Classification of mental disorders in ICD-11 (Part 2)

A rare disorder phenomenon called dissociative identity disorder is an extreme case of dissociative pathology. It is characterized by the process by which a person's actions, thoughts and emotions become separate from the rest of his personality and function independently.

Dissociative identity disorder has a complex of symptoms quite similar to schizophrenia, but despite this, the diseases differ from each other in the following ways:

amnesia as a symptom is a mandatory criterion for diagnosing dissociative identity disorder, when in schizophrenia, memory loss occurs only in rare cases of acute psychosis;
Psychological trauma in childhood most often contributes to the development of dissociative identity disorder. In terms of severity of childhood trauma, schizophrenia shows lower results in psychological testing of patients;
Affective flattening is a negative symptom of schizophrenia, but it is absent in dissociative identity disorder. The symptom is a weak manifestation or loss of higher emotions (feelings of gratitude, compassion, respect and others). Also, with schizophrenia, the patient is often unable to perform basic actions to care for himself, which can rarely be observed with dissociative identity disorder;
the presence of two or more identities in the patient’s consciousness or subconscious is characteristic of dissociative identity disorder. Patients with schizophrenia can only embody an alternative personality, but this process is accompanied by delusional ideas;
Adequate thinking abilities and the ability to logically organize activities are rarely impaired in people with dissociative identity disorder. When a patient has schizophrenia, these abilities deteriorate significantly.

Diagnosis F 44.0 Dissociative amnesia

The main feature is loss of memory, especially for important recent events, which is not caused by organic mental illness and is too severe to be explained by ordinary forgetfulness or fatigue. Amnesia is usually focused on traumatic events, such as an accident or unexpected bereavement, and is usually partial and selective. Complete and generalized amnesia is rare and is usually part of ambulatory automatism (fugue) (F44.1); in this case, the disorder should be classified as such. The diagnosis of dissociative amnesia should not be made in the presence of organic brain disease, intoxication or excessive fatigue.

Excluded: amnestic disorder caused by the use of alcohol or other psychoactive substances (F10-F19 with a common fourth character .6) amnesia:

NOS (R41.3)
anterograde (R41.1)
retrograde (R41.2)

non-alcoholic organic amnestic syndrome (F04)

amnesia after an epileptic attack (G40.-)

Diagnostics

Diagnosis of dissociative disorder includes a detailed medical history, history of the development of the disease, physical, neurological and psychiatric examinations, assessment of the clinical picture; studying the characteristics of the psychosocial environment, living conditions, the patient’s environment, stress factors, and the ability to cope with life’s stressful situations. This excludes physiological or neurological disorders that could lead to similar symptoms.

Differential diagnoses include separation anxiety disorder, generalized anxiety disorder, panic disorder, school phobia (in children), depression, and sometimes impending psychosis.

False-positive diagnoses (less than 5% of cases) are more often made in women, children with mental disorders, patients with unusual movement disorders or epilepsy.

Diagnosis F 44.2 Dissociative stupor

Dissociative stupor is diagnosed based on a marked reduction or absence of voluntary movements and normal responses to external stimuli such as light, noise, and touch, but examination and examination reveal no obvious physical cause. In addition, there is absolute evidence of a psychogenic cause in the form of recent stressful events or problems.

Excludes: organic catatonic disorder (F06.1) stupor:

NOS (R40.1)
catatonic (F20.2)
depressed (F31-F33)
manic (F30.2)

