Etiology and Introduction

Overview
Since the 1980s, the concept of dissociative disorders has taken on a new significance. They now receive a large amount of theoretical and clinical attention from persons in the fields of psychiatry and psychology. Dissociative disorders are a group of psychiatric syndromes characterized by disruptions of aspects of consciousness, identity, memory, motor behavior, or environmental awareness. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) includes 4 dissociative disorders and one category for atypical dissociative disorders. These include dissociative amnesia (DA), dissociative identity disorder (DID), dissociative fugue, depersonalization disorder, and dissociative disorder not otherwise specified (DDNOS).[1]

Case Studies
Dissociative amnesia A 29-year-old female experienced the onset of dissociative amnesia during an academic trip to China.[2] She was found in a hotel bathroom unconscious, with no signs of structural or neurologic abnormalities or alcohol or chemical consumption. The woman was sent home but could not remember her name, address, family, or any facts about her home life. The amnesia persisted for nearly 10 months, until the feeling of blood on the woman's fingers triggered the recollection of events from the night of onset of dissociative amnesia, and, subsequently, other facts and events. The woman finally remembered having witnessed a murder that night in China. She recalled being unable to help the victim out of fear for her own safety. She came to remember other aspects of her life; however, some memories remain unretrievable. Dissociative identity disorder In a case of dissociative identity disorder, a woman who had been physically and sexually abused by her father throughout her childhood and adolescence exhibited at least 4 personalities as an adult. Each personality was of a different age, representing the phases of the woman's experience a fearful child, a rebellious teenager, a protective adult, and the woman's primary personality. Only one of the personalities, the protective adult, was consciously aware of the others, and during therapy sessions was realized to have been developed to protect the woman during the abusive experiences. When one of the secondary personalities took over, it often led to episodic dissociative amnesia, during which the woman acted out according to the nature of the dominating personality. During intensive therapy sessions, each personality was called upon as necessary to facilitate their integration. Dissociative fugue Commonly, individuals who experience the onset of dissociative fugue are found wandering in a dazed or confused state, unable to recall their own identity or recognize their own relatives or daily surroundings. Often, they have suffered from some post-traumatic stress, as in the case of a 35-year-old businessman who disappeared more than 2 years after narrowly escaping from the World Trade Center attack in 2001, leaving behind his wife and children. The man was missing for more than 6 months when an anonymous tip helped police in Virginia identify him. Depersonalization disorder

Depersonalization disorder generally leads to observable distress in the affected individual. It often occurs in individuals who are also affected by some other psychological nondissociative disorder, as in the case of a 19-year-old college student who was suffering from sleep deprivation at the onset of depersonalization disorder. The young man experienced increased anxiety as he struggled to meet his responsibilities as a scholarship-dependent student athlete. Teammates expressed concern about his apparent distress to their coach who arranged for the young man to speak with a therapist. The young man described feeling as though he were observing the interactions of others as if it were a film. The young man's anxiety was determined to contribute to severe sleep deprivation, which triggered episodes of depersonalization. Pathology From a psychological perspective, dissociation is a protective activation of altered states of consciousness in reaction to overwhelming psychological trauma. After the patient returns to baseline, access to the dissociative information is diminished. Psychiatrists have theorized that the memories are encoded in the mind but are not conscious, ie, they have been repressed. In normal memory function, memory traces are laid down in 2 forms, explicit and implicit. Explicit memories are available for immediate and conscious recall and include recollection of facts and experiences of which one is conscious, whereas implicit memories are independent of conscious memory. Further, explicit memory is not well developed in children, raising the possibility that more memories become implicit at this age. Alterations at this level of brain function in response to trauma may mediate changes in memory encoding for those events and time periods. Dissociation is also a neurologic phenomenon that can occur from various drugs and chemicals that may cause acute, subchronic, and chronic dissociative episodes.

Dissociative Amnesia
The essential feature of dissociative amnesia is an inability to recall important personal information that is more extensive than can be explained by normal forgetfulness. Remembering such information is usually traumatic or produces stress. DSM-IV-TR diagnostic criteria for dissociative amnesia include a predominant disturbance of one or more episodes of an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. Also, the disturbance does not occur exclusively during the course of dissociative identity disorder, dissociative fugue, posttraumatic stress disorder (PTSD), acute stress disorder, or somatization disorder and is not due to the direct physiological effects of a substance or of a neurological or other general medical condition. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Different types of memory loss have been identified in persons with dissociative amnesia. These include localized, generalized, continuous, and systematized amnesia. Localized amnesia occurs when patients cannot remember certain time periods or events such as experiences in battle or situations of torture. Generalized amnesia occurs when patients cannot remember anything in their lifetime, including their own identity. Continuous amnesia occurs when patients have no memory of events up to and including the present time. This means that patients are alert and aware of their surroundings but are not able to remember anything. Systematized amnesia occurs when patients have a loss of memory for certain categories of information, such as certain places or persons.

Mental status
Patient is alert and oriented. Patient is subadequately related with limited eye contact. Speech is slow and logical. Attention and concentration are limited. Energy level is not characterized by hyperactivity or slowing. Recent memory may be slightly impaired. Remote memory is intact. Mood is anxious or dysphoric. Affect is constricted. A negligible degree of conceptual disorganization is present. Reasoning and judgment are limited, and insight is lacking. An increased likelihood of passive suicidal ideation as well as violent ideation, sometimes even homicidal, is present, most likely due to severe frustration of the dissociation. Patients present with symptoms and behaviors that help determine their condition and subsequent diagnosis. Two factors help distinguish between the forms of dissociative amnesia present in the patient. The first is a sudden, dramatic disturbance in which a vast amount of memories related to personal information are not available for conscious verbal recall. Although this presentation is rare, it is frequently featured in the media and is portrayed as a common occurrence. Patients with this manifestation often present in the emergency department or at neurology departments because the acute onset of memory loss requires immediate medical assessment. Patients present as disoriented, perplexed, and in a purposeless, wandering state. For example, one young lady, who discovered her boyfriend of 1 year was married with 2 children, handled the information by forgetting who she was for several weeks. The second is a more common presentation and is a patient with a deletion of a large aspect of personal history from the conscious memory. These patients ordinarily do not complain of memory loss, and their condition is usually discovered after obtaining a thorough life history. Dissociative amnesia usually has a clear-cut onset and finish. This means that the patient is aware of the deletion in continuous memory, as opposed to a gradual loss of normal memory. For example, patients may not remember a certain year of schooling or a certain job, even though they remember other years of schooling and other jobs. This is usually due to a traumatic experience during that time period, such as a rape or a kidnapping. In extreme cases, patients cannot remember their teenage years or other periods of their lifetime. An acute onset of dissociative amnesia usually begins after a psychologically stressful life event that threatens the patient physically or emotionally (eg, a patient who is a victim of a rape or who is witness to the accidental death of a loved one). Onset and termination of the amnesia are usually abrupt. Patients usually recover the memory after proper treatment, but sometimes the patient develops a chronic form of amnesia. Unfortunately, some patients develop dissociative

