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Dissociative disorder

Introduction
Dissociative phenomena are best understood through the term dsagrgation (disaggregation)
originally given by Janet ( 1920 ). Events normally experienced as connected to one another on a
smooth continuum are isolated from the other mental processes with which they would ordinarily
be associated. The dissociative disorders are a disturbance in the organization of identity,
memory, perception, or consciousness.
Definitions
Dissociative disorders are fascinating phenomena in and of themselves, involving the loss of or
change in identity, or memory, or a feeling of detachment from extreme and traumatic physical
events.
Etiological Implications for Dissociative Disorders
Genetics
The DSM-IV-TR suggests that DID is more common in first-degree relatives of people with the
disorder than in the general population. The disorder is often seen in more than one generation of
a family.
Neurobiological
Although available information is inadequate, it is possible that dissociative amnesia and
dissociative fugue may be related to neurophysiological dysfunction.
Several substances such as sodium lactate, metachlorophenylpiperazine have been shown to
elicit dissociative symptoms in patients with PTSD or panic disorder, but not in normal controls..
Still the relationship between trauma exposure, cortisol, hippocampus damage, memory, and
dissociation is tentative at best, and remains to be thoroughly investigated.
Psychodynamic Theory
Freud (1962) believed that dissociative behaviors occurred when individuals repressed
distressing mental contents from conscious awareness. He believed that the unconscious was a
dynamic entity in which repressed mental contents were stored and unavailable to conscious
recall. Current psychodynamic explanations of dissociation are based on Freuds concepts. The
repression of mental contents is perceived as a coping mechanism for protecting the client from
emotional pain that has arisen from either disturbing external circumstances or anxiety provoking
internal urges and feelings (Maldonado & Spiegel, 2003). In the case of depersonalization, the
pain and anxiety are expressed as feelings of unreality or detachment from the environment of
the painful situation.
Psychological Trauma
A growing body of evidence points to the etiology as a set of traumatic experiences that
overwhelms the individuals capacity to cope by any means other than dissociation. These
experiences usually take the form of severe physical, sexual, or psychological abuse by a parent
or significant other in the childs life. The most widely accepted explanation is that it begins as a
survival strategy that serves to help children cope with the horrifying sexual, physical, or
psychological abuse. In this traumatic environment, the child uses dissociation to become a
passive victim of the cruel and unwanted experience. He or she creates a new being who is able
to endure the overwhelming pain of the cruel reality, while the primary self can then escape
awareness of the pain. Each new personality has as its nucleus a means of responding without
anxiety and distress to various painful or dangerous stimuli.

DISSOCIATIVE AMNESIA
Dissociative amnesia represents the classical functional disorder of episodic memory. The
disorder does not involve procedural memory or problems in memory storage, as in classic
organic amnesia (e.g., Wernicke-Korsakoff syndrome). Dissociative amnesia is an inability to
recall important personal information, usually of a traumatic or stressful nature, that is too
extensive to be explained by ordinary forgetfulness and is not due to the direct effects of
substance use or a neurological or other general medical condition (APA, 2000). It has three
primary characteristics:
1. Type of memory lost: The memory loss is episodic and usually involves the loss of first-
person recollection of specific events and identity, rather than knowledge of procedures.
2. Temporal structure: The memory loss is for one or more discrete time periods, ranging
from minutes to years. It is not vagueness or inefficient retrieval of memories but rather a
dense unavailability of memories that were encoded and stored. The amnesia of
dissociative disorders is typically retrograde rather than anterograde. However, a
dissociative syndrome of continuous difficulty incorporating new information that
mimics organic amnestic syndromes has been observed (Schacter 1995 ).
3. Type of events forgotten: The memory loss is usually for events of a traumatic or
stressful nature. This fact has been noted in the language of the DSM-IV diagnostic
criteria.
Types:
Five types of disturbance in recall have been described. In the following examples, the individual
is involved in a traumatic automobile accident in which a loved one is killed.
1. Localized Amnesia. The inability to recall all incidents associated with the traumatic
event for a specific time period following the event (usually a few hours to a few days).
The individual cannot recall events of the automobile accident and events occurring
during a period after the accident (a few hours to a few days).
2. Selective Amnesia. This type is the inability to recall only certain incidents associated
with a traumatic event for a specific period after the event. The individual may not
remember events leading to the impact of the accident but may remember being taken
away in the ambulance.
3. Continuous Amnesia. This is the inability to recall events occurring after a specific time
up to and including the present. The individual cannot remember events associated with
the automobile accident and anything that has occurred since. That is, the individual
cannot form new memories although he or she is apparently alert and aware.
4. Generalized Amnesia. The rare phenomenon of not being able to recall anything that has
happened during the individuals entire lifetime, including his or her personal identity.
5. Systematized Amnesia. With this type of amnesia, the individual cannot remember
events that relate to a specific category of information (e.g., ones family) or to one
particular person or event.
.
Clinical features
Confabulation and Self-Monitoring Because amnesia can have a disastrous effect on a
patient's day-to-day life, many people with chronic amnesia develop adaptive strategies.
One such strategy is confabulation, the invention of false information to cover up a gap in
memory.
Distortions in Time Perception Episodes of amnesia are often characterized by the
subject's misperception of elapsed time. The patient may have a distorted sense of the
rapid passage of time from the last moment of fully remembered consciousness to the
present.
Amnesia and Memories of Abuse Patients are often amnestic for traumatic experiences
The individual with amnesia usually appears alert and may give no indication to observers that
anything is wrong, although at the onset of the episode there may be a brief period of
disorganization or clouding of consciousness (Sadock & Sadock, 2003). Clients suffering from
amnesia are often brought to general hospital emergency departments by police who have found
them wandering confusedly around the streets. Onset of an amnestic episode usually follows
severe psychosocial stress. Termination is typically abrupt and followed by complete recovery.
Recurrences are unusual.