Dissociative identity disorder

Imagine a sedate married woman who works in a library and is raising a five-year-old daughter. As always, she leaves for work in the morning, but does not return in the evening; All her relatives are looking for her, and a few days later they find her - in a psychiatric clinic. The patient herself says that some part of the day fell out of her memory without any external reason, and the next morning she found herself in bed with an unknown man in a cheap hotel in another city. She was taken to the hospital by the police, who were called by the hotel administrator, because a frightened woman had hit a man lying next to him, he, sleepily responded in kind, and a fight ensued. At the same time, the woman - who really had no signs of injury or signs of intoxication - cried and swore that she did not remember how she ended up here with this man and with her knowledge this could not have happened in any case; the man says that she did it completely voluntarily and for a sufficient fee. The unfortunate librarian doesn't look at all like the multifaceted Billy Milligan, but this is exactly what dissociative identity disorder looks like in real clinical practice. Compared to other terms (for example, multiple personality disorder, as in ICD-10), this one is good because it includes the definition of “dissociative” and immediately refers us to the category of dissociative disorders. In essence, episodes in which the patient feels like a “different person” are hysterical attacks. The classics of psychiatry, the masters of clinical descriptions, taught us to see, even in typical cases, how inventive and talented hysteria can be. But cases when the “second personality” suddenly begins to speak a language that the patient has never known, or knows how to do something that the patient has never been able to do, are casuistic, and they should not always be believed; and the “second personality” is asocial, behaving inappropriately to the situation, maladaptive, or even directly threatening the patient’s life will inevitably lead him to a psychiatrist. Here are the symptoms of this disorder as they are described in the DSM-5 criteria that serve as the basis for diagnosis.

A disturbance of one's own identity, which is characterized by the presence in one person of two or more distinct personality states - in some cultures these states may be interpreted as episodes of obsession. The sense of themselves as an integral personality, independently controlling their actions, is intermittent and torn in such patients, and this gap is manifested in a change in the states of all spheres of the psyche: affect, thinking, memory, perception, and can affect the somatic state, the sensitive and motor spheres.
Repeated loss from memory (with subsequent recovery) of information about one’s daily life, basic personal information, emotionally significant, usually traumatic events, which cannot be interpreted as ordinary forgetting.
Symptoms significantly impair the patient's social and occupational functioning.
The disorder cannot be associated with the religious practice accepted in a given culture (for example, if we are not talking about some shaman, for whom states of “possession by spirits” are the norm, but about an “ordinary” member of such a culture, who will be seriously disturbed by them), but for children - with play.
Symptoms cannot be due to substance use or a medical/neurological disorder.

In essence, within the framework of dissociative identity disorder, any dissociative symptoms can appear: this includes dissociative amnesia with difficulty remembering episodes from the past; and dissociative fugue, when the patient outwardly behaves in an orderly manner, but in fact completely unconsciously runs away or goes to another city; and disturbances of sensitivity or motor function of a dissociative nature, when, for example, only one of the “personalities” is lame or suffers from blindness. Determining whether a disorder is dissociative based on all these symptoms greatly helps the doctor in diagnosis; for this purpose, many questionnaires and structured interviews have been created specifically aimed at identifying dissociative symptoms (adapted, for example, Somatoform Dissociation Scale SDQ-20, Dissociation Scale DES, Cambridge Depersonalization CDS scale). However, the peculiarity of dissociative identity disorder is what prompts us to call the different states of the patient different “personalities”: although within the framework of dissociative episodes, they have their own character, thinking, memory, which are just as stably preserved and transmitted from episode to episode as and characteristics of the “main” personality in the “light intervals”. This is the key difference between dissociative identity disorder and schizophrenia. Although a patient with schizophrenia may also call himself by different names, imagine himself as different characters, suddenly begin to behave uncharacteristically, and then return to his previous behavior, in his case we are not talking about any redundant personalities; no matter what names and figures he clings to, the patient rapidly loses the only personality he had.

However, the question of differential diagnosis of dissociative disorder with schizophrenia invariably arises, since in addition to dissociative symptoms, patients can also talk about typical psychotic symptoms:

disturbances of perception: auditory pseudohallucinations in the form of voices that comment on their actions, or negative hallucinations, including the interesting phenomenon of voluntary analgesia, when the patient can independently “reduce” pain sensitivity
automatisms: a feeling that someone is interfering with the patient’s train of thought or controlling his actions against his will;

There are two forms of dissociative identity disorder:

so-called “possession”, when another state of personality is caused, in the opinion of the patient himself, by the intervention of spirits or demons; arises on a certain cultural and religious basis

not associated with a feeling of obsession, when different “personalities” are, as a rule, people of different gender, age, worldview.