amnesia as an alternative to suicide, and if the memory is recovered without proper psychotherapy, patients can be at risk for suicide. Dissociative amnesia occurs in 2-7% of the general population and has a high occurrence in those involved in wars, in patients with a history of child abuse or sexual abuse, in survivors of concentration camps, in victims of torture, and in survivors of natural disasters. Studies have shown that the extent of trauma is correlated with the development of amnesia.[3]

Differential diagnoses
The differential diagnoses of dissociative amnesia are any organic mental disorders, dementia, delirium, transient global amnesia, Korsakoff disease, postconcussion amnesia, substance abuse, other dissociative disorders, and malingering factitious disorder. Memory loss in organic mental disorders is typically gradual and incomplete. Clinicians may encounter difficulty in differentiating substance abuse and dissociative amnesia because many patients minimize their abuse and also misattribute their amnesia to alcohol or drugs because of fear of a diagnosis of dissociation. Obtaining a careful history from multiple informants is often necessary to clarify the situation. However, unlike dissociative amnesia, memory loss due to substance abuse is seldom reversible. Korsakoff disease may also be confused with dissociative amnesia. This disease, also known as alcohol amnestic disorder, is associated with heavy and prolonged alcohol abuse and is not associated with psychological stress. However, unlike dissociative amnesia, patients with Korsakoff disease are not able to learn new information and they often experience significant deterioration in personal functioning. Amnesia from brain injury or head trauma can be differentiated from dissociative amnesia based on a history of trauma; patients usually have retrograde amnesia before the trauma, unlike patients with dissociative amnesia, who have anterograde amnesia. In addition, patients with brain injury do not show the susceptibility or response to hypnosis so frequently observed in patients with dissociative disorders. Because dissociative disorders are associated with some evidence of biological causality, not every case of trauma results in symptoms that produce the disorder, nor does every person with the disorder have a history of childhood or adult trauma.

Indications for hospitalization

In most instances in which patients present a clear and present danger to themselves or others, when medication effects must be evaluated, and in instances in which a diagnosis has not been determined, hospitalization is often necessary. Hospitalization allows patients to separate themselves from the environmental stimuli, sexual and physical abuses, and stresses that may be contributing to their reactions and episodes of amnesia, compulsive behaviors, and recklessness. It also protects them during a perplexing period of their lives when they honestly do not know who they are. Other indications are suicidal behavior or gesturing. Patients may experience problems with concentration and feelings of rejection, reoccurrence of preexisting psychiatric conditions, intrusive reexperiencing of trauma or negative thinking, feelings of emotional overwhelm, paranoia or general distrust, and episodes of schizophrenia and fear.

Treatment

Importantly, when psychotherapeutic techniques are applied in treatment, do not overwhelm patients with the force of intervention and the speed at which recovery is estimated to occur. Hence, in psychotherapy, timing and progressing at the appropriate speed are critical. Many cases of dissociative amnesia resolve spontaneously when the individual is removed from the stressful situation. The treatment of choice for dissociative amnesia is psychotherapy with augmentation by hypnosis or drug-facilitated interview. Patients with dissociative amnesia frequently have comorbid disorders of mood and anxiety disorders and PTSD. These disorders should be treated with pharmacological agents. Currently some of the new antiepileptic agents in combination with SNRIs, SSRIs, and atypical neuroleptics in more severe cases. Hypnosis as a treatment process is supported by the state-dependent learning theory, in which therapeutic hypnosis is undertaken in a context of a consenting contract and is guided by the therapist. It has been viewed as a controlled form of dissociation; therefore, clinicians assume that the mental content and images that emerge are also controlled and that the patient can control the pace of the therapy. Although hypnosis is helpful, it is not necessary for recovery of historical material or for dealing with that which is recovered. It can be used as a vehicle to gain confidence in the patient. Self-hypnosis methods are available that help the patient apply some control over the pace and style of therapy. According to Freud, the unconscious is affected by external stimuli on many levels; therefore, the suggestions made by medical practitioners to their patients influence the processing of information, traumatic memories, and patients' perception of their own experiences. For this reason, hypnosis can be a valuable tool for helping heal the trauma and assessing or retrieving additional historical data, which may clue the practitioner into the patient's needs and developmental health. This is not always the case when dealing with dissociative amnesia. Freud indicated that trauma depletes the ego of the patient when he or she is overstimulated. In this way, providing the patient with tools to rebuild the ego is imperative to better mental health and appropriate behavior. The unconscious is stimulated in hypnosis; therefore, the patient has the opportunity to recover lost memories, if needed, and piece together the past. As a result, the incidence of patients claiming they remember old, forgotten, and remote episodes of childhood abuse is increasing, so much so that it has created controversy in this diagnostic group. Studies have shown that as many as 38% of victims of abuse who require a hospital visit did not recall the abuse 20 years late

Dissociative Identity Disorder

Dissociative identity disorder, formerly referred to as multiple personality disorder, is characterized by the existence of 2 or more identities or personality traits within a single individual. Patients with this disorder demonstrate transfer of behavioral control among alter identities either by state transitions or by inference and overlap of alters who manifest themselves simultaneously. It is observed in 1-3% of the general population.

Mental status
Patient is alert and oriented in all spheres. Affect may be labile or irritable. Mood is euthymic or anxious.

