DSM IV

Dissociative Amnesia	Depersonalization Disorder
Dissociative Fugue	Dissociative Disorder Not Otherwise Specified
Dissociative Identity Disorder	Associated Features and Disorders

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, Post traumatic 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., Amnesic Disorder Due to Head Trauma).

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

A. The predominant disturbance is sudden, unexpected travel away from home or one's customary place of work, with inability to recall one's past.

B. Confusion about personal identity or assumption of a 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

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). In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body (e.g., feeling like one is in a dream).

C. The depersonalization causes clinically significant distress or impaintient 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).

This category is included for disorders in which the predominant feature is a Dissociative symptom (i.e., a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment) that does not meet the criteria for any specific Dissociative Disorder. Examples include

1. Clinical presentations similar to Dissociative Identity Disorder that fail to meet full criteria for this disorder.Examples include presentations in which a) there are not two or more distinct personality states, or b) amnesia for important personal information does not occur.

3 -States of dissociation that occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion (e.g., brainwashing, thought re- form, or indoctrination while captive).

4. Dissociative trance disorder: single or episodic disturbances in the state of consciousness, identity, or memory that are indigenous to particular locations and cultures. Dissociative trance involves narrowing of awareness of immediate surroundings or stereotyped behaviors or movements that are experienced as being beyond one's control. Possession trance involves re placement of the customary sense of personal identity by a new identity, attributed to the influence of a spirit, power, deity, or other person, and associated with stereotyped "involuntary" movements or amnesia. Examples include amok (Indonesia), bebainan (Indonesia), latab (Malaysia), pibloktoq (Arctic), ataque de nervios (Latin America), and possession (India). The Dissociative or trance disorder is not a normal part of a broadly accepted collective cultural or religious practice.

5. Loss of consciousness, stupor, or coma not attributable to a general medical condition.

6. Ganser syndrome: the giving of approximate answers to questions (e.g., "2 plus 2 equals 5") when not associated with Dissociative Amnesia or Dissociative Fugue

Individuals with Dissociative Identity Disorder frequently report having experienced severe physical and sexual abuse, especially during childhood. Controversy surrounds the accuracy of such report, because childhood memories can be subject to distortion and individuals with this disorder tend to be highly hypnotizable and especially vulnerable to suggestive influences. On the other hand, those responsible for acts of physical and sexual abuse may be prone to deny or distort their behavior. Individuals with Dissociative Identity Disorder may manifest post traumatic symptoms (e.g.,nightmares, flashbacks, and startle responses) or Post traumatic Stress Disorder. Self-mutilation and suicidal and aggressive behavior may occur. Some individuals may have a repetitive pattern of relationships involving physical and sexual abuse. Certain identities may experience conversion symptoms (e.g., pseudoseizures) or have unusual abilities to control pain or other physical symptoms. Individuals with this disorder may also have symptoms that meet criteria for Mood, Substance-Related, Sexual, Eating, or Sleep Disorders. Self-mutilative behavior, impulsivity, and sudden and intense changes in relationships may warrant a concurrent diagnosis of Borderline Personality Disorder.

Associated laboratory findings. Individuals with Dissociative Identity Disorder score toward the upper end of the distribution on measures of hypnotizability and Dissociative capacity. There are reports of variation in physiological function across identity states (e.g., differences in visual acuity, pain tolerance, symptoms of asthma, sensitivity to allergens, and response of blood glucose to insulin).

Associated physical examination findings and general medical conditions. There may be scars from self-inflicted injuries or physical abuse. individuals with this disorder may have migraine and other types of headaches, irritable bowel syndrome, and asthma.

It has been suggested that the recent relatively high rates of the disorder reported in the United States might indicate that this is a culture-specific syndrome. In preadolescent children, particular care is needed in making the diagnosis because the manifestations may be less distinctive than in adolescents and adults. Dissociative Identity Disorder is diagnosed three to nine times more frequently in adult females than in adult males; in childhood, the female-to-male ratio may be more even, but data are limited. Females tend to have more identities than do males, averaging 15 or more, whereas males average approximately 8 identities.

The sharp rise in reported cases of Dissociative Identity Disorder in the United States in recent years has been subject to very different interpretations. Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. In contrast, others believe that the syndrome has been over diagnosed in individuals who are highly suggestible.

Dissociative Identity Disorder appears to have a fluctuating clinical course that tends to be chronic and recurrent. The average time period from first symptom presentation to diagnosis is 6-7 years. Episodic and continuous courses have been described. The disorder may become less manifest as individuals age beyond their late 40's, but may reemerge during episodes of stress or trauma or with Substance Abuse.

Several studies suggest that Dissociative Identity Disorder is more common among the first-degree biological relatives of persons with the disorder than in the general population.

Dissociative Identity Disorder must be distinguished from symptoms that are caused by the direct physiological effects of a general medical condition (e.g., seizure disorder) (see p. 165). This determination is based on history, laboratory findings, or physical examination. Dissociative Identity Disorder should be distinguished from Dissociative symptoms due to complex partial seizures, although the two disorders may co-occur. Seizure episodes are genrally brief (30 seconds to 5 minutes) and do not involve the complex and enduring structures of identity and behavior typically found in Dissociative Identity Disorder. Also, a history of physical and sexual abuse is less common in individuals with complex partial seizures. EEG studies, especially sleep deprived and with nasopharyngeal leads, may help clarify the differential diagnosis.

Symptoms caused by the direct physiological effects of a substance can be distinguished from Dissociative Identity Disorder by the fact that a substance (e.g., a drug of abuse of a medication) is judged to be etiologically related to the disturbance (see p. 192).

The diagnosis of Dissociative Identity Disorder takes precedence over Dissociative Amnesia, Dissociative Fugue, and Depersonalization Disorder. Individuals with Dissociative Identity Disorder can be distinguished from those with trance and possession trance symptoms that would be diagnosed as Dissociative Disorder Not Otherwise Specified by the fact that those with trance and possession trance symptoms typically describe external spirits or entities that have their bodies and taken control.

Controversy exists concerning the differential diagnosis between Dissociative Identity Disorder and a variety of other mental disorders, including Schizophrenia and other Psychotic Disorders, Bipolar Disorder, With Rapid Cycling, Anxiety Disorders, Somatization Disorders, and Personality Disorders. Some clinicians believe that Dissociative Identity Disorder has been under diagnosised (e.g., the presence of more than one dissociated personality state may be mistaken for a delusion or the communication from one identity to another may be mistaken for an auditory hallucination, leading to confusion with the Psychotic Disorders; shifts between states may be confused with cyclical mood fluctuations leading to confusion with Bipolar Disorder). In contrast, others are concerned that Dissociative Identity Disorder may be overdiagnosed relative to other mental disorders based on the media interest in the disorder and the suggestible nature of the individuals. Factors that may support a diagnosis of Dissociative Identity Disorder are the presence of clear-cut Dissociative symptomatology with sudden shifts in identity states, reversible amnesia, and high scores on measures of dissociation and hypnotizability in individuals who do not have the characteristic presentations of another mental disorder.

Dissociative Identity Disorder must be distinguished from Malingering in situations in which there may be financial or forensic gain and from Factitious Disorder in which there may be a pattern of help-seeking behavior.