Depending on the form of the disorder, the “voice” or sense of control of one’s thoughts and actions will be attributed to “spirits” or the sudden intervention of another person. But on the other hand, in principle, the validity of such a diagnosis raises many questions. How can we confidently say that the patient is not deceiving us? If we return to the case with the library worker, the police did not find any signs of violence, and the patient herself was found in such a way that they were more inclined to believe the man; She was taken to a psychiatric hospital rather because of the violent expression of emotions, and the doctors suspected something more serious than a reactive disorder only after they figured out what kind of life she usually leads. Dissociative identity disorder, like other dissociative disorders, is often feigned, so much so that malingerers become the control group in studies to identify neurophysiological correlates. However, there are signs that help the doctor identify the true disorder and the patient who can truly be helped. In the overwhelming majority of cases, dissociation becomes a reaction to psychological trauma, so in the patient’s history it is necessary to look for circumstances that, even in childhood, could cause him to react this way in the future (physical and sexual abuse, alienation from parents and conflicts between them) and, if the disorder manifested itself in adulthood, an event that could have triggered it. In our clinical case, such a provoking event was the death of the father, although the patient practically did not communicate with him, and he was also the source of childhood trauma: he suffered from alcoholism, beat his wife and children, then completely left the family, did not work and lived on the street. Another feature is the multitude of concomitant mental disorders, since psychological trauma provokes them or facilitates their development. These can be personality disorders (not to be confused with identity disorder - a continuous sense of oneself as a single person; here we are talking about character pathology, maladaptive behavioral strategies in the “main” personality), depression, anxiety disorders, obsessive-compulsive disorder. Before her current hospitalization, our library worker was unsuccessfully treated by a psychiatrist for anxiety depression. There are many psychological concepts that explain how trauma leads to dissociative symptoms, and each justifies a particular approach to psychotherapy; In this material we will focus on the biological concept. We know that a threat situation causes a “fight or flight” reaction in an animal, when all physiological processes are aimed at increasing sensitivity to important signals, reactivity, and muscle tone. But there is another type of reaction that works when neither one nor the other is possible - the so-called “feigned death.” It is less adaptive than fight or flight, but it can also minimize damage to some extent. At the same time, muscle tone, on the contrary, decreases, sensitivity to stimuli and reactivity decrease. This is exactly the situation a child finds himself in when the threat comes from an adult. It is assumed that in the state of “imaginary death”, functional deafferentation occurs, detachment from all external stimuli, as in a dream - to which patients with dissociative disorder often compare their state. The normal state of connections between the subcortical sensory centers, the structures directly associated with them that are responsible for the affective response, and the cortex itself provides that same continuous feeling of singularity and integrity of one’s own personality. If episodes of functional deafferentation are frequent in childhood, when the bulk of such connections are formed, they may subsequently function unstable in adulthood, especially in situations of threat. Neuroimaging can record the results of such pathological development: in patients with dissociative disorder, for example, a restructuring of the hippocampus is observed, a decrease in its volume is recorded by MRI, and it correlates with the severity of psychological trauma in childhood. Another feature is the alternation of states of hypoarousal (similar to “imaginary death”) and hyperarousal (similar to the “fight or flight” reaction). It was previously described in post-traumatic stress disorder, which, according to modern research, is close to dissociative disorders. The state of hypoarousal corresponded to the real experience of a traumatic situation, and hyperarousal corresponded to the so-called “flashbacks,” hyperrealistic memories of already experienced events. The same change of states, and the same neuronal correlates of these states (with hypoarousal - preferential activation of the prefrontal cortex, cingulate and parohippocampal gyri; with hyperarousal - amygdala, insula, dorsal striatum) are shown in dissociative identity disorder - and they correspond to different “personalities”. That is, for the psychological situation in which the patient exists, different personalities are functional in their own way, and if we want to cure him, we need to teach him other methods of adaptation. We do not yet have any ways to directly control the mechanisms of adaptive behavior, so psychotherapy remains the main approach in the treatment of dissociative identity disorder. Individual sessions with a therapist and a psychodynamic approach (eg, cognitive behavioral therapy) are preferred.