 Relatedness is very limited, and eye contact is frequently minimal. Thought content may be characterized by significant hypervigilance, preoccupations, or hallucinations. Patient appears fixed on extraneous or internal stimuli. Reasoning and judgment are diminished and insight is poor. An overall increased incidence of both suicidal and homicidal ideation in these patients is present. Orientation is frequently off. Long-term memory is poor. DSM-IV-TR diagnostic criteria for dissociative identity disorder include the presence of 2 or more distinct identities or personality states, with at least 2 of these identities or personality states recurrently taking control of the person's behavior. Also, the inability of the patient to recall important personal information is too extensive to be explained by ordinary forgetfulness. In addition, the disturbance is not due to the direct physiologic effects of a substance or a general medical condition. Importantly, note that symptoms in children are not attributable to imaginary playmates or other fantasy play. The dramatic and extreme patients with dissociative identity disorder depicted in the media probably represent fewer than 5% of patients with this disorder. Most patients with dissociative identity disorder have a covert and subtle presentation. The typical clinical presentation is one of a refractory psychiatric disorder, usually a mood disorder, or with multiple somatic symptoms. Patients have often received several psychiatric diagnoses over many years of treatment, such as bipolar disorder[4] , PTSD, personality disorders, or various anxiety disorders. Alter-identities vary in complexity and psychological structure. In some patients, highly developed alter-identities are present with marked presentational differences in posture, voice, mood, energy, interests, talents, capacities, manifest age, and even sex. However, in most cases, the alter-personalities are relatively limited in their depth and do not manifest dramatic differences. In general, all alter-identities should be held responsible for the behavior of each of the other alter-identities, despite subjective amnesia to the behavior. Dissociative identity disorder is thought to begin in childhood in response to repeated traumatic and/or overwhelming life experiences, most of which involve physical and sexual abuse. Other traumatic events include long and painful childhood medical experiences and wartime dislocation. In studies of patients with dissociative identity disorder, a range of 70% of patients to more than 95% of patients reported childhood abuse. However, some patients cause controversy because they revise their histories as treatment progresses. Patients with dissociative identity disorder typically also have dissociative amnesia. They cannot remember important life events. They have blackout phases and also experience fluctuations in personalities and talents. Some patients actually have variable blood pressures, blood glucose levels, changes in visual acuity, and variable responses to drugs and treatments with the shifting of identities. Most patients with dissociative identity disorder are diagnosed in adulthood. However, with new knowledge and awareness of the sequela of abuse, patients are now being diagnosed in childhood and adolescence.

The current view is that dissociative identity disorder is a developmental posttraumatic disorder usually starting before age 6 years, although it is diagnosed much later. Traumatizing circumstances and poor relationships with caretakers disrupt the normal consolidation of personal identity across shifts in state, mood, and personal and social context. These traumatic memories are encapsulated to permit development in other areas of life such as academics and social life. These entities show some development separate from other identities. The outcome is a person embodying a number of relatively concrete independent self-states. These self-states are often in conflict with each other.

Differential diagnoses
When diagnosing dissociative identity disorder, clinicians should also consider other disorders such as other dissociative disorders, mood disorder, personality disorder, schizophrenia, seizure disorder, eating disorders, malingering, and factitious disorders. Schizophrenia is in the differential diagnosis because patients often hear voices; the difference is that they hear voices within their heads, not from outside. Careful history taking to recognize chronic amnesia, symptoms of PTSD, a history of maltreatment, and the presence of alter identities may allow making a diagnosis of dissociative identity disorder even if other comorbid disorders are observed.

Indications for hospitalization

The treatment of dissociative disorders is difficult and time-consuming and is mostly enacted via behavioral modifications through outpatient therapy. However, in extreme cases or when physical or emotional harm is imminent, hospitalization may be a required intervention. Some of the indications for inpatient assessment or hospitalization include severe depression over a long period, anxiety and delusion disorders that lead to compulsive acting out of behaviors, cognitive reactions (eg, nightmares, flashbacks), physical reactions, fatigue, and interpersonal reactions (eg, conflict, problems with mood regulation, antisocial behavior, physical aggressiveness, suicidal behavior, traumatic and schizophrenic episodes). The ultimate goal for hospitalization of a patient is to ensure immediacy in restoring safety and stability. The patient remains at risk as long as no change in behavior or in approach for generating behavior modifications to improve response to stress and quality of life occurs.

Treatment
In general, dissociative identity disorder is treated as a complex, chronic, trauma-based disorder. Accordingly, a developmental process of re-educating patients is used in treatment. The primary goals are encouraging healthy coping behaviors, logging and monitoring emotions, and developing a crisis plan. Kluft found that in patients with dissociative identity disorders, treatment of traumatic memories appears crucial in the recovery process, even though the reported memories may not be historically accurate.[5] The ultimate goal of psychotherapy is to bring together all the facets of the person into 1 individual. In developing healthy coping behavior, positive affirmations, 12-step group participation, group therapy, and developing hobbies and interests all may be part of the plan. Patients may learn the importance of setting goals, keeping time schedules, and being organized. Unfortunately, when triggers occur at an early enough age, they may be encompassed in the developing personality, and may be ingrained into personality disorders (ie, borderline personality disorder).

In logging and monitoring emotions, patients may keep a journal in which they write down their feelings at different parts of the day, foods consumed, and activities engaged in and the feelings or effects on their mood and desire to participate in activities. In this way, patients begin to identify possible triggers and make appropriate decisions regarding whether or not a possible trigger activity is worth the risk of their comfort or stability. Lastly, developing a crisis plan may be extremely important in responding to situations that begin to feel out of control for the patient. In the crisis plan, when prevention is too late, the patient can self-soothe by having a specific, easy-to-follow plan for calming down and easing their emotional burden. The plan may include physical activity, focusing exercise, meditation, calling a specific person, or listening to a particular piece of music. The goal is essentially to allow patients to calm themselves, become able to learn from the experience, and try to not repeat the provoking behavior. A case example is a 33-year-old woman with a history of sexual, physical, and emotional trauma. She has a crisis plan for dealing with her anger and grief. During episodes of rage, she hits a plastic bat against a pillow until she is able to get in touch with the feelings that caused her to be overwhelmed. Once she is aware of the emotions that have caused the anger response, she writes about the pain and shares it with a trusted friend over the telephone. In dealing with grief, she has a plan that includes listening to soothing music, crying, holding her cat or a favorite stuffed animal, and rocking until she feels soothed enough to have a discussion with a friend or therapist about the experience that caused her grief. The patient sometimes resents the level of commitment required for caring for herself, but she realizes that accepting her situation is more productive than the alternative, which may be increased dosages of medication or inpatient treatment if she does not reduce the number and intensity of her episodes.

