8 somatic symptom and dissociative disorders
learning objectives 8
· 8.1 What are somatic symptom disorders?
· 8.2 What is illness anxiety disorder?
· 8.3 What is conversion disorder (functional neurological symptom disorder)?
· 8.4 What is the difference between a factitious disorder and malingering?
· 8.5 What are the primary features of dissociative disorders?
· 8.6 What is depersonalization/derealization disorder?
· 8.7 What is dissociative amnesia?
· 8.8 What is dissociative identity disorder?
Have you ever had the experience, particularly during a time of serious stress, when you felt like you were walking around in a daze or like you just weren’t all there? Or have you known people who constantly complained about being sure they had a serious illness even though medical tests failed to show anything wrong? Both of these are examples of mild dissociative and somatic symptoms experienced at least occasionally by many people. However, when these symptoms become frequent and severe and lead to significant distress or impairment, a somatic symptom or dissociative disorder may be diagnosed. Somatic symptom disorders (formerly known as somatoform disorders ) and dissociative disorders appear to involve more complex and puzzling patterns of symptoms than those we have so far encountered. As a result, they confront the field of psychopathology with some of its most fascinating and difficult challenges. Unfortunately, however, we do not know much about them—in part because many of them are quite rare and difficult to study.
As we have seen ( Chapter 6 ), both somatic symptom and dissociative disorders were once included with the various anxiety disorders (and neurotic depression) under the general rubric neuroses, where anxiety was thought to be the underlying cause of all neuroses whether or not the anxiety was experienced overtly. But in 1980, when DSM-III abandoned attempts to link disorders together on the basis of hypothesized underlying causes (as with neurosis) and instead focused on grouping disorders together on the basis of overt symptomatology, the anxiety, mood, somatic symptom, and dissociative disorders each became separate categories.
Somatic Symptom and Related Disorders
The somatic symptom disorders lie at the interface between abnormal psychology and medicine. They are a group of conditions that involve physical symptoms combined with abnormal thoughts, feelings, and behaviors in response to those symptoms (APA, 2013 ). Soma means “body,” and somatic symptom disorders involve patterns in which individuals complain of bodily symptoms that suggest the presence of medical problems but where there is no obvious medical explanation that can satisfactorily explain the symptoms such as paralysis or pain. Despite a wide range of clinical manifestations, in each case the person is preoccupied with some aspect of her or his health to the extent that she or he shows significant impairments in functioning.
In DSM-IV a great deal of emphasis was placed on the idea that the symptoms were medically unexplained. In other words, although the patient’s complaints suggested the presence of a medical condition no physical pathology could be found to account for them (Allen & Woolfolk, 2012 ; Witthöft & Hiller, 2010 ). In DSM-5 this idea is less prominent, because it is recognized that medicine is fallible and that a medical explanation for symptoms cannot always be provided. Nonetheless, medically unexplained symptoms are still a key part of some disorders (such as conversion disorder) that we will describe later.
Equally key to these disorders is the fact that the affected patients have no control over their symptoms. They are also not intentionally faking symptoms or attempting to deceive others. For the most part, they genuinely believe something is terribly wrong with them. Not surprisingly, these patients are frequent visitors to their primary-care physicians.
Sometimes, of course, people do deliberately and consciously feign disability or illness. Also placed in the somatic symptoms and related disorders category in DSM-5 is factitious disorder. In factitious disorder the person intentionally produces psychological or physical symptoms (or both). Although this may strike you as strange, the person’s goal is to obtain and maintain the benefits that playing the “sick role” (even to the extent of undergoing repeated hospitalizations) may provide, including the attention and concern of family and medical personnel. However, there are no tangible external rewards. In this way factitious disorder differs from malingering. In malingering the person is intentionally producing or grossly exaggerating physical symptoms and is motivated by external incentives such as avoiding work or military service or evading criminal prosecution (APA, 2013 ; Maldonado & Spiegel, 2001 ).
In our discussion, we will focus on four disorders in the somatic symptom and related disorders category. These are (1) somatic symptom disorder; (2) illness anxiety disorder; (3) conversion disorder; and (4) factitious disorder.
Somatic Symptom Disorders
This new diagnosis includes several disorders that were previously considered to be separate diagnoses in DSM-IV. The old disorders of (1) hypochondriasis, (2) somatization disorder, and (3) pain disorder have all now disappeared from DSM-5. Most of the people who would in the past have been diagnosed with any one of these disorders will now be diagnosed with a somatic symptom disorder. In each case, individuals must be experiencing chronic somatic symptoms that are distressing to them and they must also be experiencing dysfunctional thoughts, feelings, and/or behaviors. In the past, the diagnosis required evidence that the symptoms were medically unexplained. However, as we noted earlier, this is no longer required for the diagnosis (in part because it is very difficult to prove something is medically unexplainable). Instead the focus in DSM-5 is on there being at least one of the following three features: (1) disproportionate and persistent thoughts about the seriousness of one’s symptoms; (2) persistently high level of anxiety about health or symptoms; and/or (3) excessive time and energy devoted to these symptoms or health concerns (Allen & Woolfolk, 2013). Symptoms have to have persisted for at least six months.
Patients with somatic symptom disorder are usually seen in medical clinics. They are more likely to be female, nonwhite, and less educated than are people with symptoms that have an obvious medical basis. Patients with somatic symptom disorder frequently engage in illness behavior that is dysfunctional, such as seeking additional medical procedures or diagnostic tests when the physician fails to find anything physically wrong with them. Whereas most of us are relieved when tests do not reveal any problems, people with somatic symptom disorder are likely to think something was missed and therefore seek help from another physician, leading to needlessly high medical bills due to unnecessary tests, hospitalizations, and even surgeries. High levels of functional impairment are common, as is comorbid psychopathology—especially depression and anxiety.
Research suggests that people with somatic symptom disorders tend to have a cognitive style that leads them to be hyper-sensitive to their bodily sensations. They also experience these sensations as intense, disturbing, and highly aversive. Another characteristic of such patients is that they tend to think catastrophically about their symptoms, often overestimating the medical severity of their condition.
In the following sections, we will be discussing hypochondriasis, pain disorder, and somatization disorder. It’s important to note that in DSM-5, these disorders were technically dropped and are now part of the somatic symptom disorders. However, the history of and the research on these disorders is still important to understand.
DSM-5 criteria for: Somatic Symptom Disorder
· A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
· B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
· 1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
· 2. Persistently high level of anxiety about health or symptoms.
· 3. Excessive time and energy devoted to these symptoms or health concerns.
· C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.
Approximately 75 percent of people previously diagnosed with hypochondriasis will be diagnosed with somatic symptom disorder in DSM-5 (APA, 2013 ). In hypochondriasis the person is preoccupied either with fears of contracting a serious disease or with the idea that of having that disease even though they do not. These very distressing preoccupations are thought to all be based on a misinterpretation of one or more bodily signs or symptoms (e.g., being convinced that a slight cough is a sign of lung cancer). Of course the decision that a complaint is hypochondriacal and is based on a misinterpretation of bodily signs or symptoms can only be made after a thorough medical evaluation has failed to find a medical condition that could account for the signs or symptoms. Another typical feature of hypochondriasis is that the person cannot be reassured by the results of a medical evaluation. In other words, the fear or idea of having a disease persists despite lack of medical evidence. Indeed, these individuals are sometimes disappointed when no physical problem is found. The condition has to persist for at least 6 months for the diagnosis to be made so as to not diagnose relatively transient health concerns.
Not surprisingly, people with hypochondriasis usually first see a medical doctor for their physical complaints. Because they are never reassured for long and are inclined to suspect that their doctor has missed something, they sometimes shop for additional doctors, hoping one might discover what their problem really is. Because they repeatedly seek medical advice (e.g., Bleichhardt & Hiller, 2006 ; Fink et al., 2004 ), it is hardly surprising that their annual medical costs are much higher than average (e.g., Fink et al., 2010 ; Hiller et al., 2004 ). People with hypochondriasis are generally resistant to the idea that their problem is a psychological one that might be best treated by a psychologist or psychiatrist.
Prior to DSM-5, hypochondriasis was one of the two most commonly seen somatic symptom disorders with a prevalence in general medical practices of 2 to 7 percent (APA, 2000 ). Hypochondriasis occurs about equally often in men and women and can start at almost any age, although early adulthood is the most common age of onset. Hypochondriasis is regarded as a persistent disorder if left untreated, although its severity can fluctuate over time. Individuals with hypochondriasis often also suffer from mood disorders, panic disorder, or other types of somatic symptom disorders (Creed & Barsky, 2004 ). This is one reason why hypochondriasis is now not differentiated from other somatic symptom disorders in DSM-5.
Individuals with hypochondriasis tend to be highly preoccupied with bodily functions (e.g., heart beats or bowel movements), or with minor physical abnormalities (e.g., a small sore or an occasional cough), or with vague and ambiguous physical sensations (such as a “tired heart” or “aching veins”). They attribute these symptoms to a particular disease and often have intrusive thoughts about it. The diagnoses they make for themselves include cancer, exotic infections, AIDS, and numerous other diseases. Watchthe Video Henry: Hypochondriasis on MyPsychLab
Although people with hypochondriasis are usually in good physical condition, they are sincere in their conviction that the symptoms they detect represent real illness. In other words, they are not malingering—consciously faking symptoms to achieve a specific goals such as winning a personal injury lawsuit. Not surprisingly, given their tendency to doubt the soundness of their doctors’ conclusions (i.e., that they have no medical problem) and recommendations, the relationships they have with their doctors are often marked by conflict and hostility.
The following case captures the typical clinical picture in hypochondriasis. It also demonstrates that a high level of medical sophistication does not necessarily protect someone from developing this or a related disorder.
An “Abdominal Mass” This 38-year-old physician/radiologist initiated his first psychiatric consultation after his 9-year-old son accidentally discovered his father palpating (examining by touch) his own abdomen and said, “What do you think it is this time, Dad?” The radiologist describes the incident and his accompanying anger and shame with tears in his eyes. He also describes his recent return from a 10-day stay at a famous out-of-state medical diagnostic center to which he had been referred by an exasperated gastroenterologist colleague who had reportedly “reached the end of the line” with his radiologist patient. The extensive physical and laboratory examinations performed at the center had revealed no significant physical disease, a conclusion the patient reports with resentment and disappointment rather than relief.
The patient’s history reveals a long-standing pattern of overconcern about personal health matters, beginning at age 13 and exacerbated by his medical school experience. Until fairly recently, however, he had maintained reasonable control over these concerns, in part because he was embarrassed to reveal them to other physicians. He is conscientious and successful in his profession and active in community life. His wife, like his son, has become increasingly impatient with his morbid preoccupation about life-threatening but undetectable diseases.
In describing his current symptoms, the patient refers to his becoming increasingly aware, over the past several months, of various sounds and sensations emanating from his abdomen and of his sometimes being able to feel a “firm mass” in its left lower quadrant. His tentative diagnosis is carcinoma (cancer) of the colon. He tests his stool for blood weekly and palpates his abdomen for 15 to 20 minutes every 2 to 3 days. He has performed several X-ray studies of himself in secrecy after hours at his office.
Source: Adapted with permission from DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 88–90). Washington, DC: (Copyright © 2002). American Psychiatric Association.
Our knowledge of causal factors involved in somatic symptom disorders, including hypochondriasis, is quite minimal. This is especially true when compared to knowledge about the mood and anxiety disorders discussed in the preceding chapters. Currently, cognitive-behavioral views of hypochondriasis are perhaps most widely accepted. These have as a central tenet that it is a disorder of cognition and perception. Misinterpretations of bodily sensations are currently a defining feature of the syndrome, but in the cognitive-behavioral view these misinterpretations also play a causal role. It is believed that an individual’s past experiences with illnesses (in both him- or herself and others, and as observed in the mass media) lead to the development of a set of dysfunctional assumptions about symptoms and diseases that may predispose a person to developing hypochondriasis (Marcus et al., 2007 ; Salkovskis & Warwick, 2001 ). These dysfunctional assumptions might include notions such as, “Bodily changes are usually a sign of serious disease, because every symptom has to have an identifiable physical cause” or “If you don’t go to the doctor as soon as you notice anything unusual, then it will be too late” (Salkovskis & Bass, 1997 , p. 318; see also Marcus et al., 2007 ).
Individuals with hypochondriasis are preoccupied with unrealistic fears of disease. They are convinced that they have symptoms of physical illness, but their complaints typically do not conform to any coherent symptom pattern, and they usually have trouble giving a precise description of their symptoms.
Because of these dysfunctional assumptions, individuals with hypochondriasis seem to focus excessive attention on symptoms, with experimental studies showing that these individuals do in fact have an attentional bias for illness-related information (Owens et al., 2004 ; see also Jasper & Witthöft, 2011 ). Although their physical sensations probably do not differ from those in normal controls (Marcus et al., 2007 ), they perceive their symptoms as more dangerous than they really are and judge a particular disease to be more likely or dangerous than it really is. Once they have misinterpreted a symptom, they tend to look for confirming evidence and to discount evidence that they are in good health; in fact, they seem to believe that being healthy means being completely symptom-free (Rief et al., 1998a ). They also perceive their probability of being able to cope with the illness as extremely low (Salkovskis & Bass, 1997 ) and see themselves as weak and unable to tolerate physical effort or exercise (Rief et al., 1998a ). All this tends to create a vicious cycle in which their anxiety about illness and symptoms results in physiological symptoms of anxiety, which then provide further fuel for their convictions that they are ill.
If we also consider the secondary reinforcements that individuals with hypochondriasis obtain by virtue of their disorder, we can better understand how such patterns of thought and behavior are maintained in spite of the misery these individuals often experience. Most of us learn as children that when we are sick special comforts and attention are provided and, furthermore, that we may be excused from a number of responsibilities. Barsky and colleagues ( 1994 ) found that their patients with hypochondriasis reported much childhood sickness and missing of school. People with hypochondriasis also tend to have an excessive amount of illness in their families while growing up, which may lead to strong memories of being sick or in pain (Pauli & Alpers, 2002 ), and perhaps also of having observed some of the secondary benefits that sick people sometimes reap (Cote et al., 1996 ; Kellner, 1985 ).
