Prior to beginning work on this discussion, please read Chapters 2, 6, and 7 in DSM-5 Made Easy: The Clinician’s Guide to Diagnosis. Additionally, please watch the video Beer Is Cheaper than Therapy: Fort Hood’s PTSD Problem . (https://fod.infobase.com/OnDemandEmbed.aspx?Token=49272&aid=18596&Plt=FOD&loid=0&w=640&h=480&ref)
For this discussion, the patient for whom you wrote your transcript in the Week One Initial Call discussion has come to your office for a 15-minute initial assessment. As part of the intake process, you have asked the patient to fill out a biographical form that contains the same information included in the case study. Based on this information, propose three questions you would ask the patient to determine a diagnosis and treatment plan.
Provide a transcript of this brief initial session including your three questions and the answers you would expect the prospective patient to give. Beneath the transcript, provide a rationale for each of the three questions you proposed. Include the case study title you chose for your Week One Initial Call discussion post.
Examine your colleague’s transcript, and write an evaluation of the prospective patient’s apparent symptoms and presenting problem(s) within the context of a theoretical orientation. Theoretical orientations are based on the personality theories you learned about in PSY615, and are referred to as “approaches” in Abnormal and Clinical Psychology: An Introductory Textbook.
Remember that symptoms may not be explicitly mentioned by the patient, but they may be inferred by the patient’s presenting problem(s). Summarize views of these symptoms from at least two historical perspectives. For instance, how have these symptoms have been conceptualized and understood, historically? Finally, suggest diagnostic manuals and handbooks besides the DSM-5 that might be used to assess this patient.
Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY: The Guilford Press.Retrieved from https://redshelf.com
“CHAPTER 6 Trauma- and Stressor-Related Disorders
“Trauma- and Stressor-Related Disorders Quick Guide to Trauma- and Stressor-Related Disorders Various types of stress and trauma are responsible for the disorders we’ll consider in this chapter. By now, you know the drill: The link indicates where a more detailed discussion begins. Primary Trauma- and Stressor-Related Disorders Reactive attachment disorder. There is evidence of pathogenic care in a child who habitually doesn’t seek comfort from parents or surrogates. Disinhibited social engagement disorder. There is evidence of pathogenic care in a child who fails to show normal reticence in the company of strangers. Posttraumatic stress disorder. These adolescents or adults repeatedly relive a severely traumatic event, such as combat or a natural disaster. Posttraumatic stress disorder in preschool children. Children repeatedly relive a severely traumatic event, such as car accidents, natural disasters, or war. Acute stress disorder. This condition is much like posttraumatic stress disorder, except that it begins during or immediately after the stressful event and lasts a month or less. Adjustment disorder. Following a stressor, an individual develops symptoms that disappear once the cause of stress has subsided. Other specified, or unspecified, trauma- and stressor-related disorder. Patients whose stress or trauma appears related to other presentations may be classified in one of these categories. Other Problems Related to Trauma or Stress Problems related to abuse or neglect. An astonishing number of Z-codes (V-codes in ICD-9) cover the categories of difficulties that arise from neglect or from physical or sexual abuse of children or adults. Separation anxiety disorder. The patient becomes anxious when separated from parent, other attachment figure, or home. INTRODUCTION Another new chapter for the DSMs incorporates certain diagnoses formerly listed as anxiety, developmental, or adjustment disorders. The unifying factor here is that something traumatic or stressful in the patient’s history appears to be at least partly responsible for the symptoms that develop. It is part of a trend toward grouping together patients of any age who have the right mix of symptoms, rather than separating patients by developmental stage. Many diagnoses include statements about what is not causative, but here is the only full DSM-5 section that presumes any etiology at all, let alone one rooted in the psychology of a pathological developmental process. In the instances of reactive attachment and disinhibited social engagement disorders, there must be evidence of pathogenic care; for posttraumatic stress disorder (PTSD) and its cousins, a horrific event; for adjustment disorder a stressful—well, stressor. The respective criteria sets permit us to check off the fulfilled criteria and go on our way, perhaps thinking that we’ve solved the puzzle. While we rejoice that we’ve successfully determined a cause–effect relationship, nagging at the back of our minds must be a sense that there is more to the story. Otherwise, why do some people become symptomatic while others, exposed to the (as nearly as we can tell) exact same stimulus, go untrammeled on their way? Furthermore, studies have demonstrated that, sooner or later, significant stressors will visit the majority of us. Shouldn’t we conclude that the stimulus in question is necessary, but not sufficient, for the outcome observed? At least this DSM-5 chapter has herded most of these etiology-specific diagnoses into one corral, where we can keep a watchful eye on them. F43.10 [309.81] Posttraumatic Stress Disorder Many people who survive severely traumatic events will develop PTSD. Survivors of combat are the most frequent victims, but it is also encountered in those who have experienced other disasters, both natural and contrived. These include rape, floods, abductions, and airplane crashes, as well as the threats that may be posed by a kidnapping or hostage situation. Children can have PTSD as a result of inappropriate sexual experience, whether or not actual injury has occurred. PTSD can be diagnosed even in those who have only learned about severe trauma (or its threat) suffered by someone to whom they are close—children, spouses, other close relatives. One or two in every 1,000 patients who have undergone general anesthesia have afterwards reported awareness of pain, anxiety, helplessness, and the fear of impending death during