Dissociative Fugue
Dissociative fugue is characterized by sudden, unexpected travels from the home or workplace with an inability to recall some or all of one's past. Some of these patients assume a new identity or are confused about their own identity. They seem to be running away from something of which they are unaware. After the fugue episode resolves, patients are unable to remember the events of the state. Although moving occurs in other disorders, in fugue it is purposeful and is not enacted in a confused or dazed state. In a typical case, the fugue is brief, with purposeful travel, and with limited contact with others. Approximately 0.2% of the general population has dissociative fugue.

Mental status
The mental status exam varies widely. Patient may present alert and oriented only to self. Eye contact and relatedness are limited to fair at best. Psychomotor activity is characterized by normal activity. Thought processes are intact, although thought content may vary widely from preoccupations to perseverations to obsessive fixations to none.

 Reasoning and judgment are lacking, and insight is poor. An increased finding of violent or homicidal ideation is present, but suicidal ideation is lacking. DSM-IV-TR diagnostic criteria for fugue require that the predominant disturbance is sudden, unexpected travel away from home or one's workplace coupled with the inability to recall one's past. Also, the person has confusion about personal identity or assumes a new identity. The disturbance does not occur exclusively during the course of dissociative identity disorder and is not due to the direct physiologic effects of a substance or medication. The symptoms also must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. An episode of fugue often starts in the context of psychological stress such as social dislocation or war. Usually, the fugue lasts for a few days; occasionally, it may last months, with a few extreme cases noted.

Differential diagnoses
Dissociative fugue includes other dissociative disorders, seizure disorder, amnestic disorder, schizophrenia, mania, dementia (often of the Alzheimer type), malingering, frontal lobe disorders, head trauma and injury, and factitious disorder. Fugue differs from other mental disorders in that the flight behavior is organized and purposeful. Patients with seizure disorder do not assume a new identity and usually have an altered state of conscious with abnormal findings on electroencephalogram testing.

Indications for hospitalization

In making a primary diagnosis, observing the patient in a controlled setting is often necessary. Patients reveal their level of need through interactions with others, inappropriate behavior without remorse, or by verbalizing their symptoms when they are aware of their suffering. In general, hospitalization is indicated when medical or surgical treatment is required, when the diagnosis is unclear, when no safe alternative exists for housing the patient, or as a means of stopping the ongoing abuse. Additionally, any time a patient experiences severe confusion regarding his or her identity or chronic amnesia regarding the total fugue episode, hospitalization is indicated. Hospitalization is also a tool for assessing and administering social services and medication, developing behavior, and ensuring that a patient will respond to medication under the safety and care of medical professionals. And, of course, hospitalization provides containment. Most patients with dissociative fugue symptoms receive acute treatment in general hospital settings and psychiatric departments because they have a tendency to be brought in during an episode. In this way, the hospital provides the safety and treatment mechanism needed for a disorder that, without intervention, remains undiagnosed. Hospitalization most often occurs in order to provide emergency crisis treatment that is best provided in an acute care setting.

Treatment
Although patients with dissociative fugue often recover spontaneously, medical observation may serve the patient in providing insight and safety during the episode. Patients should be treated with psychotherapy with additional hypnosis and psychopharmacology in order to allow integration of feelings, anxieties associated with the fugue, and recovery techniques. Treatment addresses the many symptoms, ranging from schizophrenia to mania to seizure disorders. Medication and cognitive therapies in combination tend to provide the best overall treatment

approach for fugue, allowing patients to understand their symptomology and the risks involved and to address their discomfort. More development of therapeutic techniques are being researched and used

Depersonalization Disorder
Derealization or depersonalization is characterized by feelings that the objects of the external environment are changing shape and size, or that people are automated and inhuman, and features detachment as a major defense. Depersonalization disorder usually begins in adolescence; typically, patients have continuous symptoms. Onset can be sudden or gradual. An estimated 2.4% of the general population meets the diagnostic criteria for this disorder. However, the prevalence rate is questioned by many clinicians and may be lower. This disorder frequently coexists with mood, anxiety, and psychotic disorders.

Mental status
Patient presents alert and disoriented in some spheres. Both relatedness and eye contact are limited. Patient may appear preoccupied and irritable. A distressed facial expression with constricted affect is characteristic. Reasoning, judgment, and insight are fair to limited. The DSM-IV-TR defines depersonalization disorder as the occurrence of persistent or recurrent episodes of depersonalization and/or derealization that are not related to any other mental disorder and cause marked distress. Depersonalization is defined as persistent or recurrent experiences of feeling detached, as if one is an outside observer of one's mental processes or body. Results from reality testing are usually normal during the experience. The episodes cause clinically significant distress and/or impairment in social, occupational, and other main areas of functioning. The depersonalization does not occur exclusively during the course of another mental disorder and is not due to direct effects of substance abuse or general medication.

Treatment
Unfortunately, at this time, a specific and effective treatment plan has not been developed for depersonalization disorder. Studies show that psychotherapy and medications are not effective. Reports indicate that some patients respond to selective serotonin reuptake inhibitors or benzodiazepines. Further studies are needed to find an effective treatment regimen. At his time, the most viable treatment is to assist the patient in achieving comfort and stability, away from traumatic interactions.

Unspecified Dissociative States

DDNOS is a category of disorders that manifest with dissociative symptoms but fail to meet the diagnostic criteria for any of the dissociative syndromes described. An example of DDNOS is Ganser syndrome. This entity occurs primarily in men (80%) and is currently regarded as a dissociative means of withdrawal from a traumatic or stressful circumstance. It is characterized by absurd or approximate responses to interview dialogue, a dazed or clouded level of consciousness, somatic conversion symptoms (eg, pseudoparalysis), hallucinations, and,

frequently, anterograde amnesia regarding the episode. Patients who demonstrate this phenomenon characteristically have an underlying cluster B personality disorder and, as such, may have a past history of abuse or other trauma. In general, these patients are at higher risk for dissociative symptoms when under stress.

