DIAGNOSTIC CRITERIA

DISSOCIATIVE DISORDERS A. Disruption of identity characterized by two or more distinct

Dissociative Disorders personality states, which may be described in some cultures as
an experience of possession. The disruption in identity involves
 Characterized by a disruption of and/or discontinuity in the marked discontinuity in sense of self and sense of agency,
normal integration of consciousness, memory, identity, accompanied by related alterations in affect, behavior,
emotion, perception, body representation, motor control, and consciousness, memory, perception, cognition, and/or sensory-
behavior motor functioning. These signs and symptoms may be observed
 Frequently found in the aftermath of a wide variety of by others or reported by the individual.
psychologically traumatic experiences in children, adolescents, B. Recurrent gaps in the recall of everyday events, important
and adults personal information, and/or traumatic events that are
 “traumatic experiences” refers to experiences that result in inconsistent with ordinary forgetting.
psychological sequelae, as opposed to the physical impact that C. The symptoms cause clinically significant distress or
can cause traumatic brain injury impairment in social, occupational, or other important areas of
functioning.
Dissociative Symptoms D. The disturbance is not a normal part of a broadly accepted
cultural or religious practice.
 Unbidden intrusions into awareness and behavior, with Note: In children, the symptoms are not better
accompanying losses of continuity in subjective experience explained by imaginary playmates or other fantasy
 Ex: ‘‘positive’’ dissociative symptoms such as division of play.
identity, depersonalization, and derealization and/or
 Inability to access information or to control mental functions E. The symptoms are not attributable to the physiological effects
that normally are readily amenable to access or control of a substance (e.g., blackouts or chaotic behavior during
 Ex: amnesia alcohol intoxication) or another medical condition (e.g.,
complex partial seizures).
ADDED INFO:
 Across cultural contexts, risk factors for dissociative pathology  Typically present with comorbid depression, anxiety, substance
include: abuse, self-injury, or another common symptom
 Earlier onset of trauma;  Report dissociative flashbacks - as though it were occurring in
 Neglect and sexual, physical, and emotional abuse by parents; the present but: often with a change of identity,
 cumulative early life trauma and adversities; and repeated  A partial or complete loss of contact with or disorientation to
sustained trauma or torture associated with captivity (e.g., current reality during the flashback,
experienced by prisoners of war, victims of trafficking).  And a subsequent amnesia for the content of the flashback.
 Individuals with the disorder typically report:
DISSOCIATIVE IDENTITY DISORDER  Multiple types of interpersonal maltreatment during
The presence of two or more distinct personality states or an childhood and adulthood
experience of possession  Overwhelming early life events, such as multiple long,
 Sustained periods of identity confusion/alteration may occur painful, early-life medical procedures
when psychosocial pressures are severe and/or prolonged  Non-suicidal self-injury is frequent
 The elaboration of dissociative personality states with different  Report higher levels of hypnotizability and dissociative
names, wardrobes, hairstyles, handwritings, accents, and so symptoms compared with other clinical groups and
forth, occurs in only a minority of individuals with the non- healthy control subjects
possession-form dissociative identity disorder and is not  Experience transient psychotic phenomena or episodes
essential to diagnosis
 The presence of distinct personality states can be identified by RISK AND PROGNOSTIC FACTORS:
sudden alterations or discontinuities in the individual’s sense  Environmental - early life trauma, neglect and childhood
of self and sense of agency, and recurrent dissociative amnesias abuse, maltreatment primarily occurred outside the family, in
 Individuals with dissociative identity disorder may report the school, church, and/or neighborhoods, including being bullied
feeling that they have suddenly become depersonalized severely multiple, painful childhood medical and surgical
observers of their own speech and actions, which they may feel procedures; war; terrorism; or being trafficked beginning in
powerless to stop childhood
 May also report perceptions of voices (e.g., a child’s voice,  Onset has also been described after prolonged and often
voices commenting on the individual’s thoughts or behavior, transgenerational exposure to dysfunctional family dynamics
persecutory voices and command hallucinations) (e.g., over-controlling parenting, insecure attachment,
 May report hallucinations in all sensory modalities: auditory, emotional abuse) in the absence of clear neglect or sexual or
visual, tactile, olfactory, and gustatory physical abuse
 Strong emotions, impulses, thoughts, and even speech or other  Genetic and physiological – genetics
actions may suddenly materialize, without a sense of personal  Several brain regions have been implicated in the
ownership or control (i.e., lack of sense of agency) pathophysiology of dissociative identity disorder, including the
 Attitudes, outlooks, and personal preferences (e.g., about food, orbitofrontal cortex, hippocampus, parahippocampal gyrus, and
activities, gender identity) may suddenly shift. amygdala
 Individuals may report that their bodies feel different (e.g., like  Women with dissociative identity disorder predominate
a small child, the opposite gender, different ages  Suicidal behavior is frequent
simultaneously).
 Alterations in sense of self and agency may be accompanied by COMORBIDITY:
a feeling that attitudes, emotions, and behaviors—even the  PTSD, depressive disorders, substance-related disorders,
individual’s own body—are “not mine” or are “not under my feeding and eating disorders, obsessive-compulsive disorder,
control.” antisocial personality disorder,
 State switching may be more overt in the possession form of  and other specified personality disorder with avoidant,
dissociative identity disorder. obsessive-compulsive, or borderline personality traits
 functional neurological symptom disorder
 DISSOCIATIVE AMNESIA  Episodes of depersonalization are characterized by a feeling
 Inability to recall important autobiographical information that: of unreality or detachment from, or unfamiliarity with, the
 Should be successfully stored in memory and individual’s whole self or from aspects of the self