the procedure; up to half of them may subsequently develop PTSD symptoms. Implicitly excluded from the definition are stressful experiences of ordinary life, such as bereavement, divorce, and serious illness. Awakening from anesthesia while your surgery is still in progress, however, would qualify as a traumatic event, as would learning about a spouse’s sudden, accidental death or a child’s life-threatening illness. Watching TV images of a calamity would not be a sufficient stressor (except if the viewing was related to the person’s job). After some delay (symptoms usually don’t develop immediately after the trauma), the person in some way relives the traumatic event and tries to avoid thinking about it. There are also symptoms of physiological hyperarousal, such as an exaggerated startle response. Patients with PTSD also express negative feelings such as guilt or personal responsibility (“I should have prevented it”). Aside from the traumatic event itself, other factors may play a role in the development of PTSD. Individual factors include the person’s innate character structure and genetic inheritance. Relatively low intelligence and low educational attainment are positively associated with PTSD. Environmental influences include relatively low socioeconomic status and membership in a minority racial or ethnic group. In general, the more horrific or more enduring the trauma, the greater will be the likelihood of developing PTSD. The risk runs to one-quarter of the survivors of heavy combat and two-thirds of former prisoners of war. Those who have experienced natural disasters such as fires or floods are generally less likely to develop symptoms. (Overall lifetime prevalence of PTSD is estimated at about 9%, though European researchers usually report lower overall rates.) Older adults are less likely to develop symptoms than are younger ones, and women tend to have somewhat higher rates than do men. About half the patients recover within a few months; others can experience years of incapacity. In children, the general outline is pretty much the same as the five general points given in the list of typical symptoms, though the emphasis on symptom numbers differs, as discussed below. Mood, anxiety, and substance use disorders are frequently comorbid. A new specifier reflects findings that in perhaps 12–14% of patients, dissociation is important in the development and maintenance of PTSD symptoms. Essential Features of Posttraumatic Stress Disorder Something truly awful has happened. One patient has been gravely injured or perhaps sexually abused; another has been closely involved in the death or injury of someone else; a third has only learned that someone close experienced an accident or other violence, whereas emergency workers (police, firefighters) may be traumatized through repeated exposure. As a result, for many weeks or months these patients: • Repeatedly relive their event, perhaps in nightmares or upsetting dreams, perhaps in intrusive mental images or dissociative flashbacks. Some people respond to reminders of the event with physiological sensations (racing heart, shortness of breath) or emotional distress. • Take steps to avoid the horror: refusing to watch films or television or to read accounts of the event, or pushing thoughts or memories out of consciousness. • Turn downbeat in their thinking: with persistently negative moods, they express gloomy thoughts (“I’m useless,” “The world’s a mess,” “I can’t believe anyone.”) They lose interest in important activities and feel detached from other people. Some experience amnesia for aspects of the trauma; others become numb, feeling unable to love or experience joy. • Experience symptoms of hyperarousal: irritability, excessive vigilance, trouble concentrating, insomnia, or an intensified startle response. The Fine Print The D’s: • Duration (1+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders [especially traumatic brain injury], mood and anxiety disorders, normal reactions to stressful events) Coding Notes Specify if: With delayed expression. Symptoms sufficient for diagnosis didn’t accumulate until at least six months after the event. With dissociative symptoms: Depersonalization. This indicates feelings of detachment, as though dreaming, from the patient’s own mind or body. Derealization. To the patient, the surroundings seem distant, distorted, dreamlike, or unreal. Barney Gorse “They’re gooks! The place is staffed with gooks!” Someone sitting behind Barney Gorse had dropped a book onto the tile floor, and that had set him off. Now he had backed into a corner in the waiting room of the mental health clinic. His pupils were widely dilated, and perspiration stood out on his forehead. He was panting heavily. He pointed a shaky finger at the Asian student who stood petrified on the other side of the room. “Get this goddamn gook out of here!” He made a fist and lumbered off in the direction of the student. “Hang on, Barney. It’s OK.” Barney’s new therapist took him firmly by the elbow and led him to a private office. They sat there in silence for a few minutes, while Barney’s breathing gradually returned to normal and the clinician reviewed his chart. Barney Gorse was 39 now, but he had been barely 20 when his draft number came up and he joined the Ninth Infantry Division in Vietnam. At that time President Nixon was “winding down the war,” which made it seem all the more painful when Barney’s squad was hit by mortar fire from North Vietnamese regulars. He had never talked about it, even during “anger displacement” group therapy with other veterans. Whenever he was asked to tell his story, he would fly into a rage. But something truly devastating must have happened to Barney that day. The reports mentioned a wound in the upper thigh; he had been the only member of his squad to survive the attack. He had been awarded a Purple Heart and a full pension. Barney hadn’t been able to remember several hours of the attack at all. And he had always been careful to avoid films and television programs about war. He said he’d had enough of it to last everybody’s lifetime; in fact, he had gone to some lengths to avoid thinking about it. He celebrated his discharge from the Army by getting drunk, which was how he remained for 6 years. When he finally sobered up, he turned to drugs. Even they hadn’t been enough to obliterate the nightmares that still haunted him; he awakened screaming several times a week. Sudden noises