Psychopharmacology
The atypical neuroleptics, such as aripiprazole (Abilify), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon), are the accepted mode of treatment for dissociative disorders. Newer-generation anticonvulsants are also highly effective. Quetiapine is initiated at 25-50 mg PO bid and increased by 50 mg PO bid q3d until symptom resolution is achieved. The higher dose should be administered nightly because of the strong sedating histaminergic effects of the medicine. Other medications such as SSRIs (ie, escitalopram andparoxetine mesylate) and SNRIs (ie, duloxetine and venlafaxine) may reduce the anxiety and apprehension of the dissociation. Keppra (levetiracetam) may be effective in treating dissociation. Doses are usually kept much lower than for the treatment of seizure disorders. Lamotrigine (Lamictal) started at 25 mg and increased by 25 mg every 2 weeks is another option. The effects of these novel anticonvulsants is thought to be secondary to GABA modulation.

Patient and Family Education

In recognizing and diagnosing dissociative disorders, relating information to the patient in a productive and sensitive manner is important. Significantly effective treatment for the disorder has not been established; however, methods exist to address and educate patients to foster appropriate self-care and independence and to positively affect their quality of life and level of comfort. First, patients are taught techniques to manage symptoms and stabilize their dysfunctional lives. A broad range of psychotherapies may be used, including cognitive behavioral, psychodynamic, supportive therapies, and hypnotherapy. According to Chefetz et al, somatosensory free association and appreciation of experiential aspects of depersonalization, derealization, and dissociative amnesia open new areas of negotiation between the therapist and the patient.[6] Family members benefit from coming into sessions to understand, reassure, and provide corroboration. Pharmacological interventions can be used to treat comorbid affective, anxiety-related, and PTSD conditions. After stabilization, some patients elect intensive psychotherapy to process their traumatic memories. Clinicians should exercise caution; premature intensive focus on trauma before symptoms are properly stabilized can lead to regression or decompensation. Finally, when trauma issues are fully resolved, patients should be focused on successful living without domination by posttraumatic conditions. Most patients benefit from and need to be taught to abstain from participation in dangerous and stressful activities to reduce triggering episodes. Patients with all forms of amnesia in which trauma is present are given opportunities to develop a solid connection to others and to their healthy adult experiences and assistance with soothing the anxiety that often accompanies their amnesia. Patients are encouraged to develop coping skills that will sustain them during times of stress and difficulty. Imperative to their social survival is becoming somewhat vigilant at protecting themselves from additional trauma and harm. Therefore, patients are assisted with

developing crisis plans and building their self-awareness specifically so that they may protect themselves. As such, tracking emotional reactions and mood changes becomes integral in the assessment and prevention of future amnesic episodes. In patients in whom hypnosis is helpful, patients are assisted in developing appropriate activities to build self-esteem and commitments to allow them to maintain their successes and continue to gain social attachment and identity. Patients who are taught self-hypnosis techniques may also be encouraged to use positive affirmations, self-help books, and group therapy to continue to build necessary self-awareness and to develop interpersonal relationships with others. Assume that the patient will regress at times and have a reoccurrence of loss of memory. Therefore, give patients an emergency plan to help themselves when they are in compromised states. Teach them to build social alliances, inform others of their potential for episodes of memory loss, and develop boundaries to protect their vulnerability and allow them to grow in the areas in which they were stunted by early trauma. Overall, physicians should encourage the patient to develop healthy behavior; learn self-control; adapt to environmental stresses; and make rational, nonimpulsive decisions to avoid additional stress, abuse, and revisiting the terror of the past. Patients with dissociative amnesia, dissociative identity disorder, or dissociative fugue may benefit from psychotherapy and behavior modification. In these instances, patients are generally enrolled into one-on-one and group treatment, when beneficial, to begin building self-awareness and patterning for healthy social and interpersonal relationships. In addition, their families and significant others benefit for explanations of the problem, thus allowing them to better support individuals in psychotherapy. The family members should join support groups not only to learn and acknowledge that the disorder is limiting, but also to recognize symptoms that arise periodically that may be part of the complex. Family therapy, along with the individual, leads to a more level and smooth transition to recovery. These patients also may benefit from the use of medication as maintenance during the therapeutic process. When indicated, patients are taught to manage their medication and take it regularly. The risks of taking medication improperly should be discussed in detail to assist the patient in understanding the risks of stopping their pharmacotherapy without physician assistance.

Educational and support resources for patients and families

A number of organizations provide access to information about dissociative disorders online. The following Web sites may be of use to patients and their families: MayoClinic.com, Dissociative disorders Sidran Institute: Traumatic Stress Education & Advocacy, What is Dissociative Disorder? Cleveland Clinic, Dissociative Amnesia (includes links to information on all 4 dissociative disorders) National Alliance on Mental Illness, Dissociative Disorders (The NAMI site provides information on support resources and programs.) The following support Web sites may also be useful to patients and/or their families: PsychLinks Online, Psychology and Self-Help Forum

 PsychForums.com

Medicolegal Pitfalls
As with all other fields of medicine, medical liability and lawsuits are beginning to make a big impact on clinicians in the field of psychiatry and psychology. Criminal court trials in which an adult has filed a rape accusation against a relative, stating that the incident or incidents took place years ago but the memories were repressed, have become increasingly common in recent years. The memories are recovered after psychotherapy. If the clinician merely inquires about a trauma history, the question of whether he or she had a suggestive influence on the patient's memory then arises. This may make the therapist vulnerable to a lawsuit. If a personality disorder such as borderline personality disorder is comorbid, that risk increases significantly. Two types of lawsuits have occurred involving dissociative disorders. In the first type, the therapist allegedly reinforces memories of abuse reported by the patient, suggesting that they must be true and that the alleged perpetrators must be confronted. Because third parties are being accused of socially unacceptable crimes, lawyers may encourage them to sue the therapist for their role in the case. The second type of lawsuit involves a patient pursuing a suit against the therapist for allegedly using suggestive techniques or improper diagnoses. These lawsuits are becoming so popular that some law firms now advertise for representation on behalf of anyone diagnosed with dissociative disorders in an action against the therapist. Even though science supports clinical practice in the field of dissociative disorders, the legal field has not been properly educated. Clinicians should learn to practice defensively in cases involving memory or dissociative disorders by keeping careful notes and by more frequent use of informed consent forms. Chart notes should be qualified as to the nature and source of the information. For example, using notation such as "the patient reports that (an incident) occurred" is more prudent (and more legally accurate) than recording a statement indicating an abuse (that has not been legally established as fact) has occurred. The possibility of suggestive influence should be taken into account by the clinician when conducting interviews and evaluating the information provided by patients.