Interestingly, one study retested patients with hypochondriasis 4 to 5 years later and found that those who had remitted at follow-up had acquired significantly more (real) major medical problems than their nonremitting counterparts (Barsky et al., 1998 ). In other words, it appears that hypochondriacal tendencies were reduced by the occurrence of serious medical conditions. The authors suggested that having a serious medical illness “served to legitimize the patients’ complaints, sanction their assumption of the sick role, and lessen the skepticism with which they had previously been regarded …. As one noted, ‘Now that I know Dr. X is paying attention to me, I can believe him if he says nothing serious is wrong’” ( p. 744 ).
TREATMENT OF HYPOCHONDRIASIS
More than a dozen studies on cognitive-behavioral treatment of hypochondriasis have found that it can be a very effective treatment for hypochondriasis (e.g., Barsky & Ahern, 2004 ; Tyrer, 2011 ; see also Hedman et al., 2011 , for an example of Internet-based Cognitive Behavioral Therapy). The cognitive components of this treatment approach focus on assessing the patient’s beliefs about illness and modifying misinterpretations of bodily sensations. The behavioral techniques include having patients induce innocuous symptoms by intentionally focusing on parts of their body so that they can learn that selective perception of bodily sensations plays a major role in their symptoms. Sometimes they are also directed to engage in response prevention by not checking their bodies as they usually do and by stopping their constant seeking of reassurance. The treatment is relatively brief (6 to 16 sessions) and can be delivered in a group format. In these studies such treatment produced large changes in hypochondriacal symptoms and beliefs as well as in levels of anxiety and depression.
The DSM-IV diagnosis of somatization disorder is another disorder that has now been subsumed into the broader category of somatic symptom disorder in DSM-5. Somatization disorder is characterized by many different physical complaints. To qualify for the diagnosis, these had to begin before age 30, last for several years, and not be adequately explained by independent findings of physical illness or injury. They also had to have led to medical treatment or to significant life impairment. Not surprisingly, somatization disorder has long been seen most often among patients in primary medical care settings (Guerje et al., 1997 ; Iezzi et al., 2001 ). Indeed, patients with this variant of somatic symptom disorder are enormously costly to health care systems because they often have multiple unnecessary hospitalizations and surgeries (Barsky et al., 2005 ; Hiller et al., 2003 ).
The DSM-IV-TR (APA, 2000 ) criteria required that patients report a large number of symptoms across a wide range of domains (e.g., 4 pain symptoms, two gastrointestinal symptoms, one sexual symptom and one neurological-type symptom). Thus, to qualify for a diagnosis of somatization disorder, a patient had to have experienced at least 8 out of 33 specified symptoms (Rief & Barsky, 2005 ). Over time, the rather arbitrary nature of this became increasing apparent and the formal diagnostic criteria began to be modified by many researchers and clinicians (e.g., Rief & Broadbent, 2007 ). Following suit, in DSM-5 the long and complicated symptom count is no longer required and somatization disorder is now considered to be just another variant of somatic symptom disorder.
Another advantage of the recent change in DSM-5 is that it is no longer necessary for us to be concerned about whether somatization disorder and hypochondriasis are really two different and distinct disorders. There are indeed significant similarities between the two conditions. They also sometimes co-occur (Mai, 2004 ). Some years ago leading researchers in this area expressed concerns about whether somatization disorder and hypochondriasis could really be regarded as separate disorders (e.g., Creed & Barsky, 2004 ). Combining them both into a common category in DSM-5 and considering them to be variants of somatic symptom disorder is probably a wise move.
The main features of somatization disorder are illustrated in the following case summary, which also involves a secondary diagnosis of depression.
Not-Yet-Discovered Illness This 38-year-old married woman, the mother of five children, reports to a mental health clinic with the chief complaint of depression, meeting diagnostic criteria for major depressive disorder …. Her marriage has been a chronically unhappy one; her husband is described as an alcoholic with an unstable work history, and there have been frequent arguments revolving around finances, her sexual indifference, and her complaints of pain during intercourse.
The history reveals that the patient … describes herself as nervous since childhood and as having been continuously sickly beginning in her youth. She experiences chest pain and reportedly has been told by doctors that she has a “nervous heart.” She sees physicians frequently for abdominal pain, having been diagnosed on one occasion as having a “spastic colon.” In addition to M.D. physicians, she has consulted chiropractors and osteopaths for backaches, pains in her extremities, and a feeling of anesthesia in her fingertips. She was recently admitted to a hospital following complaints of abdominal and chest pain and of vomiting, during which admission she received a hysterectomy. Following the surgery she has been troubled by spells of anxiety, fainting, vomiting, food intolerance, and weakness and fatigue. Physical examinations reveal completely negative findings.
DEMOGRAPHICS, COMORBIDITY, AND COURSE OF ILLNESS
Somatization disorder usually begins in adolescence and is believed by many to be about three to ten times more common among women than among men. It also tends to occur more among less educated individuals and in lower socioeconomic classes. The lifetime prevalence has been estimated to be between 0.2 and 2.0 percent in women and less than 0.2 percent in men (APA, 2000 ). Somatization disorder very commonly co-occurred with several other disorders including major depression, panic disorder, phobic disorders, and generalized anxiety disorder. It has generally been considered to be a relatively chronic condition with a poor prognosis, although sometimes the disorder remits spontaneously (e.g., Creed & Barsky, 2004 ).
CAUSAL FACTORS IN SOMATIZATION DISORDER
Despite its prevalence in medical settings, researchers are still not certain about the developmental course and specific etiology of somatization disorder. There is evidence that somatization disorder runs in families and that there is a familial linkage between antisocial personality disorder in men (see Chapter 10 ) and somatization disorder in women. That is, one possibility is that some common, underlying predisposition, probably at least partly genetically based, leads to antisocial behavior in men and to somatization disorder in women (Cale & Lilienfeld, 2002b ; Guze et al., 1986 ; Lilienfeld, 1992 ). Moreover, somatic symptoms and antisocial symptoms in women tend to co-occur (Cale & Lilienfeld, 2002b ). However, we do not yet have a clear understanding of this relationship. One possibility is that the two disorders are linked through a common trait of impulsivity.
It has also become clear that people with somatization disorder selectively attend to, and show perceptual amplification of, bodily sensations. They also tend to see bodily sensations as somatic symptoms (Martin et al., 2007 ). Like patients with hypochondriasis, they tend to catastrophize about minor bodily complaints (taking them as signs of serious physical illness) and to think of themselves as physically weak and unable to tolerate stress or physical activity (Martin et al., 2007 ; Rief et al., 1998).
TREATMENT OF SOMATIZATION DISORDER
Somatization disorder was long considered to be extremely difficult to treat, and general practitioners experienced a great deal of uncertainty and frustration in working with these patients. However, in the past 15 years some treatment research has begun to suggest that a certain type of medical management along with cognitive-behavioral treatments may be quite helpful and that general practitioners can be educated in how to better manage and treat somatization patients and be less frustrated by them (Rosendal et al., 2005 ; see also Edwards & Edwards, 2010 ). One moderately effective treatment involves identifying one physician who will integrate the patient’s care by seeing the patient at regular visits (thereby trying to anticipate the appearance of new problems) and by providing physical exams focused on new complaints (thereby accepting her or his symptoms as valid). At the same time, however, the physician avoids unnecessary diagnostic testing and makes minimal use of medications or other therapies (Looper & Kirmayer, 2002 ; Mai, 2004 ). Several studies have found that these patients show substantial decreases in health care expenditures over subsequent months and sometimes an improvement in physical functioning (although not necessarily in psychological distress; e.g., Rost et al., 1994 ). This type of medical management can be even more effective when combined with cognitive-behavioral therapy that focuses on promoting appropriate behavior, such as better coping and personal adjustment, and discouraging inappropriate behavior such as illness behavior and preoccupation with physical symptoms (e.g., Bleichhardt et al., 2004 ; Mai, 2004 ).
The third DSM-IV diagnosis subsumed into the new category of somatic symptom disorder is pain disorder. Pain disorder is characterized by persistent and severe pain in one or more areas of the body that is not intentionally produced or feigned. Although a medical condition may contribute to the pain, psychological factors are judged to play an important role. Indeed psychological factors play a role in all forms of pain. The pain disorder may be acute (duration of less than 6 months) or chronic (duration of over 6 months). When working with patients with pain disorder it is very important to remember that the pain that is experienced is very real and can hurt as much as pain that comes from other sources. It is also important to note that pain is always, in part, a subjective experience that is private and cannot be objectively identified by others.
When one physician integrates a patient’s care, the physical functioning of patients with somatization disorder may improve. Why should this be?
The experience of pain is always subjective and private, making pain impossible to assess with pinpoint accuracy. Pain does not always exist in perfect correlation with observable tissue damage or irritation. Psychological factors influence all forms of pain.
The prevalence of pain disorder in the general population is unknown. It is definitely quite common among patients at pain clinics. It is diagnosed more frequently in women than in men and is very frequently comorbid with anxiety or mood disorders, which may occur first or may arise later as a consequence of the pain disorder. People with pain disorder are often unable to work (they sometimes go on disability) or to perform some other usual daily activities. Their resulting inactivity (including an avoidance of physical activity) and social isolation may lead to depression and to a loss of physical strength and endurance. This fatigue and loss of strength can then exacerbate the pain in a kind of vicious cycle (Bouman et al., 1999 ; Flor et al., 1990 ). In addition, the behavioral component of pain is quite malleable in the sense that it can increase when it is reinforced by attention, sympathy, or avoidance of unwanted activities (Bouman et al., 1999 ). Finally, there is suggestive evidence that people who have a tendency to catastrophize about the meaning and effects of pain may be the ones most likely to progress to a state of chronic pain (Seminowicz & Davis, 2006 ).
TREATMENT OF PAIN DISORDER
Perhaps because it is a less complex and multifaceted disorder than somatization disorder, pain disorder is usually easier to treat. Indeed, cognitive-behavioral techniques have been widely used in the treatment of both physical and more psychological pain syndromes. Treatment programs generally include relaxation training, support and validation that the pain is real, scheduling of daily activities, cognitive restructuring, and reinforcement of “no-pain” behaviors (Simon, 2002 ). Patients receiving such treatments tend to show substantial reductions in disability and distress, although changes in the intensity of their pain tend to be smaller in magnitude. In addition, antidepressant medications (especially the tricyclic antidepressants) and certain SSRIs have been shown to reduce pain intensity in a manner independent of the effects the medications may have on mood (Aragona et al., 2005 ; Simon, 2002 ).
ILLNESS ANXIETY DISORDER
Illness anxiety disorder is new to DSM-5. In this newly identified disorder, people have high anxiety about having or developing a serious illness. This anxiety is distressing and/or disruptive but there are very few (mild) somatic symptoms. (see the DSM-5 criteria box below).
It is estimated that around 25 percent of people who would have been diagnosed with hypochondriasis in DSM-IV will be diagnosed with illness anxiety disorder in DSM-5 (APA, 2013 ).
Conversion Disorder (Functional Neurological Symptom Disorder)
DSM-5 criteria for: Illness Anxiety Disorder
· A. Preoccupation with having or acquiring a serious illness.
· B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.
· C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
· D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
· E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
· F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.
Conversion disorder is one of the most intriguing and baffling patterns in psychopathology, and we still have much to learn about it. It involves a pattern in which symptoms or deficits affecting the senses or motor behavior strongly suggest that the patient has a medical or neurological condition. However, upon a thorough medical examination, it becomes apparent that the pattern of symptoms or deficits cannot be fully explained by any known medical condition. A few typical examples include partial paralysis, blindness, deafness, and pseudoseizures. The person is not intentionally producing or faking the symptoms, Rather, psychological factors are often judged to play an important role because symptoms usually either start or are exacerbated by preceding emotional or interpersonal conflicts or stressors.
Early observations dating back to Freud suggested that most people with conversion disorder showed very little of the anxiety and fear that would be expected in a person with a paralyzed arm or loss of sight. This seeming lack of concern (known as la belle indifférence—French for “the beautiful indifference”) in the way the patient describes what is wrong was thought for a long time to be an important diagnostic criterion for conversion disorder. However, more careful research later showed that la belle indifférenceactually occurs in only about 20 percent of patients with conversion disorder, so it was dropped as a criterion from recent editions of the DSM (Stone et al., 2006 , 2011).
The term conversion disorder is relatively recent. Historically this disorder was one of several disorders that were grouped together under the term hysteria .
Freud used the term conversion hysteria for these disorders (which were fairly common in his practice) because he believed that the symptoms were an expression of repressed sexual energy—that is, the unconscious conflict that a person felt about his or her repressed sexual desires. However, in Freud’s view, the repressed anxiety threatens to become conscious, so it is unconsciously converted into a bodily disturbance, thereby allowing the person to avoid having to deal with the conflict. For example, a person’s guilty feelings about the desire to masturbate might be solved by developing a paralyzed hand. This is not done consciously, of course, and the person is not aware of the origin or meaning of the physical symptom. Freud also thought that the reduction in anxiety and intrapsychic conflict was the “primary gain” that maintained the condition, but he noted that patients often had many sources of “secondary gain” as well, such as receiving sympathy and attention from loved ones. Authors of DSM-5 had many suggestions for changing the name of this disorder (e.g., to psychogenic, functional, and dissociative). In the end, a conservative approach was taken and the term conversion disorder was retained, although this is now followed in parentheses by “Functional neurological symptom disorder” (Stone et al., 2011).