Diagnostic criteria (DSM-1V-TR Criteria 300.12)
a. The predominant disturbance is one or more episodes of inability to recall important
personal information, usually of a traumatic or stressful nature, that is too extensive to be
explained by ordinary forgetfulness.
b. The disturbance does not occur exclusively during the course of dissociative identity
disorder, dissociative fugue, posttraumatic stress disorder, acute stress disorder, or
somatization disorder and is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a neurological or other general medical condition
(e.g., amnestic disorder due to head trauma).
c. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Treatment
The more acute and the more recent the instance of dissociative amnesia, the more likely and the
more quickly it is to be resolved. This risk is especially great for longstanding or childhood-onset
amnesias. In particularly extreme cases, hospitalization may be necessary. Once the patient has
been stabilized and a comfortable therapeutic relationship has been established, the clinician may
proceed with other measures.
Group Psychotherapy: Group interventions may lead to integration of dissociated
memories.
Hypnosis Hypnosis can help to contain and modulate the symptoms, to facilitate recall of
dissociated memories, and to reintegrate the dissociated material.
Pharmacotherapy: Agents used include sodium amytal and oral benzodiazepines. Many
cases of dissociative amnesia resolve spontaneously when the individual is removed from
the stressful situation. For other, more refractory conditions, intravenous administration
of amobarbital is useful in the retrieval of lost memories. Most clinicians recommend
Supportive psychotherapy also to reinforce adjustment to the psychological impact of
the retrieved memories and the emotions associated with them.
Techniques of persuasion and free or directed association are used to help the client
remember.


DISSOCIATIVE FUGUE
Dissociative fugue (formerly called psychogenic fugue) is an unusual but dramatic type of
dissociative disorder. Owing to its rarity, dissociative fugue has been the least studied of the
dissociative disorders in recent years.
Definition
In general, a fugue is characterized by amnesia for one's identity, which is coupled with
sudden, unexpected travel. Both psychological and organic forms of fugue exist.
Dissociative fugue combines failure of integration of certain aspects of personal memory
with loss of customary identity and automatisms of motor behavior (American
Psychiatric Association 2000).
The characteristic feature of dissociative fugue is a sudden, unexpected travel away from
home or customary place of daily activities, with inability to recall some or all of ones
past (APA, 2000).