 Ordinarily would be freely recollected  The individual may feel detached from his or her entire being
 Dissociative amnesia is conceptualized as a potentially (e.g., “I am no one,” “I have no self”).
reversible memory retrieval deficit, the memory deficit in  He or she may also feel subjectively detached from aspects of
dissociative amnesia is retrograde (backwards) the self, including feelings (e.g., hypoemotionality: “I know I
 Retrospective memory impairments include not only lost have feelings, but I don’t feel them”), thoughts (e.g., “My
memories of traumatic experiences but also lost memories of thoughts don’t feel like my own,” “head filled with cotton”),
everyday life during which no trauma occurred. whole body or body parts, or sensations (e.g., touch,
proprioception, hunger, thirst, libido)
TYPES OF AMNESIA:  There may also be a diminished sense of agency (e.g., feeling
robotic, like an automaton; lacking control of speech or
 Localized amnesia - a failure to recall events during a movements)
circumscribed period of time
 The depersonalization experience can sometimes be one of a
 Selective amnesia - —the individual can recall some, but not split self, with one part observing and one participating, known
all, of the events during a circumscribed period of time as an “out- of-body experience” in its most extreme form
 Systematized amnesia - the individual fails to recall a  Derealization - characterized by a feeling of unreality or
specific category of important information detachment from, or unfamiliarity with, the world, be it
 Ex. fragmentary recall of home growing up, but individuals, inanimate objects, or all surroundings
continuous memory for school; no recall of a violent older  The individual may feel as if he or she were in a fog, dream, or
sibling; lack of recall of a specific room in the individual’s
bubble, or as if there were a veil or a glass wall between the
childhood home
individual and the world around.
 Generalized dissociative amnesia - involves a complete  Surroundings may be experienced as artificial, colorless, or
loss of memory for most or all of the individual’s life history lifeless
 may be more common among combat veterans, sexual
 Commonly accompanied by subjective visual distortions like
assault victims, and individuals experiencing extreme
blurriness, heightened acuity, widened or narrowed visual field,
emotional stress or conflict
two-dimensionality or flatness, exaggerated three-
 Continuous amnesia - (i.e., anterograde dissociative dimensionality, or altered distance or size of objects
amnesia) an individual forgets each new event as it occurs.  Auditory distortions can also occur, whereby voices or sounds
are muted or heightened
RISK AND PROGNOSTIC FACTORS:  Individuals with depersonalization/derealization disorder may
 Environmental - Severe, acute, or chronic traumatization have difficulty describing their symptoms and may think they
 Physical and sexual abuse are “crazy” or “going crazy.”
 Severe cumulative adult trauma (e.g., repeated combat,
trafficking, prisoner-of-war or concentration camp experiences) DIAGNOSTIC CRITERIA:
also may result in extensive localized, selective, and/or A. The presence of persistent or recurrent experiences of
systematized dissociative amnesia. depersonalization, derealization, or both:
 Generalized dissociative amnesia may be more common among  Depersonalization: Experiences of unreality, detachment,
individuals who have recently experienced extreme acute or being an outside observer with respect to one’s
traumas (e.g., brutal military combat, rape, torture, often in the thoughts, feelings, sensations, body, or actions (e.g.,
context of inability to escape) and/or a prior history of major perceptual alterations, distorted sense of time, unreal or
social dislocation, asylum-seeking, or refugee status absent self, emotional and/or physical numbing).
 Others develop generalized amnesia in the context of profound  Derealization: Experiences of unreality or detachment
psychological conflict from which the individual also feels with respect to surroundings (e.g., individuals or objects
unable to escape are experienced as unreal, dreamlike, foggy, lifeless, or
 Genetic and physiological - genetics account for about 50% of visually distorted).
the inter-individual variance in dissociative symptoms, with B. During the depersonalization or derealization experiences,
non-shared, stressful environmental experiences accounting for reality testing remains intact.
most of the additional variance C. The symptoms cause clinically significant distress or
 Suicidal and other self-destructive behaviors are common impairment in social, occupational, or other important areas of
functioning.
COMORBIDITY: D. The disturbance is not attributable to the physiological effects
 Dysphoria (unhappy or dissatisfied), grief, rage, shame, guilt, of a substance (e.g., a drug of abuse, medication) or another
and psychological conflict and turmoil medical condition (e.g., seizures).
 Depressive disorders E. The disturbance is not better explained by another mental
 PTSD disorder, such as schizophrenia, panic disorder, major
 Substance-related and addictive disorders depressive disorder, acute stress disorder, posttraumatic stress
 Feeding and eating disorders disorder, or another dissociative disorder
 Sexual dysfunctions
 Personality Disorder- avoidant, obsessive-compulsive, RISK AND PROGNOSTIC FACTORS:
dependent, and borderline features  Temperamental - harm-avoidant temperament, immature
defenses, and both disconnection and over connection schemata
 Harm-avoidant temperament, immature defenses, and both
disconnection and over connection schemata
 Cognitive disconnection schemata reflect defectiveness and
DEPERSONALIZATION/DEREALIZATION emotional inhibition and subsume themes of abuse, neglect,
DISORDER and deprivation.
 The essential features of depersonalization/derealization  Over connection schemata involve impaired autonomy with
disorder are persistent or recurrent episodes of themes of dependency, vulnerability, and incompetence
depersonalization, derealization, or both.  Environmental – traumas
  Abuse dissociative disorder category is used in situations in which the clinician
 Neglect chooses not to specify the reason that the criteria are not met for a
 Physical abuse; witnessing domestic violence; growing up with specific dissociative disorder and includes presentations for which there
a seriously impaired, mentally ill parent; or unexpected death is insufficient information to make a more specific diagnosis (e.g., in
or suicide of a family member or close friend emergency room settings).
 Severe stress (interpersonal, financial, occupational),
depression, anxiety (particularly panic attacks), and illicit drug
use