Conclusion
Although in the past decade many questions have been answered about dissociative disorders, many more remain. The link between dissociative disorders and trauma is currently well accepted; however, studies in holocaust victims show that dissociation may not be related to all incidences of trauma. At present, a push exists to create a new category of trauma disorders that includes dissociative disorders. Hopefully, in the near future, proper treatment plans and effective regimens will be discovered for all dissociative disorders.

Dissociative Identity Disorder

Dissociation is the disruption of the normal integrative processes of consciousness, perception, memory, and identity that define selfhood. Dissociative identity disorder is increasingly understood as a complex and chronic posttraumatic psychopathology closely related to severe, particularly early, child abuse. Children who have been maltreated or abused are at risk for experiencing a host of mental health problems,

including dissociative identity disorder.[1] This condition manifests with an emergence of 2 or more personality states including auditory hallucinations, severe depression and suicidality, phobic anxiety, somatization, substance abuse, and borderline features that partially or fully predominate the psychologic function of the individual for a period. The deleterious effects of childhood abusive experiences on growth and development have been well documented and are associated with various later mental health problems. Diagnosis of dissociative identity disorder is not usually made until adulthood, long after the extreme maltreatment thought to engender the condition has occurred. Therefore, although the most common cause of the disorder is agreed to be early, ongoing, extreme physical and/or sexual abuse, accounts of such abuse are usually provided retrospectively by the patient and lack objective verification. Researchers have shown that, in many instances, borderline personality disorder and posttraumatic stress disorder (PTSD) in adulthood may be traced to childhood abuse. The existence of significant dissociative psychopathology related to physical and sexual abuse experienced in childhood was known to clinicians in the last century. However, only recently have modern mental health practitioners begun to appreciate implications of this forgotten linkage. Clinical and research reports indicate that a history of physical and sexual abuse in childhood is more common among adults who develop major mental illness than previously suspected. Dissociation has also been linked specifically to childhood physical neglect in patients diagnosed with schizophrenia. Various degrees of dissociative disorders are recognized, ranging from passive disengagement and withdrawal from the active environment to multiple personality disorder (MPD), a severe dissociative disorder characterized by disturbances in both identity and memory and best understood as a posttraumatic, adaptive dissociative response to the fear and pain of overwhelming trauma, most commonly abuse. Fully expressed MPD is not often diagnosed as such in the pediatric population; however, other forms of dissociative disorders are not uncommon, as described in this article.

Pathophysiology
Dissociation is a psychophysiologic process that alters a person's thoughts, feelings, or actions so that, for a time, certain information is not associated or integrated with other information as it normally is. This process, which manifests along a continuum of severity, produces a range of clinical and behavioral phenomena involving alterations in memory and identity. In extreme cases, the process gives rise to a set of psychiatric syndromes known as dissociative disorders. Not all abused children develop a dissociation disorder; however, studies have shown that abused children demonstrate more dissociation than nonabused children do.[2, 3] Regarding MPD, Kluft's reports from 1984 and 1987 view the condition as a chronic dissociative PTSD originating in childhood.[4, 5] He has proposed a 4-factor theory to explain the genesis of MPD, as follows: Individuals have an innate potential to dissociate that is reflected in hypnotizability ratings. Traumatic experiences in early childhood may disturb personality development, leading to greater potential for psychodynamic dividedness.

 Individuals may be denied the chance to spontaneously recover because of continued emotional and/or social deprivation. Final presentation is shaped by psychodynamic and extrinsic factors, including psychosocial influences.

Epidemiology
Frequency
United States

True prevalence is unknown; however, dissociative identity disorder has been shown to be more common than previously thought. Abuse may be the hidden feature in patients who are the most difficult to diagnose and treat. In 1984, by studying psychiatric inpatient charts, Carmen et al and Mills et al proposed a relationship between history of abuse and certain indicators of the severity of psychiatric symptoms.[6, 7] Incidence of child sexual abuse is difficult to estimate, partly because of differences in its definition and the varied factors that can contribute to its impact, including the age of the victims (ie, very young children who are not able to verbally report it), the relationship to perpetrators, and the characteristics of the family. People who have been sexually abused are often unaware of the possible relationship between their presenting symptoms of dissociative disorder and the sexual abuse. Even when seeking psychotherapy, patients rarely disclose abuse; they may feel ashamed to talk about it. Since mandated reporting began in the 1960s, the number of reports to children's protective services (CPS) and law enforcement agencies has steadily increased. Reports of all types of abuse increased from 669,000 children in 1976 to 3 million in 1995 (1 out of every 25 children).
International

Pathological dissociation is less well known in certain parts of the world, especially in China. It can be easily detected among psychiatric patients but is much less common in general population. It is more frequent among subsamples of population with previous evidence of emotional or psychiatric trauma.

Mortality/Morbidity
An estimated 2000 children die each year of abuse. Head trauma is the most common cause of death from physical abuse. Intra-abdominal injuries from impacts are the second most common cause of death.

Race
No racial group is exempt. Abuse has been reported from most racial, religious, and socioeconomic groups of people from most geographic, educational, and occupational backgrounds. However, higher rank-ordered scores for dissociation are reported in American children.[8]

Sex
Girls experience childhood sexual abuse more commonly than boys, with a female-to-male ratio of 10:1. Girls, more than boys, are most at risk for sexual abuse. Edwards reported a significantly

higher prevalence of childhood sexual abuse in women and a significantly higher prevalence of childhood physical abuse in men.[9] However, a factor described as pathological dissociation has emerged that was predicted by participants being male.[10]

Age
Because most abuse cases occur during the preschool years, children may be particularly vulnerable to dissociation during those years. In 1991, the National Child Abuse and Neglect Data System indicated that 24% of 838,232 reports were for physical abuse and that 7% of children who were abused were younger than 1 year, 27% were younger than 4 years, and 28% were aged 4-8 years. The rate of reports decreases for older children. Early age at onset was also correlated with a higher degree of dissociation.