Clinical features
An individual in a fugue state cannot recall personal identity and often assumes a new
identity. During [the fugue], person have complete amnesia for their past lives and
associations, but unlike patients with dissociative amnesia, they are generally unaware
that they have forgotten anything. Only when they suddenly return to their former selves
do they recall the time antedating the onset of the fugue, but then they remain amnestic
for the period of the fugue itself.
Individuals in a fugue state do not appear to be behaving in any way out of the ordinary.
Contacts with other people are minimal.
The assumed identity may be simple and incomplete or complex and elaborate. If a
complex identity is established, the individual may engage in intricate interpersonal and
occupational activities.
It was thought that the assumption of a new identity was typical of dissociative fugue.
However, [studies have] documented that in the majority of cases there is a loss of
personal identity but no clear assumption of a new identity.
Clients with dissociative fugue often are picked up by the police when they are found
wandering in a somewhat confused and frightened condition after emerging from the
fugue in unfamiliar surroundings.
They are usually presented to emergency departments of general hospitals. On
assessment, they are able to provide details of their earlier life situation but have no recall
from the beginning of the fugue state.
Information from other sources usually reveals that the occurrence of severe
psychological stress or excessive alcohol use precipitated the fugue behavior. Duration is
usually briefthat is, hours to days or more rarely, monthsand recovery is rapid and
complete. Recurrences are not common.

Diagnosis criteria (DSM-1V-TR Criteria 300.13)
a) The predominant disturbance is sudden, unexpected travel away from home or ones
customary place of work, with inability to recall ones past.
b) Confusion about personal identity or assumption of new identity (partial or complete).
c) The disturbance does not occur exclusively during the course of dissociative identity
disorder and is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).
d) The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Diagnosis
Clinical psychiatric history: history about previous childhood and adult trauma, especially
child abuse, financial and marital difficulties, depression, substance abuse, legal difficulties, and
sexual indiscretions.
Mental status examination: should pay particular attention to cognition, memory, and
orientation.
Physical and neurological examination: Because fugues may have either a psychological or
organic basis.
Initial evaluation: of dissociative disorders involves the use of screening instruments or
structured clinical interviews. An excellent instrument for screening for dissociative symptoms is
the Dissociative Experiences Scale (DES), a 28-item patient questionnaire that assesses
symptoms of amnesia, absorption, depersonalization, derealization, and identity alteration.

Treatment
Recovery from dissociative fugue is usually rapid, spontaneous, and complete.
In some instances, manipulation of the environment or psychotherapeutic support may
help to diminish stress or help the client adapt to stress in the future.
When the fugue is prolonged, techniques of gentle encouragement, persuasion, or
directed association may be helpful, either alone or in combination with hypnosis or
amobarbital interviews.
Cognitive therapy may be useful in helping the client attempt a change in inappropriate or
irrational thinking patterns.
Creative therapies (e.g., art therapy, music therapy) are also constructive in allowing
clients to express and explore thoughts and emotions in safe ways (Ford-Martin, 2001).
Group therapy can be helpful in providing the client with ongoing support from
supportive peers.
Family therapy sessions may be used to explore the trauma that precipitated the fugue
episode and to educate family members about the dissociative disorder.

The mainstay of treatment of dissociative fugue is psychodynamic psychotherapy.
In some cases free association has proven helpful.

DISSOCIATIVE IDENTITY DISORDER
Dissociative identity disorder (DID) was formerly called multiple personality disorder. This
disorder is characterized by the existence of two or more personalities in a single individual.
Only one of the personalities is evident at any given moment, and one of them is dominant most
of the time over the course of the disorder. Each personality is unique and composed of a
complex set of memories, behavior patterns, and social relationships that surface during the
dominant interval. The transition from one personality to another is usually sudden, often
dramatic, and usually precipitated by stress.
The various personalities are almost always quite disparate and may even appear to be the exact
opposite of the original personality. For example, a normally shy, socially withdrawn, faithful
husband may become a gregarious womanizer and heavy drinker with the emergence of another
personality. Subpersonalities that are amnestic for the other subpersonalities experience the
periods when others are dominant as lost time or blackouts. They may wake up in unfamiliar
situations with no idea where they are, how they got there, or who the people around them are.
They may frequently be accused of lying when they deny remembering or being responsible for
events or actions that occurred while another personality controlled the body.

Clinical features
Memory symptoms: experiences of losing time, blackout spells, and major gaps in the
continuity of recall for personal information.
Process symptoms: Dissociative process symptoms include depersonalization and derealization,
dissociative hallucinations, passive influence or interference experiences, and dissociative
cognition.
Dissociative Alterations of Identity: Patients may refer to themselves by their own first names
or make depersonalized self-references such as the body when describing themselves and
others, for example, The father hurt the body so she was upset. We tried to protect her, but it
didn't work.