would startle him into a panic attack. Now, thanks to disulfiram and a chaplain in the county jail where he had been held as a persistent public nuisance, Barney had been clean and sober for 6 months. On the condition that he would seek treatment for his substance use, he had been released. The specialists in substance misuse treatment had quickly recognized that he had other problems, and that had led him here. Last week when they met, the therapist had reminded him again that he needed to dig into his feelings about the past. Barney had responded that he didn’t have any feelings; they’d dried up on him. For that matter, the future didn’t look so good, either: “Got no job, no wife, no kids. I just wasn’t meant to have a life.” He got up and put his hand on the doorknob to leave. “It’s no use. I just can’t talk about it.” Evaluation of Barney Gorse Let’s summarize and restate the criteria that must be fulfilled to diagnose PTSD. 1. There must be severe trauma (criterion A). Barney’s occurred in the context of combat, but a variety of civilian stressors can also culminate in death, serious injury, or sexual abuse. Two features must be present for the stressor to be considered sufficiently traumatic: (a) It must involve the fact or threat of death, severe wounds or injuries, or sexual violation; and (b) it must be personally experienced by the patient in some way—through direct observation (not viewed on TV), through personal involvement, or through information obtained after the fact that it involved a relative or close friend. A first responder (police officer, ambulance attendant) could also qualify through repeated exposure to consequences of the horrific event (think workers at Ground Zero shortly after 9/11). Divorce and death of a spouse from cancer, though undeniably stressful, are relatively commonplace and expected; they don’t qualify. 2. Through some intrusive mechanism, the patient relives the stress. Barney had flashbacks (B3), during which he imagined himself actually back in Vietnam. He also experienced rather intense responses to an external cue (seeing a staff member who, to him, resembled a Viet Cong soldier). Less dramatic forms of recollection include recurrent ordinary memories, dreams, and any other reminder of the event that results in distress or physiological symptoms. 3. The patient attempts (wittingly or not) to achieve emotional distance from the stressful event by avoiding reminders of the trauma. The reminders can be either internal (feelings, thoughts) or external (people, places, activities). Barney refused to watch movies and TV programs or to talk about Vietnam (C). 4. The patient experiences expressions (two or more) of negative mood and thoughts related to the trauma. Barney’s included amnesia for much of his time in combat (D1), a persistently negative frame of mind (“I wasn’t meant to have a life”—D4), and the lack of positive mood states (his feelings had “dried up” on him, D7). 5. Finally, for PTSD, patients must have at least two symptoms of heightened arousal and reactivity associated with the traumatic event. Barney suffered from insomnia (E6) and a severe startle response (E4); others may experience general irritability, poor concentration, or excessive vigilance. As with all symptoms, the clinician would have to determine that these symptoms of arousal had not been apparent before Barney’s Vietnam trauma. Barney’s symptoms had persisted far longer than the required minimum of 1 month (F); were obviously stressful and impaired his functioning in a number of areas (G); and could not be attributed to the direct effects of substance use—now that he’d been clean and sober for half a year (H). The experience of severe trauma in combat and the typical symptoms would render any other explanation for Barney’s symptoms unlikely. A patient with intermittent explosive disorder might become aggressive and lose control, but wouldn’t have the history of trauma. Still, clinicians must always be alert to the possibility of another medical condition (H) that might produce anxiety symptoms and could be diagnosed instead of or in addition to PTSD. For example, head injuries would be relatively common among veterans of combat or other violent trauma; we’d have to mention and code any accompanying brain injury. Situational adjustment disorder shouldn’t be confused with PTSD: The severity of the trauma would be far less, and the effects would be transient and less dramatic. In PTSD, comorbidity is the rule rather than the exception. Barney had used drugs and alcohol; his clinician would have gathered additional information about use of other substances and mentioned them in his diagnostic summary. Of combat veterans who have PTSD, half or more also have a problem with a substance use disorder, and use of multiple substances is common. Anxiety disorders (phobic disorders, generalized anxiety disorder) and mood disorders (major depressive disorder and dysthymia) are likewise common in this population. Dissociative amnesia may also occur. Any coexisting personality disorder would be explored, but it is hard to make a definitive diagnosis when a patient is acutely ill from PTSD. Malingering is also a diagnosis to consider whenever there appears to be a possibility of material gain (insurance, disability, legal problems) resulting from an accident or physical attack. Although the vignette is imprecise on this point, Barney’s symptoms probably began by the time he was discharged from the military, so he would not rate the specifier with delayed onset. The vignette doesn’t provide encouragement to add with prominent dissociation. I’d give him a GAF score of 35. Pending further information on substance use, Barney’s diagnosis would read as follows: F43.10 [309.81] Posttraumatic stress disorder F10.20 [303.90] Alcohol use disorder, moderate, in early remission Z60.2 [V60.3] Lives alone Z56.9 [V62.29] Unemployed There is still considerable controversy over the specifier with delayed expression. Many experts deny that symptoms of PTSD can begin many months or years after the trauma. Nonetheless, it is there to use, should you ever find it appropriate. Posttraumatic Stress Disorder in Preschool Children There can be no doubt that preschool children are sometimes exposed to traumatic events. Mostly, these are car accidents, natural disasters, and war—in short, all the benefits contemporary life has to offer. The question is, do very young children respond with