PRECIPITATING CIRCUMSTANCES, ESCAPE, AND SECONDARY GAINS
Freud’s theory that conversion symptoms are caused by the conversion of sexual conflicts or other psychological problems into physical symptoms is no longer accepted outside psychodynamic circles. However, many of Freud’s astute clinical observations about primary and secondary gain are still incorporated into contemporary views of conversion disorder. Although the condition is still called a conversion disorder, the physical symptoms are usually seen as serving the rather obvious function of providing a plausible bodily “excuse” enabling an individual to escape or avoid an intolerably stressful situation without having to take responsibility for doing so. Typically, it is thought that the person first experiences a traumatic event that motivates the desire to escape the unpleasant situation, but literal escape may not be feasible or socially acceptable. Moreover, although becoming sick or disabled is more socially acceptable, this is true only if the person’s motivation to do so is unconscious.
Thus, in contemporary terms, the primary gain for conversion symptoms is continued escape or avoidance of a stressful situation. Because this is all unconscious (i.e., the person sees no relation between the symptoms and the stressful situation), the symptoms go away only if the stressful situation has been removed or resolved. Relatedly, the term secondary gain , which originally referred to advantages that the symptom(s) bestow beyond the “primary gain” of neutralizing intrapsychic conflict, has also been retained. Generally, it is used to refer to any “external” circumstance, such as attention from loved ones or financial compensation, that would tend to reinforce the maintenance of disability.
DSM-5 criteria for: Conversion Disorder
· A. One or more symptoms of altered voluntary motor or sensory function.
· B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
· C. The symptom or deficit is not better explained by another medical or mental disorder.
· D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.
Given the important role often attributed to stressful life events in precipitating the onset of conversion disorder, it is unfortunate that little is actually known about the exact nature and timing of these psychological stress factors (Roelofs et al., 2005 ). However, one study compared the frequency of stressful life events in the recent past in patients with conversion disorder and depressed controls and did not find a difference in frequency between them. Moreover, the greater the negative impact of the preceding life events, the greater the severity of the conversion disorder symptoms (Roelofs et al., 2005 ). Another study compared levels of a neurobiological marker of stress (lower levels of brain-derived neurotropic factor) in individuals with conversion disorder versus major depression versus no disorder. Both those with depression and those with conversion disorder showed reduced levels of this marker relative to the nondisordered controls (Deveci et al., 2007 ). This also provides support for the link between stress and the onset of conversion disorder.
DECREASING PREVALENCE AND DEMOGRAPHIC CHARACTERISTICS
Conversion disorders were once relatively common in civilian and (especially) military life. In World War I, conversion disorder was the most frequently diagnosed psychiatric syndrome among soldiers; it was also relatively common during World War II. Conversion disorder typically occurred under highly stressful combat conditions and involved men who would ordinarily be considered stable. Here, conversion symptoms—such as paralysis of the legs—enabled a soldier to avoid an anxiety-arousing combat situation without being labeled a coward or being subject to court-martial.
Conversion disorders are found in approximately 50 percent of people referred for treatment at neurology clinics. The prevalence in the general population is unknown, but even the highest estimates have been around only 0.005 percent (APA, 2013 ). Interestingly, this decreased prevalence seems to be closely related to our growing sophistication about medical and psychological disorders: A conversion disorder apparently loses its defensive function if it can be readily shown to lack a medical basis. When it does occur today, it is most likely to occur in rural people from lower socioeconomic circles who are medically unsophisticated. For example, a highly unusual “outbreak” of cases of severe conversion disorder involving serious motor weakness and wasting symptoms was reported in five 9- to 13-year-old girls living in a small, poor, rural Amish community. Each of these girls had experienced substantial psychosocial stressors including behavioral problems, dys-functional family dynamics, and significant community stress from a serious local church crisis (see Cassady et al., 2005 ). Fortunately, after the caregivers of these girls were educated regarding the psychological nature of the symptoms and given advice to stick with one doctor, minimize stress, and avoid reinforcement of the “sick role,” four of the five girls showed significant improvement over the next 3 months. In the fifth case, the family refused to acknowledge the psychological component of the illness, holding to the belief that the symptoms were caused by parasites.
Conversion disorders were fairly common during World War I and World War II. The disorder typically occurred in otherwise “normal” men during stressful combat conditions. The symptoms of conversion disorder (e.g., paralysis of the legs) enabled a soldier to avoid high-anxiety combat situations without being labeled a coward or being court-martialed.
Conversion disorder occurs two to three times more often in women than in men (APA 2013 ). It can develop at any age but most commonly occurs between early adolescence and early adulthood (Maldonado & Spiegel, 2001 ). It generally has a rapid onset after a significant stressor and often resolves within 2 weeks if the stressor is removed, although it commonly recurs. In many other cases, however, it has a more chronic course. Like most other somatic symptom disorders, conversion disorder frequently occurs along with other disorders, especially major depression, anxiety disorders, and other forms of somatic symptom or dissociative conditions.
RANGE OF CONVERSION DISORDER SYMPTOMS
The range of symptoms for conversion disorder is practically as diverse as it is for physically based ailments. In describing the clinical picture in conversion disorder, it is useful to think in terms of four categories of symptoms: (1) sensory, (2) motor, (3) seizures, and (4) a mixed presentation of the first three categories (APA, 2013 ).
Sensory Symptoms or Deficits Conversion disorder can involve almost any sensory modality, and it can often be diagnosed as a conversion disorder because symptoms in the affected area are inconsistent with how known anatomical sensory pathways operate. Today the sensory symptoms or deficits are most often in the visual system (especially blindness and tunnel vision), in the auditory system (especially deafness), or in the sensitivity to feeling (especially the anesthesias). In the anesthesias, the person loses her or his sense of feeling in a part of the body. One of the most common is glove anesthesia, in which the person cannot feel anything on the hand in the area where gloves are worn, although the loss of sensation usually makes no anatomical sense.
With conversion blindness, the person reports that he or she cannot see and yet can often navigate about a room without bumping into furniture or other objects. With conversion deafness, the person reports not being able to hear and yet orients appropriately upon “hearing” his or her own name. Such observations lead to obvious questions: In conversion blindness (and deafness), can affected people actually not see (or hear), or is the sensory information received but screened from consciousness? In general, the evidence supports the idea that the sensory input is registered but is somehow screened from explicit conscious recognition (explicit perception).
Motor Symptoms or Deficits Motor conversion reactions also cover a wide range of symptoms (e.g., Maldonado & Spiegel, 2001 ; see also Stone et al., 2010). For example, conversion paralysis is usually confined to a single limb such as an arm or a leg, and the loss of function is usually selective for certain functions. For example, a person may not be able to write but may be able to use the same muscles for scratching, or a person may not be able to walk most of the time but may be able to walk in an emergency such as a fire where escape is important. The most common speech-related conversion disturbance is aphonia, in which a person is able to talk only in a whisper although he or she can usually cough in a normal manner. (In true, organic laryngeal paralysis, both the cough and the voice are affected.) Another common motor symptom, called globus hystericus, is difficulty swallowing or the sensation of a lump in the throat (Finkenbine & Miele, 2004 ).
Seizures Conversion seizures, another relatively common form of conversion symptom, involve pseudoseizures, which resemble epileptic seizures in some ways but can usually be fairly well differentiated via modern medical technology (Bowman & Markand, 2005 ; Stonnington et al., 2006 ). For example, patients with pseudoseizures do not show any EEG abnormalities and do not show confusion and loss of memory afterward, as patients with true epileptic seizures do. Moreover, patients with conversion seizures often show excessive thrashing about and writhing not seen with true seizures, and they rarely injure themselves in falls or lose control over their bowels or bladder, as patients with true seizures frequently do.
The following case of conversion disorder clearly shows how “functional” a conversion disorder may be in the overall life circumstances of a patient despite its exacting a certain cost in illness or disability.
A Wife with “Fits” Mrs. Chatterjee, a 26-year-old patient, attends a clinic in New Delhi, India, with complaints of “fits” for the last 4 years. The “fits” are always sudden in onset and usually last 30 to 60 minutes. A few minutes before a fit begins, she knows that it is imminent, and she usually goes to bed. During the fits she becomes unresponsive and rigid throughout her body, with bizarre and thrashing movements of the extremities. Her eyes close and her jaw is clenched, and she froths at the mouth. She frequently cries and sometimes shouts abuses. She is never incontinent of urine or feces, nor does she bite her tongue. After a “fit” she claims to have no memory of it. These episodes recur about once or twice a month. She functions well between the episodes.
Both the patient and her family believe that her “fits” are evidence of a physical illness and are not under her control. However, they recognize that the fits often occur following some stressor such as arguments with family members or friends …. She is described by her family as being somewhat immature but “quite social” and good company. She is self-centered, she craves attention from others, and she often reacts with irritability and anger if her wishes are not immediately fulfilled. On physical examination, Mrs. Chatterjee was found to have mild anemia but was otherwise healthy. A mental status examination did not reveal any abnormality … and her memory was normal. An electroencephalogram showed no seizure activity.
Source: Adapted with permission from DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 469–70). Washington, DC. (Copyright © 2002). American Psychiatric Association.
IMPORTANT ISSUES IN DIAGNOSING CONVERSION DISORDER
Because the symptoms in conversion disorder can simulate a variety of medical conditions, accurate diagnosis can be extremely difficult. It is crucial that a person with suspected conversion symptoms receive a thorough medical and neurological examination. Unfortunately, however, misdiag-noses can still occur. Nevertheless, as medical tests (especially brain imaging) have become increasingly sophisticated, the rate of misdiagnoses has declined substantially from in the past, with estimates of misdiagnoses in the 1990s at only 4 percent down from nearly 30 percent in the 1950s (e.g., Stone et al., 2005 ).
Several other criteria are also commonly used for distinguishing between conversion disorders and true neurological disturbances:
· • The frequent failure of the dysfunction to conform clearly to the symptoms of the particular disease or disorder simulated. For example, little or no wasting away or atrophy of a “paralyzed” limb occurs in conversion paralyses, except in rare and long-standing cases.
Virtually all the symptoms of conversion disorder can be temporarily reduced or reproduced by hypnotic suggestion.
· • The selective nature of the dysfunction. As already noted, in conversion blindness the affected individual does not usually bump into people or objects, and “paralyzed” muscles can be used for some activities but not others.
· • Under hypnosis or narcosis (a sleeplike state induced by drugs), the symptoms can usually be removed, shifted, or re-induced at the suggestion of the therapist. Similarly, a person abruptly awakened from a sound sleep may suddenly be able to use a “paralyzed” limb.
TREATMENT OF CONVERSION DISORDER
Our knowledge of how best to treat conversion disorder is very limited because few well-controlled studies have yet been conducted (e.g., Bowman & Markand, 2005 ; Looper & Kirmayer, 2002 ). However, it is known that some hospitalized patients with motor conversion symptoms have been successfully treated with a behavioral approach in which specific exercises are prescribed in order to increase movement or walking, and then reinforcements (e.g., praise and gaining privileges) are provided when patients show improvements. Any reinforcements of abnormal motor behaviors are removed in order to eliminate any sources of secondary gain. In one small study using this kind of treatment for 10 patients, all had regained their ability to move or walk in an average of 12 days, and for seven of the nine patients available at approximately 2-year follow-up, the improvements had been maintained (Speed, 1996 ). At least one study has also used cognitive-behavior therapy to successfully treat psychogenic seizures (LaFrance et al., 2009 ). Some studies have used hypnosis combined with other problem-solving therapies, and there are some suggestions that hypnosis, or adding hypnosis to other therapeutic techniques, can be useful (Looper & Kirmayer, 2002 ; Moene et al., 2003 ).
Distinguishing Somatization, Pain, and Conversion Disorders from Malingering and Factitious Disorder
DSM-5 criteria for: Factitious Disorder
Factitious Disorder Imposed on Self
· A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
· B. The individual presents himself or herself to others as ill, impaired, or injured.
· C. The deceptive behavior is evident even in the absence of obvious external rewards.
· D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
Earlier we mentioned that the DSM distinguishes between malingering and factitious disorder on the basis of the feigning person’s apparent goals. Malingering is diagnosed if the person is intentionally producing or grossly exaggerating physical symptoms and is motivated by external incentives such as avoiding work or obtaining financial compensation. Factitious disorder is diagnosed if the person intentionally produces psychological or physical symptoms, the person’s goal being simply to obtain and maintain the personal benefits that playing the “sick role” (even undergoing repeated hospitalizations) may provide, including the attention and concern of family and medical personnel. In factitious disorder, frequently these patients surreptitiously alter their own physiology—for example, by taking drugs—in order to simulate various real illnesses. Indeed, they may be at risk for serious injury or death and may even need to be committed to an institution for their own protection. The World Around Us box above describes a particularly pathological variation on this theme. In the past, severe and chronic forms of factitious disorder with physical symptoms were called “Munchausen’s syndrome,” where the general idea was that the person had some kind of “hospital addiction” or a “professional patient” syndrome.
the WORLD around us: Factitious Disorder Imposed on Another (Munchausen’s Syndrome by Proxy)
In a somewhat bizarre variant of factitious disorder called factitious disorder imposed on another (or Munchausen’s syndrome by proxy), the person seeking medical help or consulting a mental health professional has intentionally produced a medical or psychiatric illness (or appearance of an illness) in another person who is under his or her care (usually a child; e.g., Pankratz, 2006 ). In a typical instance, a mother presents her own child for treatment of a medical condition she has deliberately caused, disclaiming any knowledge of its origin. Of course, the health of such victims is often seriously endangered by this repeated abuse, and the intervention of social service agencies or law enforcement is sometimes necessary. In as many as 10 percent of cases, this atypical form of child abuse may lead to a child’s death (Hall et al., 2000 ).
Over a period of 20 months, Jennifer, 8, shown here with her mother, Kathy Bush, was taken to the hospital more than 130 times, underwent 40 surgeries, and amassed over $3 million in medical expenses. Doctors and nurses testified that Jennifer’s condition always worsened after her mother visited her daughter at the hospital behind closed doors. In addition, Jennifer’s health had significantly improved since being removed from her mother’s care. The jury was convinced that Kathy Bush was responsible for causing Jennifer’s illnesses. Bush was arrested and diagnosed with Munchausen’s syndrome by proxy.