Diagnostic criteria (DSM-1V-Criteria 300.6)
A. The presence of two or more distinct identities or personality states (each with its own
relatively enduring pattern of perceiving, relating to, and thinking about the environment and
self).
B. At least two of these identities or personality states recurrently take control of the person's
behavior.
C. Inability to recall important personal information that is too extensive to be explained by
ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or
chaotic behavior during Alcohol intoxication) or a general medical condition (e.g., complex
partial seizures).
Diagnosis:
Complete history
Mental status examination
Physical and neurological examination
Treatment:
The goal of therapy for the client with DID is to optimize the clients function and
potential. The achievement of integration (a blending of all the personalities into one) is
usually considered desirable.
Clients are assisted to recall past traumas in detail. They must mentally re-experience the
abuse that caused their illness. This process, called abreaction, or remembering with
feeling, is so painful that clients may actually cry, scream, and feel the pain that they felt
at the time of the abuse. During therapy, each personality is actively explored and
encouraged to become aware of the others across previously amnestic barriers. Traumatic
memories associated with the different personality manifestations, especially those
related to childhood abuse, are examined.
Psychotherapy: Psychoanalytic psychotherapy, cognitive-behavioral therapy,
hypnotherapy
Hypnosis: Hypnosis is also used to create relaxed mental states in which negative life
events can be examined without overwhelming anxiety.

DEPERSONALIZATION DISORDER

Definition
DSM-IV defines depersonalization as a feeling of detachment or estrangement from one's self,
in which The individual may feel like an automaton or as if he or she is living in a dream or
movie. This may be accompanied with a sensation of being an outside observer of one's mental
processes, one's body, or parts of one's body.
Additional examples of depersonalization include emotional and mental numbness, not
recognizing oneself in the mirror, the feeling of lack of control over emotions, and feeling as if
body parts are detached or unreal.

Characteristics
Depersonalization disorder is characterized by a temporary change in the quality of self-
awareness, which often takes the form of feelings of unreality, changes in body image,
feelings of detachment from the environment, or a sense of observing oneself from
outside the body.
The DSM-IV-TR describes this disorder as the persistence or recurrence of episodes of
depersonalization characterized by a feeling of detachment or estrangement from ones
self (APA, 2000).
There may be a mechanical or dreamlike feeling or a belief that the bodys physical
characteristics have changed.
Other people in the environment may seem automated or mechanical. These altered
perceptions are experienced as disturbing, and are often accompanied by anxiety,
depression, fear of going insane, obsessive thoughts, somatic complaints, and a
disturbance in the subjective sense of time (APA, 2000).
The disorder occurs at least twice as often in women as in men, and is a disorder of
younger people, rarely occurring in individuals older than 40 years of age (Andreasen &
Black, 2006).

Clinical features
Bodily Perceptions Parts of one's body or one's entire body may feel insubstantial, unreal, or
foreign.
Emotional, Mental and Behavioral Perceptions One's internal mental and emotional
operations may seem altered or foreign, sometimes resulting in behavioral transformations or
limitations.
External Perceptions Feelings of unreality, strangeness, and discontinuity may pervade one's
perceptions of objects and people in the outside world. Thus, individuals experiencing
depersonalization may experience it in conjunction with derealization.
Anxiety Although many patients report a sense of numbness or emotional detachment, this lack
often does not extend to fear of depersonalization itself; in fact, many patients become upset by
the sense of unreality. They may have attacks of panic as a result of either hampered interaction
with the outside world or fear of encroaching insanity.
Reality Testing Although patients may report feeling as if they were unreal or automated, reality
testingthat is, the ability to distinguish between the real and the unrealalways remains intact;
depersonalization is typified by the as if quality of the experience.

Diagnosis criteria (DSM-1V-TR Criteria 300.6)
a) Persistent or recurrent experiences of feeling detached from, and as if one is an outside
observer of, ones mental processes or body (e.g., feeling like one is in a dream).
b) During the depersonalization experience, reality testing remains intact.
c) The depersonalization causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
d) The depersonalization experience does not occur exclusively during the course of another
mental disorder, such as schizophrenia, panic disorder, acute stress disorder, or another
dissociative disorder, and is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe
epilepsy).