According to the generally accepted recommendations of the ISSDT (International Society for the Study of Trauma and Dissociation), therapy takes place in three stages: in the first, the therapist tries to form a correct understanding of the disease in the patient, initially stabilize the condition and reduce the severity of concomitant depressive and anxiety symptoms; at the second, it is necessary to analyze in detail all the traumas that led to the formation of defense through the mechanism of dissociation, and the goal of the third stage is to move from dissociation to more organized and adaptive defenses.

The main goal of psychopharmacotherapy is to combat comorbid mental disorders, which makes it easier for the psychotherapist to approach dissociative disorder. An interesting aspect of pharmacotherapy is the different response to drugs that a patient may give in different personality states.

Sources

Sadock BJ, Kaplan HI Comprehensive Textbook of Psychiatry: X. – Wolters Kluwer, 2020.
Dissociation and the Dissociative Disorders: DSM-V and Beyond, edited by P. F. Dell and J. A. O'Neil. (2009). New York, NY: Routledge, 898 pp.
International Society for the Study of Trauma and Dissociation. Guidelines for treating dissociative identity disorder in adults, third revision //Journal of Trauma & Dissociation. – 2011. – T. 12. – No. 2. – pp. 115-187.
Dorahy MJ et al. Dissociative identity disorder: an empirical overview //Australian & New Zealand Journal of Psychiatry. – 2014. – T. 48. – No. 5. – pp. 402-417.
Reinders AATS et al. Opposite brain emotion-regulation patterns in identity states of dissociative identity disorder: A PET study and neurobiological model //Psychiatry Research: Neuroimaging. – 2014. – T. 223. – No. 3. – pp. 236-243.
Chalavi S. et al. Abnormal hippocampal morphology in dissociative identity disorder and post-traumatic stress disorder correlates with childhood trauma and dissociative symptoms //Human brain mapping. – 2020. – T. 36. – No. 5. – pp. 1692-1704.

Diagnosis F 44.3 Trance and obsession

Disorders in which there is a temporary loss of the sense of self as a person and a complete unawareness of the environment. This category includes only trance states that are involuntary and unwanted and occur outside of religious or culturally appropriate situations.

Excluded: conditions associated with:

acute or transient psychotic disorders (F23.-)
personality disorder of organic etiology (F07.0)
post-concussion syndrome (F07.2)
intoxication caused by the use of psychoactive substances (F10-F19 with a common fourth character of .0)
schizophrenia (F20.-)

Reasons for appearance

Dissociative identity disorder can be caused by a combination of many reasons:

severe stress;
increased anxiety;
psychological trauma;
deficiency of protection in a child in childhood;
child's violent experiences in childhood.

The most common cause of the development of the disorder is violence to which children are exposed from relatives.

More than 80% of patients with various manifestations of dissociative identity disorder were exposed to violence in childhood. But this factor is not always the key in identifying the causes of the disorder. There are cases when patients experienced the death of loved ones, serious illnesses and other stressful situations.

All the reasons leading to the occurrence of the disorder come down to the action of stress factors, the strength of which, as a result of various traumatic events, leads to the activation of the body’s defensive reaction. It consists in splitting consciousness, which allows you to avoid painful sensations, feelings and strong emotional shock.

Causes and risk factors

Split (dissociation) is a special mechanism that allows the human mind to divide thoughts and memories of ordinary consciousness into several parts. After bifurcation, the resulting parts of subconscious thoughts are preserved and can subsequently emerge in consciousness under the influence of triggers. Such mechanisms include events and objects that surrounded the patient at the time of the traumatic event.

Factors predisposing to the formation of dissociative disorders are:

prolonged severe stress;
lack of care and love from adults in childhood;
psychological, physical or sexual abuse;
prolonged insomnia;
overdose of nitrous oxide (“laughing gas”);
participation in hostilities;
suffering a car accident or natural disaster;
severe psychological conflicts;
long-term severe somatic diseases;
death of loved ones.

Concept and ICD 10

Conversion (dissociative) disorder is a psychogenic disease in which a psychological problem finds expression at the bodily (somatic) level.

Thus, in conversion disorder, a person loses sensory or motor functions, which indicates physical impairment. But there are no organic causes that can cause such disorders.