This disorder may be indicated when the victim’s clinical presentation is atypical, when lab results are inconsistent with each other or with recognized diseases, or when there are unduly frequent returns or increasingly urgent visits to the same hospital or clinic. The perpetrators (who often have extensive medical knowledge) tend to be highly resistant to admitting the truth (McCann, 1999 ), and it has been estimated that the average length of time to confirm the diagnosis is 14 months (Rogers, 2004 ). If the perpetrator senses that the medical staff is suspicious, he or she may abruptly terminate contact with that facility, only to show up at another one to begin the entire process anew. Compounding the problem of detection is the fact that health care professionals who realize they have been duped may be reluctant to acknowledge their fallibility for fear of legal action. Misdiagnosing the disorder when the parent is in fact innocent can also lead to legal difficulties for the health care professionals (McNicholas et al., 2000 ; Pankratz, 2006 ). One technique that has been used with considerable success is covert video surveillance of the mother and child during hospitalizations. In one study, 23 of 41 suspected cases were finally determined to have factitious disorder by proxy, and in 56 percent of those cases video surveillance was essential to the diagnosis (Hall et al., 2000 ).
It is sometimes possible to distinguish between a conversion (or other somatic symptom) disorder and malingering, or factitiously “sick-role-playing,” with a fair degree of confidence, but in other cases it is more difficult to make the correct diagnosis. Persons engaged in malingering (for which there are no formal diagnostic criteria) and those who have factitious disorder are consciously perpetrating frauds by faking the symptoms of diseases or disabilities, and this fact is often reflected in their demeanor. In contrast, individuals with conversion disorders (as well as with other somatic symptom disorders) are not consciously producing their symptoms, feel themselves to be the “victims of their symptoms,” and are very willing to discuss them, often in excruciating detail (Maldonado & Spiegel, 2001 , p. 109). When inconsistencies in their behaviors are pointed out, they are usually unperturbed. Any secondary gains they experience are byproducts of the conversion symptoms themselves and are not involved in motivating the symptoms. On the other hand, persons who are feigning symptoms are inclined to be defensive, evasive, and suspicious when asked about them; they are usually reluctant to be examined and slow to talk about their symptoms lest the pretense be discovered. Should inconsistencies in their behaviors be pointed out, deliberate deceivers as a rule immediately become more defensive. Thus conversion disorder and deliberate faking of illness are considered distinct patterns.
· ● What are the primary characteristics of hypochondriasis, and how does the cognitive-behavioral viewpoint explain their occurrence?
· ● What are the symptoms of somatization disorder and of pain disorder?
· ● What are sources of primary and secondary gains involved in conversion disorders, and how is conversion disorder distinguished from malingering and from factitious disorder?
Dissociative disorders are a group of conditions involving disruptions in a person’s normally integrated functions of consciousness, memory, identity, or perception (APA, 2013 ; Spiegel et al., 2013 ). Included here are some of the more dramatic phenomena in the entire domain of psychopathology: people who cannot recall who they are or where they may have come from, and people who have two or more distinct identities or personality states that alternately take control of the individual’s behavior.
The term dissociation refers to the human mind’s capacity to engage in complex mental activity in channels split off from, or independent of, conscious awareness (Kihlstrom, 1994 , 2001 , 2005 ). The concept of dissociation was first promoted over a century ago by the French neurologist Pierre Janet (1859–1947). We all dissociate to a degree some of the time. Mild dissociative symptoms occur when we daydream or lose track of what is going on around us, when we drive miles beyond our destination without realizing how we got there, or when we miss part of a conversation we are engaged in. As these everyday examples suggest, there is nothing inherently pathological about dissociation itself. Dissociation only becomes pathological when the dissociative symptoms are “perceived as disruptive, invoking a loss of needed information, as producing discontinuity of experience” or as “recurrent, jarring involuntary intrusions into executive functioning and sense of self” (Spiegel et al., 2011, p. E19).
Much of the mental life of all human beings involves automatic nonconscious processes that are to a large extent autonomous with respect to deliberate, self-aware direction and monitoring. Such unaware processing extends to the areas of implicit memory and implicit perception, where it can be demonstrated that all persons routinely show indirect evidence of remembering things they cannot consciously recall ( implicit memory ) and respond to sights or sounds as if they had perceived them (as in conversion blindness or deafness) even though they cannot report that they have seen or heard them ( implicit perception ; Kihlstrom, 2001 , 2005 ; Kihlstrom et al., 1993 ). As we learned in Chapter 3 , the general idea of unconscious mental processes has been embraced by psychodynamically oriented clinicians for many years. But only in the past 30 years has it also become a major research area in the field of cognitive psychology (though without any of the psychodynamic implications for why so much of our mental activity is unconscious).
In people with dissociative disorders, however, this normally integrated and well-coordinated multichannel quality of human cognition becomes much less coordinated and integrated. When this happens, the affected person may be unable to access information that is normally in the forefront of consciousness, such as his or her own personal identity or details of an important period of time in the recent past. That is, the normally useful capacity of maintaining ongoing mental activity outside of awareness appears to be subverted, sometimes for the purpose of managing severe psychological threat. When that happens, we observe the pathological dissociative symptoms that are the cardinal characteristic of dissociative disorders. Like somatic symptom disorders, dissociative disorders appear mainly to be ways of avoiding anxiety and stress and of managing life problems that threaten to overwhelm the person’s usual coping resources. Both types of disorders also enable the individual to deny personal responsibility for his or her “unacceptable” wishes or behavior. In the case of DSM-defined dissociative disorders, the person avoids the stress by pathologically dissociating—in essence, by escaping from his or her own autobiographical memory or personal identity. The DSM-5 recognizes several types of pathological dissociation. These include depersonalization/derealization disorder, dissociative amnesia, dissociative fugue (a subtype of dissociative amnesia) and dissociative identity disorder.
Two of the more common kinds of dissociative symptoms are derealization and depersonalization. We mentioned these in Chapter 6 because they sometimes occur during panic attacks. In derealization one’s sense of the reality of the outside world is temporarily lost, and in depersonalization one’s sense of one’s own self and one’s own reality is temporarily lost. As many as 50-74 percent of us have such experiences in mild form at least once in our lives, usually during or after periods of severe stress, sleep deprivation, or sensory deprivation (e.g., Khazaal et al., 2005 ; Reutens et al., 2010 ). But when episodes of depersonalization or derealization become persistent and recurrent and interfere with normal functioning, depersonalization / derealization disorder may be diagnosed.
In this disorder, people have persistent or recurrent experiences of feeling detached from (and like an outside observer of) their own bodies and mental processes. They may even feel they are, for a time, floating above their physical bodies, which may suddenly feel very different—as if drastically changed or unreal. During periods of depersonalization, unlike during psychotic states, reality testing remains intact. The related experience of derealization, in which the external world is perceived as strange and new in various ways, may also occur. As one leader in the field described it, in both states “the feeling puzzles the experiencers: the changed condition is perceived as unreal, and as discontinuous with his or her previous ego-states. The object of the experience, self (in depersonalization) or world (in derealization), is commonly described as isolated, lifeless, strange, and unfamiliar; oneself and others are perceived as ‘automatons,’ behaving mechanically, without initiative or self-control” (Kihlstrom, 2001 , p. 267). Often people also report feeling as though they are living in a dream or movie (Maldonado et al., 2002 ). In keeping with such reports, research has shown that emotional experiences are attenuated or reduced during depersonalization—both at the subjective level and at the level of neural and autonomic activity that normally accompanies emotional responses to threatening or unpleasant emotional stimuli (Lemche et al., 2007 ; Phillips & Sierra, 2003 ; Stein & Simeon, 2009 ). After viewing an emotional video clip, participants with depersonalization disorder showed higher levels of subjective and objective memory fragmentation than controls (Giesbrecht et al., 2010 ). Memory fragmentation is marked by difficulties forming an accurate or coherent narrative sequence of events, which is consistent with earlier research suggesting that time distortion is a key element of the experience of depersonalization (Simeon et al., 2008 ).
DSM-5 criteria for: Depersonalization/Derealization Disorder
· A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:
· 1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing).
· 2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
· B. During the depersonalization or derealization experiences, reality testing remains intact.
· C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
· D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).
· E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.
People with derealization symptoms experience the world as hazy and indistinct.
A number of researchers have noted elevated rates of comorbid anxiety and mood disorders as well as avoidant, borderline, and obsessive-compulsive personality disorders (e.g., Hunter et al., 2003 ; Mula et al., 2007 ; Reutens et al., 2010 ). Another study of over 200 cases found that the disorder had an average age of onset of 23. Moreover, in nearly 80 percent of cases, the disorder has a fairly chronic course (with little or no fluctuation in intensity; Baker, Hunter, et al., 2003 ).
The case of the foggy student below is fairly typical.
A Foggy Student A 20-year-old male college student sought psychiatric consultation because he was worried that he might be going insane. For the past 2 years he had experienced increasingly frequent episodes of feeling “outside” himself. These episodes were accompanied by a sense of deadness in his body. In addition, during these periods he was uncertain of his balance and frequently stumbled into furniture; this was more apt to occur in public, especially if he was somewhat anxious. During these episodes he felt a lack of easy, natural control of his body, and his thoughts seemed “foggy” as well ….
The patient’s subjective sense of lack of control was especially troublesome, and he would fight it by shaking his head and saying “stop” to himself. This would momentarily clear his mind and restore his sense of autonomy, but only temporarily, as the feelings of deadness and of being outside himself would return. Gradually, over a period of several hours, the unpleasant experiences would fade …. At the time the patient came for treatment, he was experiencing these symptoms about twice a week, and each incident lasted from 3 to 4 hours. On several occasions the episodes had occurred while he was driving his car and was alone; worried that he might have an accident, he had stopped driving unless someone accompanied him.
Source: Adapted with permission from DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 270–71). Washington, DC. (Copyright © 2002). American Psychiatric Association.
The lifetime prevalence of depersonalization/derealization disorder is unknown but has been estimated at 1 to 2 percent of the population (Reutens et al., 2010 ). Moreover, occasional depersonalization/derealization symptoms are not uncommon in a variety of other disorders such as schizophrenia, borderline personality disorder, panic disorder, acute stress disorder, and posttraumatic stress disorder (PTSD) (Hunter et al., 2003 ). Although severe depersonalization/derealization symptoms can be quite frightening and may make the victim fear imminent mental collapse, such fears are usually unfounded. Sometimes, however, feelings of depersonalization are clearly early manifestations of impending decompensation and the development of psychotic states ( Chapter 13 ). In either case, professional assistance in dealing with the precipitating stressors and in reducing anxiety may be helpful. Unfortunately, however, as of yet there are no clearly effective treatments—either through medication or psychotherapy.
Dissociative Amnesia and Dissociative Fugue
Retrograde amnesia is the partial or total inability to recall or identify previously acquired information or past experiences; by contrast, anterograde amnesia is the partial or total inability to retain new information (Gilboa et al., 2006 ; Kapur, 1999 ). Persistent amnesia may occur in several disorders, such as dissociative amnesia and dissociative fugue. It may also result from traumatic brain injury or diseases of the central nervous system. If the amnesia is caused by brain pathology, it most often involves failure to retain new information and experiences (anterograde amnesia). That is, the information contained in experience is not registered and does not enter memory storage (Kapur, 1999 ).
On the other hand, dissociative amnesia is usually limited to a failure to recall previously stored personal information (retrograde amnesia) when that failure cannot be accounted for by ordinary forgetting. The gaps in memory most often occur following intolerably stressful circumstances—wartime combat conditions, for example, or catastrophic events such as serious car accidents, suicide attempts, or violent outbursts (Maldonado & Spiegel, 2007 ; Spiegel et al., 2011). In this disorder, apparently forgotten personal information is still there beneath the level of consciousness, as sometimes becomes apparent in interviews conducted under hypnosis or narcosis (induced by sodium amytal, or so-called truth serum) and in cases where the amnesia spontaneously clears up. Watch the Video Sharon: Dissociative Amnesia on MyPsychLab
Amnesic episodes usually last between a few days and a few years. Although many people experience only one such episode, some people have multiple episodes in their lifetimes (Maldonado & Spiegel, 2007 ; Staniloiu & Markowitsch, 2010 ). In typical dissociative amnesic reactions, individuals cannot remember certain aspects of their personal life history or important facts about their identity. Yet their basic habit patterns—such as their abilities to read, talk, perform skilled work, and so on—remain intact, and they seem normal aside from the memory deficit (Kihlstrom, 2005 ; Kihlstrom & Schacter, 2000 ). Thus the only type of memory that is affected is episodic (pertaining to events experienced) or autobiographical memory (pertaining to personal events experienced). The other recognized forms of memory—semantic (pertaining to language and concepts), procedural (how to do things), and short-term storage—seem usually to remain intact, although there is very little research on this topic (Kihlstrom, 2005 ; Kihl-strom & Schacter, 2000 ). Usually there is no difficulty encoding new information (Maldonado & Spiegel, 2007 ).
DSM-5 criteria for: Dissociative Amnesia
· A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history.
· B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
· C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/traumatic brain injury, other neurological condition).
· D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.
In rare cases a person may retreat still further from real-life problems by going into an amnesic state called a dissociative fugue , which, as the term implies (the French word fugue means “flight”), is a defense by actual flight—a person is not only amnesic for some or all aspects of his or her past but also departs from home surroundings. This is accompanied by confusion about personal identity or even the assumption of a new identity (although the identities do not alternate as they do in dissociative identity disorder). During the fugue, such individuals are unaware of memory loss for prior stages of their life, but their memory for what happens during the fugue state itself is intact (Kihlstrom, 2005 ; Kihlstrom & Schacter, 2000 ). Their behavior during the fugue state is usually quite normal and unlikely to arouse suspicion that something is wrong. However, behavior during the fugue state often reflects a rather different lifestyle from the previous one (the rejection of which is sometimes fairly obvious). Days, weeks, or sometimes even years later, such people may suddenly emerge from the fugue state and find themselves in a strange place, working in a new occupation, with no idea how they got there. In other cases, recovery from the fugue state occurs only after repeated questioning and reminders of who they are. In either case, as the fugue state remits, their initial amnesia remits—but a new, apparently complete amnesia for their fugue period occurs. In DSM-5 dissociative fugue is considered to be a subtype of dissociative amnesia rather than a separate disorder as it was in DSM-IV.