Diagnosis
Screening instruments for dissociative symptoms include the Questionnaire of
Experiences of Dissociation, which consists of 26 true-false items, the Dissociative
Experiences Scale, which consists of 28 questions, and the Perceptual Alteration Scale,
which includes items from the Minnesota Multiphasic Personality Inventory relative to
dissociation.
The Dissociative Disorders Interview Schedule is a structured interview for the
assessment of dissociative disorders

Treatment
Pharmacological treatment
Anxiolytics provide symptomatic relief if anxiety is an important element of the clinical
condition (Andreasen & Black, 2006).
A study by Simeon, Stein, and Hollander (1998) found the antidepressant clomipramine
(Anafranil) to be a promising pharmacological treatment for primary depersonalization
disorder.

Psychodynamic psychotherapy
Cognitive therapies: As depersonalization may be triggered by feelings of loss of
control or victimization, cognitive therapies that counteract anxiety can help to alleviate
anxiety as well as the depersonalization.
Patient Education and Specific Techniques The patient should be educated regarding
depersonalization, its onset, development, triggers, and treatment. A review of the
defensive nature of this symptom and its triggers can be the first step in reducing anxiety
and minimizing future episodes of depersonalization.
Hypnosis Since dissociation is a feature of the hypnotic trance, this treatment may help
to demonstrate to patients how to control their own dissociation. When combined with
well-designed psychotherapy, hypnosis can lead to a reduction in depersonalization
symptoms
Behavior Therapy Reports have indicated successful response mostly to positive
reinforcement, although a few report good results with negative reinforcement. Flooding
treatment through fantasy and paradoxical intention has also been reported successfully.


DISSOCIATIVE DISORDERS NOT OTHERWISE SPECIFIED
The category of dissociative disorders not otherwise specified includes all the dissociative
conditions whose manifestations do not meet diagnostic criteria for the better delineated, specific
dissociative disorders from the fourth edition of Diagnostic and Statistical Manual of Mental
Disorders (DSM-I) that is, dissociative amnesia, dissociative fugue, dissociative identity
disorder, and depersonalization disorder.

DISSOCIATIVE TRANCE DISORDER
It encompasses a variety of dissociative phenomena that share an alteration of normal
consciousness, or trance state, which is distressing, impairing, and beyond the non pathological
trance manifestations that may be indigenous to particular cultures. Dissociative trance involves
a narrowing of awareness of the immediate surroundings with stereotypical behaviors or
movements that are experienced as involuntary and for which there may be partial or total
amnesia Alternatively, possession trance is characterized by a transient alteration in identity
whereby one's normal identity is temporarily replaced (possessed) by a spirit, ghost, deity, or
other person. Descriptions of possession trance are to be found in a variety of cultures and have
been most studied in India.
Dissociative trance disorder has been divided into two broad categories, (American Psychiatric
Association 2000 ).
Dissociative trance
Possession trance

Dissociative Trance
Dissociative trance phenomena are characterized by a sudden alteration in consciousness, not
accompanied by distinct alternative identities. In this form the dissociative symptom involves an
alteration in consciousness rather than identity. Also, in dissociative trance, the activities
performed are rather simple, usually involving sudden collapse, immobilization, dizziness,
shrieking, screaming, or crying. Memory is rarely affected, and if there is amnesia, it is
fragmented.
Dissociative trance phenomena frequently involve sudden, extreme changes in sensory and
motor control. A classic example is the ataque de nervios , prevalent in Latin American
countries..

Ataque De Nervios
Ataque de nervios is characterized by a number of somatic symptoms including trembling, heart
palpitations, a sense of heat rising to the chest and head, faintness, paresthesias, and darkened
vision. There can be difficulty moving or seizure-like convulsive movements, falling to the
ground, or lying still as if dead. Individuals also typically cry, shout, moan, or swear
uncontrollably; become hysterical; and attempt to harm themselves or strike out at others or
throw objects. The episode ends suddenly or gradually, sometimes with the intervention of others
who attempt to calm down the victim, pray, or perform alcohol rubs (alcoholado). During the
episode there is typically a narrowing of attention and general lack of awareness of the
surroundings, and after the episode there can be partial or total amnesia for what transpired.
After the episode there is a return to normal consciousness or a prolonged period of exhaustion
that can last for hours. Acute family conflict appears to comprise the hallmark trigger of this
condition. The episode typically commences with a sense of brooding, feeling overwhelmed, and
of shock, followed by the acute shift in consciousness and the narrowing of attentional focus.
Overall affective and somatic alterations are pronounced in the context of a dissociated state.
Ataque de nervios may occur as isolated incidents, lasting minutes to hours, or can become long-
term and recurring, sometimes lasting for years and causing significant disability.