typical PTSD symptoms? The best evidence would seem to indicate that they do, but with a likelihood much lower (0–12%) than for older children. Table 6.1 compares the DSM-5 criteria for PTSD in young children, PTSD in adults, and acute stress disorder (to be discussed next). The revamped criteria for PTSD in young children are, as we would hope, more sensitive to symptoms in this age group. Based on interviews with parents, they yield rates in children who have survived severe burns of 25% and 10% at 1 month and 6 months, respectively. TABLE 6.1. Comparison of PTSD in Preschool Children, PTSD in Adults, and Acute Stress Disorder Child PTSD Adult PTSD Acute Stress Disorder Trauma Direct experience Direct experience Direct experience Witness (not just TV) Witness Witness Learn of Learn of Repeat exposure (not just TV) Learn of Repeat exposure (not just TV) Intrusion symptoms (1/5)a Intrusion symptoms (1/5) All symptoms (9/14) • Memories • Memories • Memories • Dreams • Dreams • Dreams • Dissociative reactions • Dissociative reactions • Dissociative reactions • Psychological distress• Physiological reactions • Psychological distress• Physiological reactions • Psychological distress or physiological reactions Avoid/Neg. emotions (1/6) Avoidance (1/2) • Avoids memories • Avoids memories • Avoids memories • Avoids external reminders • Avoids external reminders • Avoids external reminders Negative emotions (2/7) • Altered sense of reality of self or surroundings • Amnesia • Amnesia • Negative beliefs • Distortion → self-blame • Negative emotional state • Negative emotional state • Decreased interest • Decreased interest • Social withdrawal • Detached from others • Decreased positive emotions • No positive emotions • No positive emotions Physiological (2/5) Physiological (2/6) • Irritable, angry • Irritable, angry • Irritable, angry • Reckless, self-destructive • Hypervigilance • Hypervigilance • Hypervigilance • Startle • Startle • Startle • Poor concentration • Poor concentration • Poor concentration • Sleep disturbance • Sleep disturbance • Sleep disturbance Duration >1 month >1 month 3 days–1 month Purchasers of this ebook can download a copy of this table from www.guilford.com/morrison2-forms. aFractions indicate the number of symptoms required of the number possible in the following list. F43 [308.3] Acute Stress Disorder Based on the observation that some people develop symptoms immediately after a traumatic stress, acute stress disorder (ASD) was devised several decades ago. Even then, this wasn’t exactly new information; something similar was noted as far back as 1865, just after the U.S. Civil War. For many years it was termed “shell shock.” Like PTSD, ASD can also be found among civilians. Overall rates of ASD, depending on the nature of the trauma and personal characteristics of the individual, center on 20%. Though the number and distribution of symptoms is different, the criteria embody the same elements required for PTSD: • Exposure to an event that threatens body integrity • Reexperiencing the event • Avoidance of stimuli associated with the event • Negative changes in mood and thought • Increased arousal and reactivity • Distress or impairment The symptoms usually begin as soon as the patient is exposed to the event (or learns about it), but they must be experienced farther out than 3 days after the stressful event to fulfill the criterion for duration. This gets us to a period of time beyond the stressful event itself and its immediate aftermath. Should symptoms last longer than 1 month, they are no longer acute and no longer constitute ASD. Then many patients will be rolled over into a diagnosis of PTSD. This is the fate of as many as 80% of patients with ASD. However, patients with PTSD don’t usually enter through the ASD doorway; most are identified farther along the road than one month. Essential Features of Acute Stress Disorder Something truly awful has happened—grave injury or sexual abuse, or perhaps the traumatic death or injury of someone else. (It could have come about through learning another has experienced violence or injury, or through repeated exposure for an emergency worker.) As a result, for up to a month the patient experiences many symptoms such as intrusive memories or bad dreams; dissociative experiences such as flashbacks or feeling unreal; the inability to experience joy or other love; amnesia for parts of the event; attempts to avoid reminders of the event (refusing to watch films or television or to read accounts of the event); pushing thoughts or memories out of consciousness. The patient may also experience symptoms of hyperarousal: irritability, hypervigilance, trouble concentrating, insomnia, or an intense startle response. The Fine Print The D’s: • Duration (3 days to 1 month) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders (especially traumatic brain injury), panic disorder, mood disorders, dissociative disorders, PTSD) Marie Trudeau Marie Trudeau and her husband, André, sat in the intake interviewer’s office. Marie was the patient, but she spent most of the time rubbing the knuckles of one hand and gazing vacantly into the room. André did most of the talking. “I just can’t believe the change in her,” he said. “A week ago, she was completely normal. Never had anything like this in her life. Heck, she’s never had anything wrong with her. Then, all of a sudden, boom! She’s a mess.” At André’s exclamation, Marie jerked around to face him and rose half out of her chair. For a few seconds she stood there, frozen except for her gaze, which darted from one side of the room to the other. “Aw, geez, I’m sorry, honey. I forgot.” He put his arm around her. Grasping her shoulders firmly but gently, he eased her back into the chair. He held her there until she began to relax her grip on his arm. A week earlier, Marie had just finished her gardening and was sitting in the back yard with a lemonade, reading a book. When she heard airplane engines, she looked up and saw two small planes flying high overhead, directly above her. “My God,” she thought, “they’re going to collide!” As she watched in horror, they did collide. She could see perfectly. The sun was low, highlighting the two planes brilliantly against the deep blue of the late afternoon sky. Something seemed to have been torn off one of them—the news media later reported that the right wing of one plane had ripped right through the cockpit of the other. Thinking to call 