The pattern in dissociative amnesia and dissociative fugue is essentially similar to that in conversion symptoms, except that instead of avoiding some unpleasant situation by becoming physically dysfunctional, a person unconsciously avoids thoughts about the situation or, in the extreme, leaves the scene (Maldonado & Spiegel, 2007 ; Maldonado et al., 2002 ). Thus people experiencing dissociative amnesia and fugue are typically faced with extremely unpleasant situations from which they see no acceptable way to escape. Eventually the stress becomes so intolerable that large segments of their personalities and all memory of the stressful situations are suppressed.
Several of these aspects of dissociative fugue are illustrated in the following case.
A Middle Manager Transformed into a Short-Order Cook Burt Tate, a 42-year-old short-order cook in a small-town diner, was brought to the attention of local police following a heated altercation with another man at the diner. He gave his name as Burt Tate and indicated that he had arrived in town several weeks earlier. However, he could produce no official identification and could not tell the officers where he had previously lived and worked. Burt was asked to accompany the officers to the emergency room of a local hospital so that he might be examined ….
Burt’s physical examination was negative for evidence of recent head trauma or any other medical abnormality …. He was oriented as to current time and place, but manifested no recall of his personal history prior to his arrival in town. He did not seem especially concerned about his total lack of a remembered past ….
Meanwhile, the police … discovered that Burt matched the description of one Gene Saunders, a resident of a city some 200 miles away who had disappeared a month earlier. The wife of Mr. Saunders … confirmed the real identity of Burt, who … stated that he did not recognize Mrs. Saunders.
Prior to his disappearance, Gene Saunders, a middle-level manager in a large manufacturing firm, had been experiencing considerable difficulties at work and at home. A number of stressful work problems, including failure to get an expected promotion, the loss of some of his key staff, failure of his section to meet production goals, and increased criticism from his superior—all occurring within a brief time frame—had upset his normal equanimity. He had become morose and withdrawn at home and had been critical of his wife and children. Two days before he had left, he had had a violent argument with his 18-year-old son, who had declared his father a failure and had stormed out of the house to go live with friends.
Source: Adapted with permission from DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 254–55). Washington, DC. (Copyright © 2002). American Psychiatric Association.
MEMORY AND INTELLECTUAL DEFICITS IN DISSOCIATIVE AMNESIA AND FUGUE
Unfortunately, very little systematic research has been conducted on individuals with dissociative amnesia and fugue. What is known comes largely from intensive studies of the memory and intellectual functioning of isolated cases with these disorders, so any conclusions should be considered tentative pending further study of larger samples with appropriate control groups. What can be gathered from a handful of such case studies is that these individuals’ semantic knowledge (assessed via the vocabulary subtest of an IQ test) seems to be generally intact. The primary deficit these individuals exhibit is their compromised episodic or autobiographical memory (Kihlstrom, 2005 ; Kihlstrom & Schacter, 2000 ). Indeed, several studies using brain-imaging techniques have confirmed that when people with dissociative amnesia are presented with autobiographical memory tasks, they show reduced activation in their right frontal and temporal brain areas relative to normal controls doing the same kinds of tasks (Kihlstrom, 2005 ; Markowitsch, 1999 ). In a recent review of nine cases of dissociative amnesia for which brain imaging data were available, the authors concluded there was evidence of significant changes in the brains of these patients, mostly centered on subtle loss of function in the right anterior hemisphere—changes similar to those seen in the brains of patients with organic memory loss (Staniloiu & Markowitsch, 2010 ).
However, several cases (some nearly a century old) have suggested that implicit memory is generally intact. For example, Jones (1909, as cited in Kihlstrom & Schacter, 2000 ) studied a patient with dense amnesia and found that although he could not remember his wife’s or daughter’s names, when asked to guess what names might fit them, he produced their names correctly. In a more contemporary case (Lyon, 1985, as cited in Kihlstrom & Schacter, 2000 ), a patient who could not retrieve any autobiographical information was asked to dial numbers on a phone randomly. Without realizing what he was doing, he dialed his mother’s phone number, which then led to her identifying him. In one particularly fascinating contemporary case of dissociative fugue, Glisky and colleagues ( 2004 ) describe a German man who had come to work in the United States several months before he had experienced a traumatic incident in which he had been robbed and shot. After the trauma, he wandered along unfamiliar streets for an unknown period of time. Finally, he stopped at a motel and asked if the police could be called because he did not know who he was (and had no ID because he’d been robbed) and could not recall any personal details of his life. He spoke English (with a German accent) but could not speak German and did not respond to instructions in German (which he denied that he spoke). In spite of his extensive loss of autobiographical memory (and the German language), when given a variety of memory tasks, he showed intact implicit memory. Especially striking was his ability to learn German–English word pairs, which he learned much faster than did normal controls, suggesting implicit knowledge of German even though he had no conscious knowledge of it.
Some of these memory deficits in dissociative amnesia and fugue have been compared to related deficits in explicit perception that occur in conversion disorders. This has convinced many people that conversion disorder should be classified with dissociative disorders rather than with somatic symptom disorders. This issue is discussed in more detail in the Thinking Critically About DSM-5 box below.
Dissociative Identity Disorder (Did)
DSM-5 THINKING CRITICALLY about DSM-5: Where Does Conversion Disorder Belong?
Starting with Freud and Janet, and for a large portion of the twentieth century prior to the publication of DSM-III in 1980, conversion disorders were classified together with dissociative disorders as subtypes of hysteria. When it was determined that DSM-III would rely heavily on overt behavioral symptoms rather than on presumed underlying etiology (namely, repressed anxiety) for classifying disorders, the decision was made to include conversion disorder with the other somatic symptom disorders. This was because its symptoms were physical ones with no demonstrable medical basis. However, as Kihlstrom ( 1994 , 2001 , 2005 ) and others have pointed out, this ignores some very important differences between conversion disorders and other somatic symptom disorders. The most important overall difference is that conversion symptoms (but not those of the other somatoform disorders) are nearly always pseudoneurological in nature (blindness, paralysis, anesthesias, deafness, seizures, etc.), mimicking some true neurological syndromes, just as most of the dissociative disorders do.
The disorders we currently classify as dissociative disorders (such as dissociative amnesia and DID) involve disruptions in explicit memory for events that have occurred, or who or what one’s identity is, or both. However, it is clear that events occurring during a period of amnesia or in the presence of one identity are indeed registered in the nervous system because they influence behavior indirectly even when the person cannot consciously recollect them (i.e., implicit memory remains at least partially intact in dissociative disorders). Similarly, Kihlstrom and others have argued that the conversion disorders involve disruptions in explicit perception and action. That is, people with conversion disorders have no conscious recognition that they can see or hear or feel, or no conscious knowledge that they can walk or talk or feel. However, patients with conversion disorder can see, hear, feel, or move when tricked into doing so or when indirect physiological or behavioral measures are used (see Janet, 1901 , 1907 ; Kihlstrom, 1994 , 2001 , 2005 ). Thus Kihlstrom ( 1994 , 2001 , 2005 ) and others made a compelling argument that in future editions, the term conversion disorder should be dropped and the sensory and motor types of the syndrome should be reclassified as forms of dissociative disorders. This way, the central feature of all dissociative disorders would be a disruption of the normally integrated functions of consciousness (memory, perception, and action). Such a proposal is also consistent with observations that dissociative symptoms and disorders are quite common in patients with conversion disorder (e.g., Sar et al., 2004 ). This proposal was seriously considered and heavily debated by the DSM-5 task force. In the end, the proponents for moving conversion disorder into the dissociative disorders category did not succeed and in DSM-5 conversion disorder (at least for now) is still listed as a somatic symptom disorder.
Dissociative identity disorder (DID) , formerly known as multiple personality disorder is a dramatic dissociative disorder in which a patient manifests two or more distinct identities that alternate in some way in taking control of behavior. There is also an inability to recall important personal information that cannot be explained by ordinary forgetting. Each identity may appear to have a different personal history, self-image, and name, although there are some identities that are only partially distinct and independent from other identities. In most cases the one identity that is most frequently encountered and carries the person’s real name is the host identity . Also in most cases, the host is not the original identity, and it may or may not be the best-adjusted identity. The alter identities may differ in striking ways involving gender, age, handedness, handwriting, sexual orientation, prescription for eyeglasses, predominant affect, foreign languages spoken, and general knowledge. For example, one alter may be carefree, fun-loving, and sexually provocative, and another alter quiet, studious, serious, and prudish. Needs and behaviors inhibited in the primary or host identity are usually liberally displayed by one or more alter identities. Certain roles such as a child and someone of the opposite sex are extremely common.
Much of the reason for abandoning the older diagnostic term multiple personality disorder in favor of DID was the growing recognition that it had misleading connotations, suggesting multiple occupancy of space, time, and people’s bodies by differing, but fully organized and coherent, “personalities.” In fact, alters are not in any meaningful sense personalities but rather reflect a failure to integrate various aspects of a person’s identity, consciousness, and memory (Spiegel, 2006). The term DID better captures this. Indeed Spiegel (one prominent theorist in this area) has argued that “the problem is not having more than one personality, it is having less than one” (Spiegel, 2006, p. 567).
Chris Sizemore was the inspiration for the book and movie Three Faces of Eve, which explore her multiple personality disorder (now known as DID). After her recovery, Sizemore worked as an advocate for the mentally ill.
DSM-5 criteria for: Dissociative Identity Disorder
· A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
· B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
· C. The symptoms cause clinically significant distress or impairment 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.
Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
· E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).
Alter identities take control at different points in time, and the switches typically occur very quickly (in a matter of seconds), although more gradual switches can also occur. When switches occur in people with DID, it is often easy to observe the gaps in memories for things that have happened—often for things that have happened to other identities. But this amnesia is not always symmetrical; that is, some identities may know more about certain alters than do other identities. Sometimes one submerged identity gains control by producing hallucinations (such as a voice inside the head giving instructions). In sum, DID is a condition in which normally integrated aspects of memory, identity, and consciousness are no longer integrated. Additional symptoms of DID include depression, self-mutilation, frequent suicidal ideation and attempts, erratic behavior, headaches, hallucinations, posttraumatic symptoms, and other amnesic and fugue symptoms (APA, 2013 ; Maldonado et al., 2002 ). Depressive disorders, PTSD, substance-use disorders, and borderline personality disorder are the most common comorbid diagnoses (Maldonado & Spiegel, 2007 ). One recent study found that among patients with diagnoses of DID, the average number of comorbid diagnoses (based on structured diagnostic interviews) was five, with PTSD being the most common (Rodewald et al., 2011 ).
DID usually starts in childhood, although most patients are in their teens, 20s, or 30s at the time of diagnosis (Maldonado & Spiegel, 2007 ). Approximately three to nine times more females than males are diagnosed as having the disorder, and females tend to have a larger number of alters than do males (Maldonado & Spiegel, 2007 ). Some believe that this pronounced gender discrepancy is due to the much greater proportion of childhood sexual abuse among females than among males (see Chapter 12 ), but this is a highly controversial point.
Many of these features are illustrated in the case of Mary Kendall below.
the WORLD around us: DID, Schizophrenia, and Split Personality: Clearing Up the Confusion
The general public has long been confused by the distinction between DID and schizophrenia. It is not uncommon for people diagnosed with schizophrenia to be referred to as having a “split personality.” We have even heard people say such things as, “I’m a bit schizophrenic on this issue” to mean that they have more than one opinion about it!
Although this misuse of the term split personality actually began among psychiatric professionals, today it reflects the public’s general misunderstanding of schizophrenia, which does not involve a “split” or “Jekyll and Hyde” personality at all. The original confusion may have stemmed from the term schizophrenia, which was first coined by a Swiss psychiatrist named Bleuler. Schizien is German for “split,” and phren is the Greek root for “mind.” The notion that schizophrenia is characterized by a split mind or personality may have arisen this way (see McNally, 2007 , for a historical review of how this confusion arose).
However, this is not at all what Bleuler intended the word schizophrenia to mean. Rather, Bleuler was referring to the splitting of the normally integrated associative threads of the mind—links between words, thoughts, emotions, and behavior. Splits of this kind result in thinking that is not goal-directed or efficient, which in turn leads to the host of other difficulties known to be associated with schizophrenia.
It is very important to remember that people diagnosed with schizophrenia do not have multiple distinct identities that alternately take control over their mind and behavior. They may have a delusion and believe they are someone else, but they do not show the changes in identity accompanied by changes in tone of voice, vocabulary, and physical appearance that are often seen when identities “switch” in DID. Furthermore, people with DID (who are probably closer to the general public’s notion of “split personality”) do not exhibit such characteristics of schizophrenia as disorganized behavior, hallucinations coming from outside the head, and delusions, or incoherent and loose associations (e.g., Kluft, 2005 ).
Mary and Marian Mary, a 35-year-old divorced social worker, had … in her right forearm and hand … chronic pain. Medical management of this pain had proved problematic, and it was decided to teach her self-hypnosis as a means whereby she might control it. She proved an excellent hypnotic subject and quickly learned effective pain control techniques.
Her hypnotist/trainer, a psychiatrist, describes Mary’s life in rather unappealing terms. She is said to be competent professionally but has an “arid” personal and social life …. She spends most of her free time doing volunteer work in a hospice ….
In the course of the hypnotic training, Mary’s psychiatrist discovered that she seemed to have substantial gaps in her memory. One phenomenon in particular was very puzzling: She reported that she could not account for what seemed an extraordinary depletion of the gasoline in her car’s tank. She would arrive home from work with a nearly full tank, and by the following morning as she began her trip to work would notice that the tank was now only half-full. When it was advised that she keep track of her odometer readings, she discovered that on many nights on which she insisted she’d remained at home the odometer showed significant accumulations of up to 100 miles. The psychiatrist, by now strongly suspecting that Mary had a dissociative disorder, also established that there were large gaps in her memories of childhood. He shifted his focus to exploring the apparently widespread dissociative difficulties.
