSM-status as do the specific disorders. In fact, NOS examples have no diagnostic status whatsoever, except as almost a footnote in the NOS category. NOS examples simply identify some clinical presentations that the DSM does not recognize as specific disorders. So, even though the DSM lists some NOS examples, they are not official disorders. That is why NOS examples do not have their own numerical ICD-9 codes. Only the NOS category as a whole (e.g., DDNOS) has a numerical ICD-9 code (i.e., 300.15). Note also that NOS examples do not have a set of framed “Diagnostic Criteria,” as do all of the specific disorders in the DSM. So, what does this mean for DDNOS-1? It means that partial DID (i.e., DDNOS-1) exists in the minds of clinicians, but that it has no diagnostic status in the DSM. It means that partial DID exists in the empirical literature (which diagnoses it as DDNOS and reports its prevalence and dissociative characteristics), but partial DID has no official existence in the DSM.1 This is a signifi - cant problem because, in studies of clinical populations, DDNOS-1 is the most common diagnosis (see the following). In fact, partial forms of DID are so common that the term DDNOS has come to mean “DDNOS-1” in the dissociative disorders field. The bottom line is that clinicians and researchers in the dissociative disorders field treat DDNOS as if it were a specific disorder (see the following), but it is not.
Article
Forty-seven separate incidents of exorcism, conducted on 15 Dissociative Identity Disorder (DID) patients, were retrospectively investigated by a neutral interviewer using the Exorcism Experiences Questionnaire. Rye types of exorcism were identified based on eight methodological factors. These factors were patient permission, noncoercion, active participation of the patient, understanding of DID dynamics by the exorcist, implementation of the exorcism within the context of psychotherapy, compatibility of the procedure with the patient's spiritual beliefs, incorporation of the patient's belief system, and encouragement of patient self-independence regarding exorcism. Descriptive analysis yielded 24 positive patient responses and 23 diverse responses, based on the presence or absence of these factors. Exorcisms that incorporated all factors consistently had positive responses. Symptom outcomes and experiences are discussed in light of the five different types of exorcism.