911, Marie picked up her portable phone, but she didn’t dial. She could only watch as two tiny objects suddenly appeared beside the stricken airplanes and tumbled toward her in a leisurely arc. “They weren’t objects, they were people.” It was the first time she had spoken during the interview. Marie’s chin trembled, and a lock of hair fell across her eye. She didn’t try to brush it back. As she continued to watch, one of the bodies hurtled into her yard 15 feet from where she was sitting. It buried itself 6 inches deep in the soft earth behind her rose bushes. What happened next, Marie seemed to have blanked out completely. The other body landed in the street a block away. Half an hour later, when the police knocked on her door, they found her in the kitchen peeling carrots for supper and crying into the sink. When André arrived home an hour after that, she seemed dazed. All she would say was “I’m not here.” In the 6 days since, Marie hadn’t improved much. Although she might start a conversation, something would appear to distract her, and she would usually trail off in midsentence. She couldn’t focus much better on her work at home. Amy, their 9-year-old daughter, seemed to be taking care of her. Sleep had slipped to a restless struggle, and three nights running Marie had awakened from a dream, trying to cry out but managing only a terrified squeak. She kept the blinds in the kitchen closed, so she wouldn’t even have to look into the back yard. “It’s like someone I saw in a World War II movie,” André concluded. “You’d think she’d been shell-shocked.” Evaluation of Marie Trudeau Anxiety and depressive symptoms are nearly universal following a severe stress. Usually these are relatively short-lived, however, and do not include the full spectrum of symptoms required for ASD. This diagnosis should only be considered when major symptoms last 3 days or more after personal exposure to a horrific event. Such an event was the plane crash Marie witnessed (criterion A2). She was dazed (B6) and emotionally unresponsive (B5), and could not recall what had happened during part of the accident (B7). When she could sleep at all (B10), she had nightmares (B2); she also avoided looking into the back yard (B9), startled easily (B14), and even in the interviewer’s office appeared hypervigilant (B12). From her inability to finish conversations, we infer poor concentration (B13), as she was distracted by intrusive recollections of the event (B1). As far as we are aware, she had had none of these symptoms (DSM-5 requires 9 of the 14 symptoms listed in criterion B) prior to witnessing the accident. Since then, just a week earlier (C), she had been unable to carry on with her work at home (D). Would any other diagnosis be possible? According to André, Marie’s previous health had been good, reducing the likelihood of another medical condition (E). We aren’t told whether she used alcohol or drugs, though the fact that she was drinking lemonade at the time of the crash could suggest that she did not. (OK, I’m definitely out on a limb here; her clinician needs to rule out a substance use disorder.) Brief psychotic disorder would be ruled out by the lack of delusions, hallucinations, or disorganized behavior or speech. Patients with ASD are likely to have severe depressive symptoms (“survivor’s guilt”), to the point that a concomitant diagnosis of major depressive disorder may sometimes be justified; Marie deserves further investigation along those lines. Until then, with a GAF score of 61, her diagnosis would be straightforward: F43.0 [308.3] Acute stress disorder Adjustment Disorder Patients with adjustment disorder (AD) may be responding to one stress or to many; the stressor may happen once or repeatedly. If the stressor goes on and on, it can even become chronic, as when a child lives with parents who fight continually. In clinical situations, the stressor has usually affected only one person, but it can affect many (think flood, fire, and famine). However, almost any relatively commonplace event could be a stressor for someone. Those most often cited for adults are getting married or divorced, moving, and financial problems; for adolescents, they are problems at school. Whatever the nature of the stressor, patients feels overwhelmed by the demands of something in the environment. As a result, they develop emotional symptoms such as low mood, crying spells, complaints of feeling nervous or panicky, and other depressive or anxiety symptoms—which must not, however, meet criteria for any defined mood or anxiety disorder. Some patients have mainly behavioral symptoms—especially ones we might think of as conduct symptoms, such as driving dangerously, fighting, or defaulting on responsibilities. The course is usually relatively brief; DSM-5 criteria specify that the symptoms must not persist longer than 6 months after the end of the stressor or its consequences. (Some studies report that a large minority of patients continue to have symptoms longer than the 6-month limit.) Of course, if the stressor is one that will be ongoing, such as a chronic illness, it may take a very long time for the patient to adjust. Although AD has been reported in 10% or more of adult primary care patients, and in huge percentages of mental health patients, one recent study found a prevalence of only 3%; many of these patients were being inappropriately treated with psychotropic medications, and in only two cases had the AD diagnosis been made. The discrepancies probably rest on the rather poorly developed criteria and on the (mistaken) view of AD as a residual diagnosis. AD is found in all cultures and age groups, including children. It may be more firmly anchored in adults than in adolescents, whose early symptoms often evolve into other, more definitive mental disorders. The reliability and validity of AD tend to be quite low. In a recent study, in under two-thirds of patients receiving the clinical diagnosis of AD could it be subsequently confirmed with ICD-10 criteria. Personality disorders or cognitive disorders may make a person more vulnerable to stress, and hence to AD. Patients in whom AD is diagnosed often misuse substances as well. Essential Features of Adjustment Disorder A stressor causes someone to develop depression, anxiety, or behavioral symptoms—but the response exceeds what you’d expect for most people in similar circumstances. After the stressor has ended, the symptoms might drag on, but not longer