In the course of one of the continuing hypnotic sessions, the psychiatrist again asked about “lost time,” and was greeted with a response in a wholly different voice tone that said, “It’s about time you knew about me.” Marian, an apparently well-established alter identity, went on to describe the trips she was fond of taking at night … Marian was an extraordinarily abrupt and hostile “person,” the epitome in these respects of everything the compliant and self-sacrificing Mary was not. Marian regarded Mary with unmitigated contempt, and asserted that “worrying about anyone but yourself is a waste of time.”
In due course some six other alter identities emerged …. There was notable competition among the alters for time spent “out,” and Marian was often so provocative as to frighten some of the more timid others, which included a 6-year-old child ….
Mary’s history, as gradually pieced together, included memories of physical and sexual abuse by her father as well as others during her childhood …. Her mother was described … as having abdicated to a large extent the maternal role, forcing Mary from a young age to assume these duties in the family.
Four years of subsequent psychotherapy resulted in only modest success in achieving a true “integration” of these diverse trends in Mary Kendall’s selfhood.
Source: Adapted with permission from DSM-IV-TR Casebook (pp. 56–57). Washington, DC. (Copyright © 2002). American Psychiatric Association.
The number of alter identities in DID varies tremendously and has increased over time (Maldonado & Spiegel, 2007 ). One early review of 76 classic cases reported that two-thirds of these cases had only two personalities and most of the rest had three (Taylor & Martin, 1944 ). More recent estimates are that about 50 percent now show over 10 identities with some respondents claiming as many as a hundred. This historical trend of increasing multiplicity suggests the operation of social factors, perhaps through the encouragement of therapists, as we discuss below (e.g., Kihlstrom, 2005 ; Lilienfeld et al., 1999 ; Piper & Merskey, 2004a , 2004b ). Another recent trend is that many of the reported cases of DID now include more unusual and even bizarre identities than in the past (such as being an animal) and more highly implausible backgrounds (e.g., ritualized satanic abuse in childhood).
PREVALENCE—WHY HAS DID BEEN INCREASING?
Owing to their dramatic nature, cases of DID receive a great deal of attention and publicity in fiction, television, and motion pictures. But in fact, until relatively recently, DID was extremely rare—or at least rarely diagnosed—in clinical practice. Prior to 1979, only about 200 cases could be found in the entire psychological and psychiatric literature worldwide. By 1999, however, over 30,000 cases had been reported in North America alone (Ross, 1999 ), although as we will discuss later, many researchers believe that this is a gross overestimate (e.g., Piper & Merskey, 2004b ). Because their diagnosed occurrence in both clinical settings and in the general population increased enormously in recent years, prevalence estimates in the general population vary. One study of 658 people in upstate New York estimated a 1.5 percent prevalence (Johnson et al., 2006 ), but it is possible that no such estimates are valid, given how hard it is to make this diagnosis reliably. (For example, recall that Mary’s DID was uncovered only in the course of hypnotic sessions for pain management.)
Many factors probably have contributed to the drastic increase in the reported prevalence of DID (although in an absolute sense it is still very rare, and most practicing psychotherapists never see a person with DID in their entire careers). For example, the number of cases began to rise in the 1970s after the publication of Flora Rhea Schreiber’s Sybil ( 1973 ) This increased public awareness of the condition. (Ironically, however, the case has now been thoroughly discredited (see Borch-Jacobsen, 1997 ; Paris, 2012 ; Rieber, 1999 ). At about the same time, the diagnostic criteria for DID (then called multiple personality disorder) were clearly specified for the first time with the publication of DSM-III in 1980. This seems to have led to increased acceptance of the diagnosis by clinicians, which may have encouraged reporting of it in the literature. Clinicians were traditionally (and often still are today) somewhat skeptical of the astonishing behavior these patients often display.
Another reason why the diagnosis was made more frequently after 1980 is that the diagnostic criteria for schizophrenia were tightened in DSM-III. People who had perhaps been inappropriately diagnosed with schizophrenia could now receive the more appropriate diagnosis of multiple personality disorder. In addition, beginning in about 1980, prior scattered reports of instances of childhood abuse in the histories of adult patients began building into what would become a crescendo. As we will see later, many controversies arose regarding how to interpret such findings, but it is definitely true that these reports of abuse in patients with DID drew a great deal of attention to this disorder, which in turn may have increased the rate at which it was being diagnosed.
Finally, it is almost certain that some of the increase in the prevalence of DID is artifactual and has occurred because some therapists looking for evidence of DID in certain patients may suggest the existence of alter identities (especially when the person is under hypnosis and very suggestible; e.g., Kihlstrom, 2005 ; Piper & Merskey, 2004b ). The therapist may also subtly reinforce the emergence of new identities by showing great interest in these new identities. Nevertheless, such factors cannot account for all cases of diagnosed DID, which has been observed in most parts of the world, even where there is virtually no personal or professional knowledge of DID, including rural Turkey (Akyuz et al., 1999 ; see also Maldonado & Spiegel, 2007 ) and Shanghai, China (Xiao et al., 2006 ).
EXPERIMENTAL STUDIES OF DID
Much of what is known about DID comes from patients’ self-reports and from therapists’ or researchers’ clinical observations. Indeed, only a small number of experimental studies of people with DID have been conducted to corroborate clinical observations. Moreover, most of these studies have been conducted on only one or a few cases, although very recently a few larger studies have been done that include appropriate control groups (e.g., Dorahy et al., 2005 ; Huntjens et al., 2003 , 2007 ). In spite of such shortcomings, most of the findings from these studies are generally consistent with one another and reveal some very interesting features of DID.
The primary focus of these studies has been to determine the nature of the amnesia that exists between different identities. As we have already noted, most people with DID have at least some identities that seem completely unaware of the existence and experiences of certain alter identities, although other identities may be only partially amnesic of some alters (e.g., Elzinga et al., 2003 ; Huntjens et al., 2003 ). This feature of DID has been corroborated by studies showing that when one identity (Identity 1) is asked to learn a list of word pairs, and an alter identity (Identity 2) is later asked to recall the second word in each pair using the first word as a cue, there seems to be no transfer to Identity 2 of what was learned by Identity 1. This interpersonality amnesia with regard to conscious recall of the activities and experiences of at least some other identities has generally been considered a fundamental characteristic of DID (Kihlstrom, 2001 , 2005 ; Kihlstrom & Schacter, 2000 ). Nevertheless, several interesting recent studies, each with about 20 DID patients, have challenged any idea that this interpersonality amnesia is complete, instead sometimes finding partial transfer of explicit memory across identities in certain tasks (Huntjens et al., 2003 , 2007 , 2012; see also Dorahy & Huntjens, 2007 , for a review).
As noted earlier, there are kinds of memory other than simply what can be brought to awareness (explicit memory). As with dissociative amnesia and fugue, there is evidence that Identity 2 has some implicit memory of things that Identity 1 learned. That is, although Identity 2 may not be able to recall consciously the things learned by Identity 1, these apparently forgotten events may influence Identity 2’s experiences, thoughts, and behaviors unconsciously (Kihlstrom, 2001 , 2005 ). This might be reflected in a test asking Identity 2 to learn the list of words previously learned by Identity 1. Even though Identity 2 could not consciously recall the list of words, Identity 2 would learn that list more rapidly than a brand-new list of words, an outcome that suggests the operation of implicit memory (e.g., Eich et al., 1997 ; Elzinga et al., 2003 ; see Kihlstrom, 2001 , 2005 , for reviews).
Related studies on implicit transfer of memories have shown that emotional reactions learned by one identity often transfer across identities, too. Thus, even though Identity 2 may not be able to recall an emotional event that happened to Identity 1, a visual or auditory reminder of the event (a conditioned stimulus) administered to Identity 2 may elicit an emotional reaction even though Identity 2 has no knowledge of why it did so (e.g., Ludwig et al., 1972 ; Prince, 1910 ). Moreover, one study by Huntjens and colleagues ( 2005 ) had 22 DID patients in Identity 1 learn to reevaluate a neutral word in a positive or negative manner through a simple evaluative conditioning procedure in which neutral words are simply paired with positive or negative words; the neutral words then come to take on positive or negative connotations. When Identity 2 was later asked to emerge, he or she also categorized the formerly neutral word in the same positive or negative manner as learned by Identity 1, showing implicit memory for the reevaluation of the word learned by Identity 1 (although complete subjective amnesia was reported by Identity 2). Nevertheless, other sophisticated studies have made it clear that implicit memory transfer across personalities does not always occur, particularly with certain kinds of implicit memory tasks where memory performance may be strongly influenced by the identity currently being tested (e.g., Dorahy, 2001 ; Eich et al., 1997 ; Nissen et al., 1988 ). However, the results that do show implicit memory transfer are very important because they demonstrate that explicit amnesia across identities cannot occur simply because one identity is trying actively to suppress any evidence of memory transfer. If this were possible, there would be no leakage of implicit memories across identities (Dorahy, 2001 ; Eich et al., 1997 ).
An even smaller number of experimental studies have examined differences in brain activity when individuals with DID are tested with different identities at the forefront of consciousness. For example, in an early classic study, Putnam ( 1984 ) investigated EEG activity in 11 DID patients during different identities, and in 10 control subjects who were simulating different personality states, in order to determine whether there were different patterns of brain wave activity during different identities (real or simulated), as would be found if separate individuals were assessed. The study found that there were indeed differences in brain wave activity when the patients with DID were in different personality states and that these differences were greater than those found in the simulating subjects (see Kihlstrom et al., 1993 ; Putnam, 1997 ).
One particularly interesting study by Reinders and colleagues ( 2006 ) examined subjective and cardiovascular activation patterns to both neutral and traumatic memories in 11 people diagnosed with DID. Each patient had one alter with a neutral identity such as the one active when they were functioning in everyday life, and each had another alter with a traumatic identity who had access to traumatic memories. As expected, when exposed to a script of neutral personal memories neither identity displayed much subjective or cardiovascular reactivity. However, when exposed to a script of personal memories of traumatizing events, responding differed in the two identity states. Specifically, the traumatic identity state (but not the neutral identity state) showed subjective and cardiovascular reactivity reflecting emotional distress to the personal traumatic memory. Such results could be seen as providing support for the idea that one function of certain alters is to protect the person from traumatic memories that a traumatic identity state has access to.
CAUSAL FACTORS AND CONTROVERSIES ABOUT DID
There are at least four serious, interrelated controversies surrounding DID and how it develops. First, some have been concerned with whether DID is a real disorder or is faked, and whether, even if it is real, it can be faked. The second major controversy is about how DID develops. Specifically, is DID caused by early childhood trauma, or does the development of DID involve some kind of social enactment of multiple different roles that have been inadvertently encouraged by careless clinicians? Third, those who maintain that DID is caused by childhood trauma cite mounting evidence that the vast majority of individuals diagnosed with DID report memories of an early history of abuse. But are these memories of early abuse real or false? Finally, if abuse has occurred in most individuals with DID, did the abuse play a causal role, or was something else correlated with the abuse actually the cause?
DID: Real or Faked? The issue of possible factitious or malingering origins of DID has dogged the diagnosis of DID for at least a century. One obvious situation in which this issue becomes critical is when it has been used by defendants and their attorneys to try to escape punishment for crimes (“My other personality did it”). For example, this defense was used, ultimately unsuccessfully, in the famous case of the Hillside Strangler, Kenneth Bianchi (Orne et al., 1984 ), but it has probably been used successfully in other cases that we are unaware of (unaware because the person is not sent to prison but rather to a mental hospital in most cases). Bianchi was accused of brutally raping and murdering 10 young women in the Los Angeles area. Although there was a great deal of evidence that he had committed these crimes, he steadfastly denied it, and some lawyers thought perhaps he had DID. He was subsequently interviewed by a clinical psychologist, and under hypnosis a second personality, “Steve,” emerged. Steve confessed to the crimes, thereby creating the basis for a plea of “not guilty by reason of insanity” (see Chapter 17 ). However, Bianchi was later examined even more closely by a renowned psychologist and psychiatrist specializing in this area, the late Martin Orne. Upon closer examination, Orne determined that Bianchi was faking the condition. Orne drew this conclusion in part because when he suggested to Bianchi that most people with DID have more than two identities, Bianchi suddenly produced a third (Orne et al., 1984 ). Moreover, there was no evidence of multiple identities existing prior to the trial. When Bianchi’s faking the disorder was discovered, he was convicted of the murders. In other words, some cases of DID may involve complete fabrication orchestrated by criminal or other unscrupulous persons seeking unfair advantages, and not all prosecutors have as clever and knowledgeable an expert witness as Martin Orne to help detect this. Nevertheless, most researchers think that factitious and malingering cases of DID (such as the Bianchi case or cases in which the person has a need to be a patient) are relatively rare.
FIGURE 8.1 Reported childhood abuse in five separate studies of DID patients (Total n = 843).
If DID Is Not Faked, How Does It Develop: Posttraumatic Theory or Sociocognitive Theory? Many professionals acknowledge that, in most cases, DID is a real syndrome (not consciously faked), but there is marked disagreement about how it develops and how it is maintained. In the contemporary literature, the original major theory of how DID develops is posttraumatic theory (Gleaves, 1996 ; Maldonado & Spiegel, 2007 ; Ross, 1997 , 1999 ). The vast majority of patients with DID (over 95 percent by some estimates) report memories of severe and horrific abuse as children (see Figure 8.1 below). According to this view, DID starts from the child’s attempt to cope with an overwhelming sense of hopelessness and powerlessness in the face of repeated traumatic abuse. Lacking other resources or routes of escape, the child may dissociate and escape into a fantasy, becoming someone else. This escape may occur through a process like self-hypnosis (Butler et al., 1996 ), and if it helps to alleviate some of the pain caused by the abuse it will be reinforced and occur again in the future. This notion is consistent with recent evidence that inducing a dissociative state in research participants can lead to decreased pain sensitivity (Ludascher et al., 2009 ). Sometimes the child simply imagines the abuse is happening to someone else. If the child is fantasy prone, and continues to stay fantasy prone over time, the child may unknowingly create different selves at different points in time, possibly laying the foundation for multiple dissociated identities.