History
Because children normatively exhibit age-related differences in levels of dissociative behavior, exhibiting fantasy play and displaying various parts of their personalities in various settings, the clinician must determine if a particular behavior deviates from that of other children of the same age and if a child is exhibiting dissociative symptoms. Children have a much poorer sense of continuity of their behavior and the flow of time than adults do. Symptoms such as the sense of loss of time are not easy for children to discern. Even well into adolescence, children may not recognize loss of time or discontinuity of experience as unusual or abnormal experiences. In fact, discontinuity of experience is probably the norm for young children; it is consistent with the cycle through sleep and drowsy states and is developmentally appropriate for children to find themselves in new or changed surroundings without awareness of passage of time. This is qualitatively distinct from the loss of time of dissociation, during which the individual is awake. Dissociation reflects disruptions in the integration of memories, perception, and identity into a coherent sense of self. Disruptions in identity may assume the blurring of boundaries between a child's self and fantasy characters. Important to note, however, is that in young children, dissociation is often viewed as a normative process related to imagination and fantasy capacity. Dissociative phenomena are divided into 2 categories: detachment and compartmentalization. These 2 factors have diverse natures and manifest as conversion disorder, hypnosis, dissociative amnesia, and dissociative identity disorder. Dissociative identity disorder is characterized by the existence of 2 or more personalities within the individual. Clinically, only one of the personalities is present at any given moment, and one of them is dominant most of the time. The various personalities are almost always quite discrepant and often seem to be opposite. The original personality usually has no knowledge of the other personality. When a given personality is dominant and interacting with the environment, the other personalities may not perceive all that is happening. Each personality is well integrated and is a complex aggregate of unique memories, behavior patterns, and social relationships that control each individual's function during its dominant intervals. Transition from one personality to another is sudden, often dramatic, and usually precipitated by stress.

 Patients with dissociative disorder have associated borderline personality disorder, somatization disorder, major depression, PTSD, and history of suicide attempt more often than other psychiatric patients. Childhood sexual abuse, physical neglect, and emotional abuse are strongly associated with dissociative disorders. Other, more subtle, signs of dissociation may be present, such as episodes of amnesia or blackout in the absence of substance abuse, the patient referring to himself or herself as we, the patient being told by others of behavior he or she does not recall, or the patient being greeted by people he or she does not know. A patient may miss objects that cannot be accounted for or find objects or samples of strange handwriting. Fugue states, sleepwalking, and automatic writing may represent dissociation. A child who is experiencing dissociative symptoms may appear withdrawn, frightened, or uninvolved. Frequently, the child is identified as being "different" from other children, although referring clinicians, caseworkers, foster parents, and teachers are often at a loss to characterize the differences. Children with dissociative disorders exhibit a plethora of fluctuating abilities, moods, fears, and anxieties; shifting preferences; inconsistent knowledge; and other evidence of erratic access to information and skills. Auditory hallucinations are present in most children and adolescents with dissociative disorder; however, "phobic" hallucinations in severely stressed children and young adolescents do not necessarily indicate an enduring psychotic disorder and may be transient phenomena. Initial or short-term effects of abuse include early reactions occurring within the first 2 years of termination of abuse. o Emotional reactions and self-perceptions In 1981, Anderson et al reviewed clinical charts of 155 female adolescent sexual assault victims and reported psychosocial complications in 63% of them.[11] Tuft's researchers found differences in the amount of pathology reported for different age groups.[12] The highest incidence of psychopathology was found in children aged 7-13 years. Of the group aged 4-6 years, 17% met the criteria for clinically significant pathology. The following reactions are found to be common among patients who have been abused: breaking down emotional impact into specific reactions, anger and hostility, and guilt and shame. o Effects of sexual abuse on sexuality: Reactions of inappropriate sexual behavior in patients who have been sexually abused are well documented. Patients with dissociative disorder are more likely to have experienced childhood physical abuse and childhood sexual abuse than patients with other psychiatric conditions. Effects on social functioning: People who have experienced sexual abuse are also found to have problems in social functioning, including the following: School difficulties

 Truancy Running away from home Delinquency Long-term effects are noted in the same areas. o Emotional reactions and self-perceptions: Depression, anxiety, and tension are the most commonly reported long-term problems among adults who were molested as children. Impact on interpersonal relations Difficulty in parenting and responding to their own children Difficulty trusting others Fear, often undifferentiated Hostility Sense of betrayal o Effects on sexuality Problems with sexual adjustment Promiscuity (increased level of sexual behavior) o Effects on social functioning Prostitution Substance abuse

Physical
Suspect physical abuse when a child who presents with possible dissociate disorder has an injury is unexplained, unexplainable, or implausible. Bruises are the most common manifestation of child abuse and may be found on any body surface. Approximately 10% of cases of physical abuse involve burns. A burn's shape or pattern may be diagnostic when it reflects the pattern of an object or method of injury.

Causes
No evidence suggests any biological cause for dissociative identity disorders. Traumatic experiences in childhood may enhance the individual's ability to dissociate. In 1986, Putnam et al reported the highest correlative figures; 97% of patients with MPD were reported by their clinicians to have a history of abuse in childhood.[13] Sexual abuse, usually incest, was reported in 75% of those cases. Middleton provided early photographs and school reports that provided further suggestive evidence of childhood disturbance.[14] In 2001, Macifie documented that maltreated children, especially children who were physically and/or sexually abused, demonstrated more dissociation than did normally

treated children.[15] Maltreated children are at higher risk to develop dissociation compared with well-treated children. In a study of children from low-income families, authors concluded that maltreated children have illogical thought processes considered to be in the pathological range compared with well-treated children. In another study, maltreated children had less inhibition of event memory compared with well-treated children.[16, 17] Gast reported high prevalence of traumatic experiences during childhood.[18] Of the participants in this study, 85% reported some sort of childhood trauma. In Sar et al's 2004 study, the rates of reported childhood physical and sexual abuse were 44.7% and 26.3%, respectively.[19] MPD tends to have its origin in early childhood, from age 2.5-8 years, and issues arise during adolescence. Traumatic childhood experiences, especially of physical abuse and neglect, are reported to be common in people who develop MPD. How these traumatic experiences lead to a presentation of MPD in later life is unclear. The effects of exposure to situations of extreme ambivalence and abuse in early childhood may be coped with in a psychodynamic formulation by an elaborate form of denial so that the child believes the event to be happening to someone else. This process may be facilitated in childhood, a time with a rich fantasy life that often includes imaginary companions. Foster children are at higher risk to develop dissociative identity disorder in their middle childhood if there is history of early maltreatment experiences. A study by Hulette et al showed that foster children were more dissociative than others who had experienced physical and emotional abuse. They also found that dissociation is related to the number of foster placements.[20] Dissociation is also common among college students who report abusive behaviors. In a recent study, a Spanish-speaking population sample at the University of Puerto Rico was enrolled and authors identified that dissociation fully mediates the relationship between childhood abusive experiences and the Anxious Arousal and Dysfunctional Sexual Behavior scales of the Trauma Symptom Inventory.[21] Men with alcohol dependency are also at higher risk to develop dissociation and lifetime posttraumatic stress disorder if they have a history of childhood trauma.[22]