than 6 more months. The Fine Print The D’s: • Duration (starts within 3 months of stressor’s onset, stops within 6 months of stressor’s end) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (just about everything you can name: substance use and physical disorders, mood and anxiety disorders, trauma-related disorders, somatic symptom disorder, psychotic disorders, conduct and other behavior disorders, milder reactions to life’s stresses, normal bereavement) Coding Notes Specify: F43.21 [309.0] With depressed mood. The patient is mainly tearful, sad. F43.22 [309.24] With anxiety. The patient is mainly nervous, tense, or fearful of separation. F43.23 [309.28] With mixed anxiety and depressed mood. Symptoms combine the preceding. F43.24 [309.3] With disturbance of conduct. The patient behaves inappropriately or unadvisedly, perhaps violating societal rules, norms, or the rights of others. F43.25 [309.4] With mixed disturbance of emotions and conduct. The clinical picture combines emotional and conduct symptoms. F43.20 [309.9] Unspecified. Use for other maladaptive stress-related reactions, such as physical complaints, social withdrawal, work or academic inhibition. Specify if: Acute. The condition has lasted less than 6 months. Persistent (or chronic). 6+ months duration of symptoms, though still not lasting more than 6 months after the stressor has ended. Clarissa Wetherby “I know it’s temporary, and I know I’m overreacting. I sure don’t want to, but I just feel upset!” Clarissa Wetherby was speaking of her husband’s new work schedule. Arthur Wetherby was foreman on a road-paving crew whose current job was to widen and resurface a portion of the interstate highway just a few miles from the couple’s house. Because the section the crew was working on involved an interchange with another major highway, the work had to be done at night. For the past 2 months, Arthur had slept days and gone to work at 8:00 P.M. Clarissa worked the day shift as cashier in a restaurant. Except on weekends, when he tried to revert to a normal sleep schedule so he could be with her, they hardly ever saw one another. “I feel like I’ve been abandoned,” she said. The Wetherbys had been married only 3 years, and they had no children. Each partner had been married once before; each was 35. Neither drank or used drugs. Clarissa’s only previous encounter with the mental health system had occurred 7 years earlier, when her first husband had left her for another man. “I respected his right not to continue living a lie,” she said, “but I felt terribly alone and humiliated.” Clarissa’s symptoms now were much as they had been then. Most of the time when she was at work, she felt “about normal” and maintained good interest in what she was doing. But when alone at home in the evenings, she would be overwhelmed by waves of sadness. These left her virtually immobilized, unable even to turn on the television for company. She often cried to herself and felt guilty for giving in to her emotions. “It’s not as if someone had died, after all.” Although she had some difficulty getting to sleep at night, she slept soundly in the morning. Her weight was constant, her appetite was good, and she had no suicidal ideas or death wishes. She did not report any problems with her concentration. She denied ever having mania symptoms. The previous time she’d sought help, she had remained depressed and upset until a few weeks after the divorce was final. Then she seemed suddenly able to put it behind her and begin dating once again. “I know I’ll feel better, once Arthur gets off that schedule,” she said. “I guess it just makes me feel worthless, playing second fiddle to an overpass.” Evaluation of Clarissa Wetherby As she herself recognized, Clarissa’s reaction to the stress of her husband’s work schedule might be considered extreme by some observers. That is one of the important points of this diagnosis: The patient’s misery seems disproportionate to the apparent degree of the stress that has caused it (criterion B1). Her history provides a clue as to the source of her reaction: She was reminded of that awful time when her previous husband abandoned her—for good, and under circumstances that she considered humiliating. It is important, however, always to consider carefully whether a patient’s reaction occurs as a nonpathological response to a genuine danger, which was not the case with Clarissa. The time course of Clarissa’s symptoms was right for AD: They developed shortly after she learned about Arthur’s new work schedule (A). Although we have no way of knowing how long this episode might last, her previous episode ended after a few months, when the aftermath of her divorce had subsided (E). Of course, bereavement didn’t enter into her differential diagnosis (D). Note that AD is not intended as a residual diagnosis, though it is often used that way. Nonetheless, it does come at the end of a long differential diagnosis that comprises every other condition listed in DSM-5 (C). For Clarissa, the symptoms of mood disorder were the most prominent. She had never been manic, so could not qualify for a bipolar disorder. She had low mood, but only when alone in the evenings (not most of the day). She maintained interest in her work (rather than experiencing loss of interest in nearly all activities). Without at least one of these symptoms, there could not be a diagnosis of major depressive disorder, regardless of her guilt feelings, low energy, and trouble getting to sleep at night. Of course, her symptoms had lasted far less than 2 years, ruling out dysthymia. Although she remained fully functional at work, she was seriously distressed, fulfilling the severity requirement. The question of PTSD (and acute stress disorder) often arises in the differential diagnosis of AD. Each of those diagnoses requires that the stressor threaten serious harm and that the patient react with a variety of responses; Clarissa did not fulfill these conditions. She similarly did not have symptoms that would suggest generalized anxiety disorder, another diagnosis prominent in the differential for AD. A personality disorder may worsen (and hence become more apparent) with stress, but there is no hint that Clarissa had any lifelong character pathology. I’d assign her a GAF score of 61. F43.21 [309.0] Adjustment disorder, with depressed mood, acute Although some data support the utility of AD, which has been used clinically for decades, I recommend reserving