Kenneth Bianchi, known as the “Hillside Strangler,” brutally raped and murdered 10 women in the Los Angeles area. Hoping to create a plea of “not guilty by reason of insanity,” Bianchi fabricated a second personality—“Steve”—who “emerged” while Kenneth was under hypnosis. A psychologist and psychiatrist specializing in DID determined he was faking the diagnosis, and Bianchi was subsequently convicted of the murders.
But only a subset of children who undergo traumatic experiences are prone to fantasy or self-hypnosis, which leads to the idea that a diathesis-stress model may be appropriate here. That is, children who are prone to fantasy and those who are easily hypnotizable may have a diathesis for developing DID (or other dissociative disorders) when severe abuse occurs (e.g., Butler et al., 1996 ; Kihlstrom et al., 1993 ). However, it should also be emphasized that there is nothing inherently pathological about being prone to fantasy or readily hypnotizable (Kihlstrom et al., 1994 ).
Increasingly, those who view childhood abuse as playing a critical role in the development of DID are beginning to see DID as perhaps a complex and chronic variant of posttraumatic stress disorder, which by definition is caused by exposure to some kind of highly traumatic event(s), including abuse (e.g., Brown, 1994 ; Maldonado & Spiegel, 2007 ; Maldonado et al., 2002 ). Anxiety symptoms are more prominent in PTSD than in DID, and dissociative symptoms are more prominent in DID than in PTSD. Nevertheless, both kinds of symptoms are present in both disorders (Putnam, 1997 ). Moreover, some (but not all) investigators have estimated that a very high percentage of individuals diagnosed with DID have a comorbid diagnosis of PTSD, suggesting the likelihood of some important common causal factors (Vermetten et al., 2006; see also Rodewald et al., 2011 ).
At the other extreme from posttraumatic theory is sociocognitive theory , which claims that DID develops when a highly suggestible person learns to adopt and enact the roles of multiple identities, mostly because clinicians have inadvertently suggested, legitimized, and reinforced them and because these different identities are geared to the individual’s own personal goals (Lilienfeld & Lynn, 2003 ; Lilienfeld et al., 1999 ; Spanos, 1994 , 1996 ). It is important to realize that at the present time, the sociocognitive perspective maintains that this is not done intentionally or consciously by the afflicted individual but, rather, occurs spontaneously with little or no awareness (Lilienfeld et al., 1999 ). The suspicion is that overzealous clinicians, through fascination with the clinical phenomenon of DID and unwise use of such techniques as hypnosis, are themselves largely responsible for eliciting this disorder in highly suggestible, fantasy-prone patients (e.g., Giesbrecht et al., 2008 ; Piper, Merskey, 2004a , 2004b ; Spanos, 1996 ).
Consistent with the sociocognitive hypothesis, Spanos et al. ( 1985 ) demonstrated that normal college students can be induced by suggestion under hypnosis to exhibit some of the phenomena seen in DID, including the adoption of a second identity with a different name that shows a different profile on a personality inventory. Thus people can enact a second identity when situational forces encourage it. Related situational forces that may affect the individual outside the therapist’s office include memories of one’s past behavior (e.g., as a child), observations of other people’s behavior (e.g., others being assertive and independent, or sexy and flirtatious), and media portrayals of DID (Lilienfeld et al., 1999 ; Piper & Merskey, 2004b ; Spanos, 1994 ).
Sociocognitive theory is also consistent with evidence that most DID patients do not show unambiguous signs of the disorder before they enter therapy and with evidence that the number of alter identities often increases (sometimes dramatically) with time spent in therapy (Piper & Merskey, 2004b ). It is also consistent with the increased prevalence of DID since the 1970s, when the first popular accounts of DID reached the general public, and since 1980, when therapist awareness of the condition increased as well (Lilienfeld et al., 1999 ; Piper & Merskey, 2004a ).
However, there are also many criticisms of sociocognitive theory. For example, Spanos and colleagues’ demonstration of role-playing in hypnotized college students is interesting, but it does not show that this is the way DID is actually caused in real life. For example, someone might be able to give a convincing portrayal of a person with a broken leg, but this would not establish how legs are usually broken. Moreover, the hypnotized participants in this and other experiments showed only a few of the most obvious symptoms of DID (such as more than one identity) and showed them only under short-lived, contrived laboratory conditions. No studies have shown that other symptoms such as depersonalization, memory lapses for prolonged periods, or auditory hallucinations can occur under similar laboratory conditions. Thus, although some of the symptoms of DID could be created by social enactment, there is no evidence that the disorder can be created this way (e.g., Gleaves, 1996 ).
Former Georgia football star Herschel Walker has written a book, Breaking Free: My Life with Dissociative Identity Disorder (2008), in which he tells about his struggle with this disorder.
Are Recovered Memories of Abuse in DID Real or False? Case reports of the cruelty and torture that some DID patients suffered as children are gut-wrenching to read or hear. However, the accuracy and trustworthiness of these reports of widespread sexual and other forms of childhood abuse in DID have become a matter of major controversy. Critics (who are often proponents of sociocognitive theory) argue that many of these reports of DID patients, which generally come up in the course of therapy, may be the result of false memories, which are in turn a product of highly leading questions and suggestive techniques applied by well-meaning but inadequately skilled and careless psychotherapists (Lilienfeld et al., 1999 ; Loftus & Davis, 2006 ; Yapko, 1994 ). It seems quite clear to many investigators that this sort of thing has happened, often with tragic consequences. Innocent family members have been falsely accused by DID patients and have sometimes been convicted and imprisoned. But it is also true that brutal abuse of children occurs far too often and that it can have very adverse effects on development, perhaps encouraging pathological dissociation (e.g., Maldonado & Spiegel, 2007 ; Nash et al., 1993 ). In such cases, prosecution of the perpetrators of the abuse is indeed appropriate. Of course, the real difficulty here is in determining when the recovered memories of abuse are real and when they are false (or some combination of the two). This bitter controversy about the issue of false memory is more extensively considered in the Unresolved Issues section at the end of this chapter.
One way to document that particular recovered memories are real might be if some reliable physiological test could be developed to distinguish between them. Thus, some researchers are currently trying to determine whether there are different neural correlates of real and false memories that could be used to make this determination reliably. Another somewhat easier way to document whether a particular recovered memory is real would be to have independent verification that the abuse had actually occurred, such as through physician, hospital, and police records. A number of studies have indeed reported that they have confirmed the reported cases of abuse, but critics have shown that the criteria used for corroborating evidence are almost invariably very loose and suspect as to their validity. For example, Chu and colleagues ( 1999 ) simply asked their subjects, “Have you had anyone confirm these events?” (p. 751) but did not specify what constituted confirmation and had no way of determining if subjects were exaggerating or distorting the information they provided as confirming evidence (Loftus & Davis, 2006 ; Piper & Merskey, 2004a ). In another example of a flawed study, Lewis and colleagues ( 1997 ) studied 12 convicted murderers and then confirmed through medical, social service, and prison records that all 12 had been severely abused as children. Unfortunately, this study did not include a control group of otherwise comparable murderers who did not exhibit DID symptoms. Hence we cannot be certain that the childhood abuse of these subjects is not as much (or more) associated with violence or conviction for murder as with the development of DID specifically. Moreover, Lewis and colleagues should have carefully assessed for the possibility that some of the murderers might have been malingering (i.e., faking DID; Lilienfeld et al., 1999 ). Thus, although this study may have been one of the most impressive attempts yet to document abuse independently in people with DID, it was significantly flawed and therefore highly inconclusive.
If Abuse Has Occurred, Does It Play a Causal Role in DID? Let us put the previous controversy about the reality of recovered memories of abuse aside for a moment and assume that severe abuse has occurred in the early childhood backgrounds of many people with DID. How can we determine whether this abuse has played a critical causal role in the development of DID (e.g., Piper & Merskey, 2004a )? Unfortunately, many difficulties arise in answering this question. For example, child abuse usually happens in family environments plagued by many other sources of adversity and trauma (e.g., various forms of psychopathology and extreme neglect and poverty). One or more of these other, correlated sources of adversity could actually be playing the causal role (e.g., Lilienfeld et al., 1999 ; Nash et al., 1993 ). Another difficulty of determining the role of abuse is that people who have experienced child abuse as well as symptoms of DID may be more likely to seek treatment than people with symptoms of DID who did not experience abuse. Thus the individuals in most studies on the prevalence of child abuse in DID may not be representative of the population of all people who suffer from DID. Finally, childhood abuse has been claimed by some to lead to many different forms of psychopathology including depression, PTSD, eating disorders, somatic symptom disorders, and borderline personality disorder, to name just a few. Perhaps the most we will ever be able to say is that childhood abuse may play a nonspecific role for many disorders, with other, more specific factors determining which disorder develops (see Chapters 10 and 12 ).
Comments on a Few of These Controversies About DID As we have seen, numerous studies indicate that the separate identities harbored by DID patients are somewhat physiologically and cognitively distinct. For example, EEG activity of various alters may be quite different. Because such differences cannot in any obvious way be simulated (e.g., Eich et al., 1997 ), it seems that DID must, in at least some cases, involve more than simply the social enactment of roles. Moreover, this should not be too surprising, given the widespread evidence of separate (dissociated) memory subsystems and nonconscious active mental processing, which indicates that much highly organized mental activity is normally carried on in all of us in the background, outside of awareness (e.g., Kihlstrom, 2005 ). Moreover, some people seem to be especially prone to pathological variants of these dissociative processes (Waller et al., 1996 ; Waller & Ross, 1997 ).
We should also note that each of these controversies has usually been stated in a dichotomous way: Is DID real or faked? What causes DID—spontaneous social enactment of roles or repeated childhood trauma? Are recovered memories of abuse real or false? If abuse occurs, does it play a primary causal role? Unfortunately, however, such dichotomously stated questions encourage oversimplified answers. The human mind does not seem to operate in these dichotomous ways, and we need to address the complex and multifaceted nature of the dissociated mental processes that these often miserable and severely stressed patients are experiencing. Fortunately, theorists on both sides have begun to soften their positions a little, acknowledging that multiple different causal pathways are likely to be involved. For example, Ross ( 1997 , 1999 ), a long-time advocate for a strong version of posttraumatic theory, later acknowledged that some cases are faked and that some may be inadvertently caused by unskilled therapists in the course of treatment. In addition, other advocates of posttraumatic theory have recently acknowledged that both real and false memories do occur in these patients, noting that it is critical that a method for determining which is which be developed (e.g., Gleaves & Williams, 2005 ; Gleaves et al., 2004 ). From the other side, Lilienfeld et al., 1999 , who have been vocal advocates for Spanos’ sociocognitive theory since his death in 1994 , have acknowledged that some people with DID may have undergone real abuse, although they believe it occurs far less often, and is less likely to play a real causal role, than the trauma theorists maintain (see also Kihlstrom, 2005 ).
Sociocultural Factors in Dissociative Disorders
There seems little doubt that the prevalence of dissociative disorders, especially their more dramatic forms such as DID, is influenced by the degree to which such phenomena are accepted or tolerated either as normal or as legitimate mental disorders by the surrounding cultural context. Indeed, in our own society, the acceptance and tolerance of DID as a legitimate disorder have varied tremendously over time. Compared to relatively high reported rates of DID in Western cultures, a recent study of 893 patients diagnosed with some type of dissociative disorder over 10 years at a psychiatric hospital in India found no cases of DID (Chaturvedi et al., 2010 ). Nevertheless, although its prevalence varies, DID has now been identified in all racial groups, socioeconomic classes, and cultures where it has been studied. For example, outside North America it has been found in countries ranging from Nigeria and Ethiopia to Turkey, India, China, Australia, and the Caribbean, to name a few (Maldonado et al., 2002 ; Xiao et al., 2006 ).
Many seemingly related phenomena, such as spirit possession and dissociative trances, occur very frequently in many different parts of the world where the local culture sanctions them (Krippner, 1994 ; Spiegel et al., 2011). When entered into voluntarily, trance and possession states are not considered pathological and should not be construed as mental disorders. But some people who enter into these states voluntarily because of cultural norms develop distress and impairment. In DSM-5, the diagnostic criteria for DID have been modified to that they now include certain phenomena associated with possession. A trance is said to occur when someone experiences a temporary marked alteration in state of consciousness or identity (but with no replacement by an alternative identity). It is usually associated with either a narrowing of awareness of the immediate surroundings, or stereotyped behaviors or movements that are experienced as beyond one’s control. A possession trance is similar except that the alteration of consciousness or identity is replaced by a new identity that is attributed to the influence of a spirit, deity, or other power. In both cases there is typically amnesia for the trance state. One study of 58 individuals from Singapore with this diagnosis, as well as 58 individuals with a diagnosis of major depression, found that conflicts over religious or cultural issues, prior exposure to trance states, and being a spiritual healer or healer’s helper were most predictive of who had dissociative trance disorder relative to major depression (Ng & Chan, 2004 ). A recent review of 402 cases of dissociative trance and possession disorders indicates that migration and struggles with acculturation are associated with these disorders (During et al., 2011 ).
There are also cross-cultural variants on dissociative disorders, such as Amok, which is often thought of as a rage disorder. Amok occurs when a dissociative episode leads to violent, aggressive, or homicidal behavior directed at other people and objects. It occurs mostly in men and is often precipitated by a perceived slight or insult. The person often has ideas of persecution, anger, and amnesia, often followed by a period of exhaustion and depression. Amok is found in places such as Malaysia, Laos, the Philippines, Papua New Guinea, and Puerto Rico and among Navajo Indians.