Laboratory Studies
Although no laboratory studies are specifically indicated for the diagnosis of dissociative disorder, studies can be performed to check for abuse. Obtain screening tests in all cases of bruising to rule out a bleeding diathesis, but remember that children with bleeding problems may also be abused. Screen urine and stool for blood if abdominal trauma is suspected.

Imaging Studies
As with laboratory studies, no imaging studies are indicated for the diagnosis of dissociative disorder; however, results of imaging studies can indicate abuse.

 A bone survey consisting of multiple views of the skull, thorax, long bones, hands, feet, pelvis, and spine is necessary with children younger than 2 years if abuse is suspected. If suspicion is strong, repeat the survey in 7-10 days to examine for healing or fractures not observed on the initial radiographs. Bone scanning may be of value in detecting new fractures of hands, feet, or ribs. They are not valuable in detecting skull fractures. Perform head CT scanning if the child has been severely injured. Abdominal CT scanning may reveal damage to internal organs

Medical Care
Patients who are survivors of extensive childhood abuse frequently present complicated clinical dilemmas. Dissociative episodes, flashbacks, and self-destructive and suicidal impulses are common difficulties encountered by such patients. Once the diagnosis of abuse has been made, the initial task of therapy is to detoxify the patient's environment by stopping all forms of abuse. Treatment must be geared toward trust issues, toleration of affect with the patient's understanding of himself or herself, and enabling the patient to function as effectively as possible. Encouraging healthy coping behaviors o The primary focus is to help patients learn to control and contain their symptoms. Patients must learn to deal with dissociation, flashbacks, and intense affects such as rage, terror, and despair. Embarking on a treatment plan can be dangerous if the patient has not developed ways to tolerate the emotional turmoil that arises when uncovering traumatic memories. Until the patient can learn healthy alternatives to tolerate feelings and control behaviors, he or she cannot adequately or safely undertake the exploratory work involved in uncovering and processing memories of abuse. Control is a major issue for survivors of abuse, and by learning new ways to control and contain their symptoms, patients no longer view themselves as victims of the past. The emphasis is to have patients reconnect with their sense of power. Encouraging patients to design and choose which technique to use and when to use it contributes to their sense of being in charge of themselves; patients can begin to deal correctly with feelings of helplessness. Many patients who experience loss of time through dissociation or flashbacks describe the events as being abruptly triggered. These symptoms sometimes become so severe that patients can no longer function in their usual way. One way to help patients begin to work with their sense of unpredictability is to have them keep a log of their emotions. The patients must first identify emotions. Once they have developed the ability to identify feelings, they can monitor the intensity of each feeling.

Logging and monitoring emotions o

Patients usually report a cluster of recurrent emotions such as anxiety, sadness, or rage. Quite frequently, these symptoms precede dissociation, flashbacks, selfdestructive impulses, and suicidal impulses. Patients should be coached on how to intervene long before anxiety rises to a critical level. Identifying the cause of the anxiety is also important. Teaching patients to develop a list that ranges from simple to complex activities is helpful. Once patients become engaged in the activities, the intensity of emotions usually decreases. In addition, patients feel more in control. This reconnects them to personal strengths and the choices that can be exercised. Most patients require time to learn new and effective coping skills. Emphasize that patients must practice new skills and techniques until they develop a sense of mastery. If the difficulties experienced by patients with histories of abuse are directly related to the abuse experiences, definitive treatment cannot seemingly be successful without acknowledgment of these experiences. Clinicians treating such patients may collude with them in their beliefs about themselves if unaware of the existence of the traumatic etiologies of the current disturbance.

Developing a crisis plan o

Consultations
If the reason for the dissociative disorder is likely abuse, promptly initiate appropriate medical, surgical, and mental health consultation. The law requires that a child suspected of being abused or neglected be reported immediately to CPS. Psychiatrist or behavioral/developmental pediatrician Social services representative Child abuse and sexual abuse (CASA) specialist

Medication Summary
Pharmacologic management is essentially the same as for Posttraumatic Stress Disorder in Children. If the patient is currently being abused, treatment should be appropriate for acute stress disorder.

Further Inpatient Care

Hospital admission is indicated for children in the following cases: When medical or surgical condition requires inpatient management When the diagnosis is unclear When no alternative safe place for custody is immediately available

Further Outpatient Care

If a child or adolescent is being treated, the parent or guardian must be seen. The guardian or parent must learn how to deal with the child during expression of multiple personalities or amnestic episodes.

A mental health professional with special experience in this area should provide follow-up care for these patients.

Inpatient & Outpatient Medications

Pharmacologic management is the same as for PTSD.

Deterrence/Prevention
Stopping child abuse as early as possible maximizes chances for prevention. With suspicion of abuse, siblings should undergo full examinations within 24 hours.

Complications
In 1981, Allison found criminal activity in patients with MPD.[25] Other literature also notes complications of other social problems, such as prostitution and antisocial outbursts and actions. Childhood sexual and physical abuse are highlighted as predictors of both paranoid and antisocial personality disorders. Patients with dissociative disorder also reported suicide attempts and self-mutilative behavior.

Prognosis
The prognosis in children and adolescents can vary widely among patients and between the specific types of dissociation disorder; however early treatment offers the greatest possibility of full recovery.[26] Recovery requires specially trained skilled psychiatrists who thoroughly understand the condition.

Patient Education
Patient education is of utmost importance. When patients with MPD understand what is really happening in their lives, they become excellent, cooperative patients. For excellent patient education resources, visit eMedicineHealth's Children's Health Center. Also, see eMedicineHealth's patient education articles Child Abuse and Sexual Assault.