it as a diagnosis of “almost last resort.” There are several reasons for this warning. For one thing, we probably too often use it when we simply have no better idea of what is going on. For another, the DSM-5 criteria do not tell us how we are to differentiate ordinary events from those that are stressful enough to cause depression, anxiety, or aberrant behavior. I suspect that an event is singled out solely on the basis that it causes and emotional or behavioral problem, and that seems to me a tad circular. F94.1 [313.89] Reactive Attachment Disorder F94.2 [313.89] Disinhibited Social Engagement Disorder In two apparently rare but extremely serious disorders, children who have been mistreated (by accident or design) respond by becoming either extremely withdrawn or pathologically outgoing. For neither disorder do we have a lot of information, placing these two among the least well understood of mental disorders that affect children (or adults, for that matter). Each disorder is conceived as a reaction to an environment in which the child experiences caregiving that is inconstant (frequent change of parent or surrogate) or pathological (abuse, neglect). One of two patterns then develops. In reactive attachment disorder (RAD), even young infants withdraw from social contacts, appearing shy or distant. Inhibited children will resist separation by tantrums or desperate clinging. In severe cases, infants may exhibit failure-to-thrive syndrome, with head circumference, length, and weight hovering around the 3rd percentile on standard growth charts. By contrast, a child’s response in disinhibited social engagement disorder (DSED) borders on the promiscuous. Small children eschew normal wariness and boldly approach strangers; instead of clinging, they may instead appear indifferent to the departure of a parent. In both subtypes, the abnormal responses are more obvious when the main caregiver is absent. Factors that indicate increased risk for either RAD or DSED include being reared in an orphanage or other institution; protracted hospitalizations; multiple and frequent changes in caregivers; severe poverty; abuse (the gamut of physical, emotional, and sexual); and a family riven by death, divorce, or discord. Complications associated with these disorders include stunted physical growth, low self-esteem, delinquency, anger management issues, eating disorders, malnutrition, depression or anxiety, and later substance misuse. In either disorder, a constant, nourishing relationship with a sensitive caregiver is required to reestablish adequate physical and emotional growth. Without such a remedy, the conditions tend to persist into adolescence. There has been almost no follow-up into adult life; despite a dearth of reliable information, you will (of course) find websites. DSM-IV listed these two conditions as subcategories of one disorder. Because of differences in symptoms, course, treatment response, and other correlates, DSM-5 now treats them as separate diagnoses—despite their supposed common etiology. However, some children will appear withdrawn when very young, then become disinhibited later, whereas others have symptoms of both conditions simultaneously. The upshot is that some observers find the dichotomy a bit forced. Essential Features of Reactive Attachment Disorder Adverse child care (abuse, neglect, caregiving insufficient or changed too frequently) has apparently caused a child to withdraw emotionally; the child neither seeks nor responds to soothing from an adult. Such children will habitually show little emotional or social response; far from having positive affect, they may experience periods of unprovoked irritability or sadness. The Fine Print The presumption of causality stems from the temporal relationship of the traumatic child care to the disturbed behavior. The D’s: • Demographics (begins before age 5; child has developmental age of at least 9 months) • Differential diagnosis (autism spectrum disorder, intellectual disability, depressive disorders) Coding Notes Specify if: Persistent. Symptoms are present longer than 1 year. Severe. All symptoms are present at a high level of intensity. Essential Features of Disinhibited Social Engagement Disorder Adverse child care (abuse, neglect, caregiving insufficient or changed too frequently) has apparently caused a child to become unreserved in interactions with strange adults. Such children, rather than showing typical first-acquaintance shyness, will little hesitate to leave with a strange adult; they don’t “check in” with familiar caregivers, and readily become excessively familiar. In so doing, they may cross normal cultural and social boundaries. The Fine Print The presumption of causality stems from the temporal relationship of the traumatic child care to the disturbed behavior. The D’s: • Demographics (child has developmental age of at least 9 months) • Differential diagnosis (autism spectrum disorder, intellectual disability, ADHD) Coding Notes Specify if: Persistent. Symptoms are present longer than 1 year. Severe. All symptoms are present at a high level of intensity. F43.8 [309.89] Other Specified Trauma- or Stressor-Related Disorder This diagnosis will serve to categorize those patients for whom there is an evident stressor or trauma, but who for a specific, stated reason don’t fulfill criteria for any of the standard diagnoses already mentioned above. DSM-5 gives several examples, including two forms of adjustment-like disorders (one form with delayed onset and another with prolonged duration relative to adjustment disorder). Others are as follows: Persistent complex bereavement disorder. For at least a year, a patient experiences intense grief for someone close who has died. There may be yearning and preoccupation of thoughts for the person, or continuing ruminations over the circumstance of death. A number of other symptoms express the patient’s loss of identity and reactive distress. Proposed criteria and discussion are given in Section III of DSM-5 on page 789. Various cultural syndromes. You’ll find a number of these in an appendix in DSM-5, page 833. F43.9 [309.9] Unspecified Trauma- or Stressor-Related Disorder This diagnosis will serve to categorize those patients for whom there is an evident stressor or trauma, but who don’t fulfill criteria for any of the standard diagnoses already mentioned above, and for whom you do not care to specify the reasons why the criteria are not fulfilled.”