COMORBIDITY:
 unipolar depressive disorder and for any anxiety disorder
 personality disorders were avoidant, borderline, and obsessive-
compulsive

DISSOCIATIVE DISORDERS:
OTHER SPECIFIED DISSOCIATIVE
DISORDER
This category applies to presentations in which symptoms
characteristic of a dissociative disorder that cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning predominate but do not meet the full criteria for any of the
disorders in the dissociative disorders diagnostic class. The other
specified dissociative disorder category is used in situations in which the
clinician chooses to communicate the specific reason that the presentation
does not meet the criteria for any specific dissociative disorder. This is
done by recording “other specified dissociative disorder” followed by the
specific reason (e.g., “dissociative trance”).

Examples of presentations that can be specified using the “other

specified” designation include the following:

1. Chronic and recurrent syndromes of mixed dissociative

symptoms: This category includes identity disturbance associated with
less-than-marked discontinuities in sense of self and agency, or
alterations of identity or episodes of possession in an individual who
reports no dissociative amnesia.

2. Identity disturbance due to prolonged and intense coercive

persuasion: Individuals who have been subjected to intense coercive
persuasion (e.g., brainwashing, thought reform, indoctrination while
captive, torture, long-term political imprisonment, recruitment by
sects/cults or by terror organizations) may present with prolonged
changes in, or conscious questioning of, their identity.

3. Acute dissociative reactions to stressful events: This category

is for acute, transient conditions that typically last less than 1 month, and
sometimes only a few hours or days. These conditions are characterized
by constriction of consciousness; depersonalization; derealization;
perceptual disturbances (e.g., time slowing, macropsia); microamnesias;
transient stupor; and/or alterations in sensory-motor functioning (e.g.,
analgesia, paralysis).

4. Dissociative trance: This condition is characterized by an acute

narrowing or complete loss of awareness of immediate surroundings that
manifests as profound unresponsiveness or insensitivity to environmental
stimuli. The unresponsiveness may be accompanied by minor stereotyped
behaviors (e.g., finger movements) of which the individual is unaware
and/or that he or she cannot control, as well as transient paralysis or loss
of consciousness. The dissociative trance is not a normal part of a broadly
accepted collective cultural or religious practice.

UNSPECIFIED DISSOCIATIVE DISORDER

This category applies to presentations in which symptoms
characteristic of a dissociative disorder that cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning predominate but do not meet the full criteria for any of the
disorders in the dissociative disorders diagnostic class. The unspecified