Possession trance
Possession trance is a category of dissociative disorders that encompasses a variety of different
cultural presentations throughout the world, best characterized in African and South Asian
cultures. It is defined by the presence of alterations in consciousness, behavior, memory, and, in
particular, identity that go beyond the culturally accepted norms and bring dysfunction and
distress to the sufferer. During the trance state a variety of behaviors similar to those seen in
ataque de nervios can occur: uncontrolled bodily movements such as shaking, flailing, or falling
to the ground; moaning and shrieking; violent behaviors directed at the self or others; and
derogatory or menacing verbalizations. Paresthesias, dizziness, and other somatic symptoms may
also occur, although they may be less pronounced and intense than in ataque de nervios. A
personality emerges that is distinct from that characteristic of the individual, and these
personalities are typically regarded as arising outside of the person. This is in contrast to
dissociative identity disorder, in which the identities are experienced and viewed as distinct
aspects of some sense of self. The possessing personalities may not disclose their identity
immediately, until tricked into doing so by family members or healing practitioners, and they
typically involve deities, demons, spirits, ghosts, or deceased family members, neighbors, or
friends who were known to the particular individual and underwent similar stress. These
verbalizations tend to be more purposeful, organized, and coherent than the affective storm
quality that characterizes ataque de nervios. After the episode the individual almost always
collapses, loses consciousness, is disoriented, and has partial or total amnesia for the events that
occurred and may remain dazed, exhausted, and confused for a number of hours. This aftermath
tends to be more pronounced than in ataque de nervios.

Diagnostic criteria (DSM-1V-TR Criteria)
A. Either (1) or (2):
1. Trance, i.e., temporary marked alteration in the state of consciousness or loss of
customary sense of personal identity without replacement by an alternate identity,
associated with at least one of the following:
a. narrowing of awareness of immediate surroundings, or unusually narrow
and selective focusing on environmental stimuli
b. stereotyped behaviors or movements that are experienced as being beyond
ones control
2. Possession trance, a single or episodic alteration in the state of consciousness
characterized by the replacement of customary sense of personal identity by a new
identity. This is attributed to the influence of a spirit, power, deity, or other
person, as evidenced by one (or more) of the following:
a. stereotyped and culturally determined behaviors or movements that are
experienced as being controlled by the possessing agent
b. full or partial amnesia for the event
B. The trance or possession trance state is not accepted as a normal part of a collective
cultural or religious practice.
C. The trance or possession trance state causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The trance or possession trance state does not occur exclusively during the course of a
psychotic disorder (including mood disorder with psychotic features and brief psychotic
disorder) or dissociative identity disorder, and is not due to the direct physiological
effects of a substance or a general medical condition.

BRAINWASHING
Definition The DSM-IV describes this dissociative disorder not otherwise specified as states of
dissociation that occur in individuals who have been subjected to periods of prolonged and
intense coercive persuasion (e.g., brainwashing, thought reform, or indoctrination while
captive). . It implies that under conditions of adequate stress and duress, individuals can be
made to comply with the demands of those in power, thereby undergoing major changes in their
personality, beliefs, and behaviors. People submitted to such conditions can undergo
considerable harm, including loss of health and life, and typically manifest a variety of
posttraumatic and dissociative symptoms.

GANSER'S SYNDROME
The hallmark symptom of Ganser's syndrome is paralogia, the giving of approximate answers to
questions, as originally described by Sigbert Ganser in 1897 in a paper entitled Concerning an
Unusual Hysterical Confusional State. Although afflicted individuals typically know their
names, they often only approximate other key personal information such as age, address, and
occupation. They also give approximate answers to questions like the number of days in a week
or months in a year, to simple calculations (e.g., 3 + 1 = 5), and perform approximate naming of
objects (e.g., pencil for pen, picture for stamp). It is generally agreed that for the diagnosis of the
syndrome additional dissociative symptoms must be present, including disorientation, dazing or
clouding of consciousness, and amnesia for past events or typically, once the episode clears, for
prior responses.