Treatment and Outcomes in Dissociative Disorders
Unfortunately, virtually no systematic, controlled research has been conducted on treatment of depersonalization disorder, dissociative amnesia, and dissociative fugue, and so very little is known about how to treat them successfully. Numerous case histories, sometimes presented in small sets of cases, are available, but without control groups who are assessed at the same time or who receive nonspecific treatments it is impossible to know the effectiveness of the varied treatments that have been attempted (Kihlstrom, 2005 ).
As noted earlier depersonalization/derealization disorder is generally thought to be resistant to treatment (e.g., Simeon et al., 1997 ), although treatment may be useful for associated psycho-pathology such as anxiety and depressive disorders. Some think that hypnosis, including training in self-hypnosis techniques, may be useful because patients with depersonalization disorder can learn to dissociate and then “reassociate,” thereby gaining some sense of control over their depersonalization and derealization experiences (Maldonado & Spiegel, 2007 ; Maldonado et al., 2002 ). Many types of antidepressant, antianxiety, and antipsychotic drugs have also been tried and sometimes have modest effects. However, one randomized controlled study showed no difference between treatment with Prozac versus with placebo (Simeon et al., 2004 ). One recent treatment showing some promise for the treatment of dissociative disorders involves administering rTMS (repetitive transcranial magnetic stimulation) to the temporo-parietal junction, an area of the brain highly involved in the experience of a unified self and body (Mantovani et al., 2011 ). After three weeks of treatment, half of the subjects showed significant reductions in depersonalization, with nonresponders showing symptom reduction after an additional three weeks of treatment. In dissociative amnesia and fugue, it is important for the person to be in a safe environment, and simply removing her or him from what he or she perceives as a threatening situation sometimes allows for spontaneous recovery of memory. Hypnosis, as well as drugs such as benzodiazepines, barbiturates, sodium pentobarbital, and sodium amobarbital, is often used to facilitate recall of repressed and dissociated memories (Maldonado & Spiegel, 2007 ; Maldonado et al., 2002 ). After memories are recalled, it is important for the patient to work through the memories with the therapist so that the experiences can be reframed in new ways. However, unless the memories can be independently corroborated, they should not be taken at their face value (Kihlstrom, 2005 ).
For DID patients, most current therapeutic approaches are based on the assumption of posttraumatic theory that the disorder was caused by abuse (Kihlstrom, 2005 ). Most therapists set integration of the previously separate alters, together with their collective merging into the host personality, as the ultimate goal of treatment (e.g., Maldonado & Spiegel, 2007 ). There is often considerable resistance to this process by the DID patients, who often consider dissociation as a protective device (e.g., “I knew my father could get some of me, but he couldn’t get all of me”; Maldonado & Spiegel, 2007 , p. 781). If successful integration occurs, the patient eventually develops a unified personality, although it is not uncommon for only partial integration to be achieved. But it is also very important to assess whether improvement in other symptoms of DID and associated disorders has occurred. Indeed, it seems that treatment is more likely to produce symptom improvement, as well as associated improvements in functioning, than to achieve full and stable integration of the different alter identities (Maldonado & Spiegel, 2007 ; Maldonado et al., 2002 ).
Typically the treatment for DID is psychodynamic and insight-oriented, focused on uncovering and working through the trauma and other conflicts that are thought to have led to the disorder (Kihlstrom, 2005 ). One of the primary techniques used in most treatments of DID is hypnosis (e.g., Kluft, 1993 ; Maldonado & Spiegel, 2007 ; Maldonado et al., 2002 ). Most DID patients are hypnotizable and when hypnotized are often able to recover past unconscious and frequently traumatic memories, often from childhood. Then these memories can be processed, and the patient can become aware that the dangers once present are no longer there. (One problem here is that such patients are suggestible under hypnosis, so much of what is recalled may not be accurate; see Kihlstrom, 2005 ; Loftus & Davis, 2006 ). Through the use of hypnosis, therapists are often able to make contact with different identities and reestablish connections between distinct, seemingly separate identity states. An important goal is to integrate the personalities into one identity that is better able to cope with current stressors. Clearly, successful negotiation of this critical phase of treatment requires therapeutic skills of the highest order; that is, the therapist must be strongly committed as well as professionally competent. Regrettably, not all therapists are.
Most reports in the literature are treatment summaries of single cases, and reports of successful cases should always be considered with caution, especially given the large bias in favor of publishing positive rather than negative results. Treatment outcome data for large groups of DID patients have been reported in only four studies we are aware of, and none of these included a control group, although it is clear that DID does not spontaneously remit simply with the passage of time, nor if a therapist chooses to ignore DID-related issues (Kluft, 1999 ; Maldonado et al., 2002 ). For example, Ellason and Ross ( 1997 ) reported on a 2-year postdischarge follow-up of DID patients originally treated in a specialized inpatient unit. Of the original 135 such patients, 54 were located and systematically assessed. All these patients, and especially those who had achieved full integration, generally showed marked improvements in various aspects of their lives. However, only 12 of the 54 had achieved full integration of their identities. Such results are promising, but we must wonder about the clinical status of the 81 “lost” patients who may likely have done less well. Another 10-year follow-up study reported similar results in a smaller sample of 25 treated DID patients. Only 12 were located 10 years later; of these, six had achieved full integration, but two of those had partially relapsed (Coons & Bowman, 2001 ). In general it has been found that (1) for treatment to be successful, it must be prolonged, often lasting many years, and (2) the more severe the case, the longer that treatment is needed (Maldonado & Spiegel, 2007 ; Maldonado et al., 2002 ).
· ● Describe the symptoms known as depersonalization and derealization, and indicate which disorder is primarily characterized by their appearance.
· ● Describe dissociative amnesia and dissociative fugue, and indicate what aspects of memory are affected.
· ● What are the primary symptoms of dissociative identity disorder (DID), and why is its prevalence thought to have increased?
· ● Review the four major controversies surrounding DID that were discussed in this chapter.
UNRESOLVED issues: DID and the Reality of “Recovered Memories”
As we have seen in this chapter, many controversies surround the nature and origins of DID. None have been more bitter than those related to the truth value of “recovered” memories of childhood abuse, particularly sexual abuse, which posttraumatic theorists assert is the major causal factor in the development of DID. Indeed, a virtual chasm has developed between the “believers” (mostly but not exclusively private practitioners who treat people with DID) and the “dis-believers” (mostly but not exclusively the more academic and science-oriented mental health professionals). The disbelievers are very sympathetic to people suffering DID symptoms, but they have tended to doubt that the disorder is usually caused by childhood abuse and have challenged the validity or accuracy of recovered memories of abuse (see Loftus & Davis, 2006 , for a review of the recovered memory debate).
For 20 years, these controversies have moved beyond professional debate and have become major public issues, leading to countless legal proceedings. DID patients who recover memories of abuse (often in therapy) have often sued their parents for having inflicted abuse. But ironically, therapists and institutions have also been sued for implanting memories of abuse that they later came to believe had not actually occurred. Some parents, asserting they had been falsely accused, formed an international support organization—the False Memory Syndrome Foundation—and have sometimes sued therapists for damages, alleging that the therapists induced false memories of parental abuse in their child. Many families have been torn apart in the fallout from this remarkable climate of suspicion, accusation, litigation, and unrelenting hostility.
Whether DID originates in childhood abuse and whether recovered memories of abuse are accurate are basically separate issues, but they have tended to become fused in the course of the debate. Hence those who doubt the validity of memories of abuse are also likely to regard the phenomenon of DID as stemming from the social enactment of roles encouraged or induced—like the memories of abuse themselves—by misguided therapy (e.g., see Bjorklund, 2000 ; Lilienfeld et al., 1999 ; Lynn et al., 2004 ; Piper & Merskey, 2004a , 2004b ). Believers, on the other hand, have usually taken both DID and the idea that abuse is its cause to be established beyond doubt (e.g., see Gleaves, 1996 ; Gleaves et al., 2001 ; Ross, 1997 , 1999 ).
Much of the controversy about the validity of recovered memories is rooted in disagreements about the nature, reliability, and malleability of human autobiographical memory. With some exceptions, evidence for childhood abuse as a cause of DID is restricted to the “recovered memories” (memories not originally accessible) of adults being treated for dissociative experiences. Believers argue that before treatment such memories had been “repressed” because of their traumatic nature or had been available only to certain alter identities that the host identity was generally not aware of. Treatment, according to this view of believers, dismantles the repressive defense and thus makes available to awareness an essentially accurate memory recording of the past abuse.
Disbelievers counter with several scientifically well-supported arguments. For example, scientific evidence in support of the repression concept is quite weak (e.g., Kihlstrom, 2005 ; Loftus & Davis, 2006 ; Piper, 1998 ). In many alleged cases of repression, the event may have been lost to memory in the course of ordinary forgetting rather than repression, or it may have occurred in the first 3 to 4 years of life, before memories can be recorded for retrieval in adulthood. In many other cases, evidence for repression has been claimed in studies where people may simply have failed to report a previously remembered event, often because they were never asked or were reluctant to disclose such very personal information (Kihlstrom, 2005 ; Loftus & Davis, 2006 ; Pope et al., 1998 ).
Even if memories can be repressed, there are very serious questions about the accuracy of recovered memories. Human memory of past events does not operate in a computer-like manner, retrieving with perfect accuracy an unadulterated record of information previously stored and then repressed. Rather, human memory is malleable, constructive, and very much subject to modification on the basis of events happening after any original memory trace is established (Loftus & Bernstein, 2005 ; Loftus & Davis, 2006 ; Schacter et al., 2000 ).
Indeed, there is now good evidence that in certain circumstances, people are sometimes very prone to the development of false memories (see Wade et al., 2007 , for a review). For example, a number of studies have now shown that when normal adult subjects are asked to imagine repeatedly events that they are quite sure had not happened to them before age 10, they later increase their estimate of the likelihood that these events actually had happened to them (Tsai et al., 2000 ). Moreover, even in a relatively short time frame, adult subjects sometimes come to believe they have performed somewhat bizarre acts (e.g., kissing a magnifying glass), as well as common acts (e.g., flipping a coin), after simply having imagined they had engaged in these acts several times 2 weeks earlier (Thomas & Loftus, 2002 ). These and other studies clearly show that repeated imagining of certain events (even somewhat bizarre events) can lead people to have false memories of events that never happened (Loftus & Bernstein, 2005 ; Loftus & Davis, 2006 ). In addition, an experimental study by McNally and colleagues ( 2005 ) looked at individuals who reported either repressed or recovered memories of childhood sexual abuse and found some evidence that they had greater difficulty on at least some measures than normal controls in distinguishing between words that they had seen versus words that they had only imagined. This suggests that people with repressed or recovered memories of abuse may have greater difficulty distinguishing between what has actually happened to them and what they have imagined happened to them. However, a different study found that those who report recovered memories of childhood sexual abuse did not show increased difficulty retrieving non-abuse-related autobiographic memories compared to those who reported continuous memories of childhood sexual abuse or a control group reporting no childhood sexual abuse (Raymaekers et al., 2010 ).
One fascinating study compared a group of people who had continuous memories of childhood abuse with two groups who had recovered memories of abuse. In one of the latter groups the memories had been recovered during therapy and in the other the memories had been recovered out of therapy. The researchers then attempted to corroborate these recovered memories, and found corroborative evidence for over half of those who had recovered memories outside of therapy and for none in the group who recovered their memories during therapy (Geraerts et al., 2007 ).
Recently, McNally and Geraerts ( 2009 ) offered a different perspective on recovered memories, one that attempts to bridge the gap between the conviction that repression underlies recovered memories and the alternate conviction that all recovered memories are false. Their third perspective suggests that some recovered memories are genuine but were never actually repressed. Instead, some abuse victims may simply not have thought about their abuse for a long period of time, have been deliberately attempting to forget the abuse (suppression rather than repression), or may have forgotten prior instances when they did recall the abuse, resulting in the false impression that a recently surfaced memory had been repressed for years.
· 8.1 What are somatic symptom disorders?
· • Somatic symptom disorders lie at the interface of abnormal psychology and medicine. These are disorders in which psychological problems are manifested in physical symptoms. In response to the symptoms the person also experiences abnormal thoughts, feelings, and behaviors.
· • Somatic symptom disorder occurs in individuals who have had multiple somatic complaints lasting at least 6 months. Even if the symptoms do not seem to have a medical explanation, the person’s suffering is regarded as authentic.
· 8.2 What is illness anxiety disorder?
· • Illness anxiety occurs in individuals who are very anxious about having an illness even though there are no apparent symptoms.
· 8.3 What is conversion disorder (functional neurological symptom disorder)?
· • Conversion disorder involves patterns of symptoms or deficits affecting sensory or voluntary motor functions leading one to think there is a medical or neurological condition, even though medical examination reveals no physical basis for the symptoms.
· 8.4 What is the difference between a factitious disorder and malingering?
· • Individuals with factitious disorder intentionally produce medical or psychological symptoms (or both). They do this in the absence of external rewards in order to take on an illness role.
· • Malingering involves the intentional production of symptoms or the exaggeration of symptoms. This is motivated by external factors such as a wish to claim insurance money, avoid work or military service, or to get leniency in a criminal prosecution.
· 8.5 What are the primary features of dissociative disorders?
· • Dissociative disorders occur when the processes that normally regulate awareness and the multichannel capacities of the mind apparently become disorganized, leading to various anomalies of consciousness and personal identity.
· 8.6 What is depersonalization/derealization disorder?
· • Depersonalization/derealization disorder occurs in people who experience persistent and recurrent episodes of derealization (losing one’s sense of reality of the outside world) and/or depersonalization (losing one’s sense of oneself and one’s own reality).
· 8.7 What is dissociative amnesia?
· • Dissociative amnesia involves an inability to recall previously stored information that cannot be accounted for by ordinary forgetting and seems to be a common initial reaction to highly stressful circumstances. The memory loss is primarily for episodic or autobiographical memory.
· 8.8 What is dissociative identity disorder?
· • In dissociative identity disorder, the person manifests at least two or more distinct identities that alternate in some way in taking control of behavior. Alter identities may differ in many ways from the host identity.
· alter identities 281