In the modern ICD-10 classification of mental illnesses, the disorder is coded F44 and includes 10 qualifying diagnoses.

How dangerous is it for the body?

The disorder completely eliminates the possibility of a full life. It is fraught with many dangers and problems that may not be obvious at first glance.

For example, a dissociative fugue is usually associated with a serious shock for the person at the moment of “returning” to his previous life.

And during the fugue period, patients are able to take the path of criminal activity, borrow a serious amount of money, and also irreversibly influence the course of events and the fate of their “real” personality.

Some patients, even some time after emerging from the fugue, cannot come to terms with the actions they took, the opportunities missed during the period of “oblivion,” etc.

Conversion disorder can also have serious consequences on a physical level.

So in people who suffer from dissociative paralysis , muscles atrophy.

Short description

The clinical picture of dissociative and conversion disorders is manifested by somatic and mental symptoms. Somatic symptoms (often resembling a neurological disease) are characterized by a sudden and temporary change or loss of some bodily function as a result of psychological conflict (for example, psychogenic paralysis). Psychiatric symptoms are also closely related to psychological conflict and are characterized by sudden onset and reversibility.

Code according to the international classification of diseases ICD-10:

F06.5 Organic dissociative disorder
F44 Dissociative [conversion] disorders

Conversion in this case means the replacement (conversion) of anxiety with somatic symptoms, which often resemble a neurological disease (for example, psychogenic paralysis). Dissociation means the origin of symptoms from insufficient interaction between various mental functions and is manifested by symptoms of mental disorders (for example, psychogenic amnesia). An alternative name for this group of neurotic disorders is hysteria. The term “hysteria” is excluded from the American classification and ICD-10 as “compromising” and replaced by dissociation, conversion, histrionic personality disorder. However, this term is widely used by domestic psychiatrists. In the American DSM-IV classification, the terms dissociative and conversion have different meanings: the concept of conversion disorder is used to define those psychologically determined disorders that are manifested by somatic symptoms; while the concept of dissociative disorders refers to disorders that are manifested by psychological symptoms (eg, amnesia). In ICD-10, the terms “dissociative” and “conversion” disorders are identical.

General information

Split personality syndrome was mentioned in the works of Paracelsus - his notes were preserved about a woman who believed that someone was stealing money from her. However, in fact, the money was spent by her second personality, about whom the woman knew nothing.

In 1791, the Stuttgart city doctor Eberhard Gmelin described a young city woman who, under the influence of the events of the French Revolution (Germany at that time became a refuge for many French aristocrats), acquired a second personality - a Frenchwoman with aristocratic manners, who spoke excellent French, although the first personality (German girl) did not own it.

There are also descriptions of the treatment of such disorders with Chinese drugs.

Split personality is often described in fiction.

The disease was considered extremely rare - until the middle of the 20th century, only 76 cases of split personality were documented.

The existence of multiple personality disorder became known to the general public after research conducted in 1957 by psychiatrists Corbett Thigpen and Hervey Cleckley. The result of their research was the book “The Three Faces of Eve,” which describes in detail the case of their patient, Eve White. The book “Sybil”, published in 1973, also aroused interest in the phenomenon, the heroine of which was diagnosed with “multiple personality disorder.”

After the release and film adaptation of these books, the number of patients suffering from dissociative identity disorder increased (from the 1980s to the 1990s, up to 40 thousand cases were registered), so some scientists consider this disease iatrogenic (caused by the influence of psychotherapists).

The Diagnostic and Statistical Manual of Mental Disorders has included multiple personality disorder as a diagnosis since 1980.

In some cases, people with multiple personality disorder do not consider the condition a disorder. Thus, the author of the best-selling book “When the Rabbit Howls,” Trudy Chase, refused to integrate her subpersonalities into a single whole, arguing that all her personalities exist as a collective.

Dissociative identity disorder currently accounts for 3% of all mental illnesses. In women, due to mental characteristics, the disease is diagnosed 10 times more often than in men. This dependence on gender may be associated with the difficulty of diagnosing split personality in men.