Nursing Diagnosis
Nursing diagnoses are formulated from the data gathered during the assessment phase and with
background knowledge regarding etiological implications for the disorder. Some common
nursing diagnoses for clients with dissociative disorders include:
Disturbed thought processes related to severe psychological stress and repression of anxiety,
evidenced by loss of memory (dissociative amnesia).
Ineffective coping related to severe psychosocial stressor or substance abuse and repressed
severe anxiety, evidenced by sudden travel away from home with inability to recall previous
identity (dissociative fugue).
Disturbed personal identity related to childhood trauma/abuse evidenced by the presence of
more than one personality within the individual (dissociative identity disorder).
Disturbed sensory perception (visual/kinesthetic) related to severe psychological stress and
repression of anxiety evidenced by alteration in the perception or experience of the self or the
environment (depersonalization disorder).

















ANNOTATED BIBLIOGRAPHY
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Harold l. Kaplon , M.D. & Benjamin j. Sadock, M.D. are working as a Professors of Psychiatry
in New york University school of medicine and also are consultant Psychiatrists in Lenox Hill
hospital New york. This book of Kaplon & Sadock is a most comprehensive book which
explains each and every concept of psychiatry health. This text provides a strong foundation of
Behavioral Sciences, clinical Psychiatry and mental disorders including Delirium, Dementia,
Schizophrenia, Mania, Anxiety disorders etc. This book provides special guidance in
pharmacology of Schizopheric drugs. It shows the illustrative view of all tablets and drugs.
Photos are intended as accurate reproduction of the drug, which can be used as a quick
identification of the aid.
Ahuja Niraj. A short textbook of Psychiatry. 5
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Niraj Ahuja, MD is working as a Associate Professor (Psychiatry) in GB Pant hospital and
Associated Maulana Azad Medical college, New delhi. This book of Niraj Ahuja is a very simple
and comprehensive text. It provides a focused through introduction to psychiatric mental health
nursing, diagnosis and classification of mental disorders, psychiatric history & mental status
examination also including nursing assessment and intervention of the common mental
disorders. This book offers a special guidance in psychological treatment of schizophrenic clients
including psychotherapy, Behavior therapy, cognitive therapy, family & group therapy and
relaxation therapies. Each and every thing regarding the psychological treatment is given very
clearly and concisely in this text.
Townsend C. Mary. Psychiatric mental health mursing; Concepts of care in evidence-
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Mary C. Townsend, DSN, PMHCNS- BC is former assistant professor and coordinator of Mental
health nursing in Kramer school of nursing Oklahoma city university in Oklahoma. This text
book provides a new scientific information about the concepts of mental health nursing. This
book emphasis on evidenced based practice in psychiatric nursing in each and every area of it.
This book is having a very simple language which is easily understandable by every person. This
guide offers a special guidance in etiology of schizophrenia. It is given in this text on the basis of
models and theories and having a logic behind every concept. Flow charts are given in this text
for the easy understanding.
Neeraja KP. Essentials of Mental health and psychiatyric nursing. Edition 1
st
. vol 2. New
delhi. Jaypee brothers; 2008.
KP Neeraja Msc (N), MA, PhD is working as a vice principal of Navodya College of nursing
Raichur, Karnataka India. This book of KP Neeraja is mainly focused on the Clinical psychiatry
which is helpful for the nurses and the other professionals to enhance and utilize their knowledge
in the clinical field. This is simple and comprehensive book, that is easily understandable by
others. It offers a useful guidance in psychiatric disorders and describe them in a wide ranging
manner, like their definition, features, prevalence, risk factors, etiological factors, clinical
manifestations and management. All matter is provided in this text in very clearly and concisely
manner which is easy to understand.
Stuart W Gail. Principles and practices of psychiatric nursing. edition 9
th
. Delhi. Elsevier;
2009.
Dr. Gail W. Stuart is dean and a tenured professor in the college of nursing and a professor in the
college of Medicine in the department of psychiatry and Behavioral sciences at the Medical
university of South Carolina. This book provides the students new learning tools to help them
become masters. The latest scientific knowledge is there in this book regarding the neurobiology,
genetics, psychopharmacology, community based treatment etc. Each and every thing is given in
a detail in this guide which helps to clear the doubts. This text provides special guidance in
pharmacology of mental disorders. Pictorial view of drugs is given in this guide. This helps to
retain their knowledge in brain and in quick identification.

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