“Dissociative Disorders Quick Guide to the Dissociative Disorders Dissociative symptoms are principally covered in this chapter, but there are some conditions (especially involving loss or lapse of memory) that are classified elsewhere. Yep, the link indicates where a more detailed discussion begins. Primary Dissociative Disorders Dissociative amnesia. The patient cannot remember important information that is usually of a personal nature. This amnesia is usually stress-related. Dissociative identity disorder. One or more additional identities intermittently seize control of the patient’s behavior. Depersonalization/derealization disorder. There are episodes of detachment, as if the patient is observing the patient’s own behavior from outside. In this condition, there is no actual memory loss. Other specified, or unspecified, dissociative disorder. Patients who have symptoms suggestive of any of the disorders above, but who do not meet criteria for any one of them, may be placed in one of these two categories. Other Causes of Marked Memory Loss When dissociative symptoms are encountered in the course of other mental diagnoses, a separate diagnosis of a dissociative disorder is not ordinarily given. Panic attack. Some patients panic may experience depersonalization or derealization as part of an acute panic attack. Posttraumatic stress disorder. A month or more following a severe trauma, the patient may not remember important aspects of personal history. Acute stress disorder. Immediately following a severe trauma, patients may not remember important aspects of personal history. Somatic symptom disorder. Patients who have a history of somatic symptoms that cannot be explained on the basis of known disease mechanisms can also forget important aspects of personal history. Non-rapid eye movement sleep arousal disorder, sleepwalking type. Sleepwalking resembles the dissociative disorders, in that there is amnesia for purposeful behavior. But it is classified elsewhere in order to keep all the sleep disorders together. Borderline personality disorder. When severely stressed, these people will sometimes experience episodes of dissociation, such as depersonalization. Malingering. Some patients consciously feign symptoms of memory loss. Their object is material gain, such as avoiding punishment or obtaining money or drugs. INTRODUCTION Dissociation occurs when one group of normal mental processes becomes separated from the rest. In essence, some of an individual’s thoughts, feelings, or behaviors are removed from conscious awareness and control. For example, an otherwise healthy college student cannot recall any of the events of the previous 2 weeks. As with so many other mental symptoms, you can have dissociation without disorder; if it’s mild, it can be entirely normal. (Perhaps, for example, while enduring a boring lecture, you once daydreamed about your weekend plans, unaware that you’ve been called on for a response?) There’s also a close connection between the phenomena of dissociation and hypnosis. Indeed, over half the people interviewed in some surveys have had some experience of a dissociative nature. Episodes of dissociation severe enough to constitute a disorder have several features in common: • They usually begin and end suddenly. • They are perceived as a disruption of information that is needed by the individual. They can be positive, in the sense of something added (for example, flashbacks) or negative (a period of time for which the person has no memory). • Although clinicians often disagree as to their etiology, many episodes are apparently precipitated by psychological conflict. • Although they are generally regarded as rare, their numbers may be increasing. • In most (except depersonalization/derealization disorder), there is a profound disturbance of memory. • Impaired functioning or a subjective feeling of distress is required only for dissociative amnesia and depersonalization/derealization disorder. Conversion symptoms (typical of the somatic symptom disorders) and dissociation tend to involve the same psychic mechanisms. Whenever you encounter a patient who dissociates, consider whether such a diagnosis is also warranted. F48.1 [300.6] Depersonalization/Derealization Disorder Depersonalization can be defined as a sense of being cut off or detached from oneself. This feeling may be experienced as viewing one’s own mental processes or behavior; some patients feel as though they are in a dream. When a patient is repeatedly distressed by episodes of depersonalization, and there is no other disorder that better accounts for the symptoms, you can diagnose depersonalization/derealization disorder (DDD). DSM-5 offers another route to that diagnosis: through the experience of derealization, a feeling that the exterior world is unreal or odd. Patients may notice that the size or shape of objects has changed, or that other people seem robotic or even dead. Always, however, the person retains insight that it is only a change in perception—that the world itself has remained the same. Because about half of all adults have had at least one such episode, we need to place some limits on who receives this diagnosis. It should not be made unless the symptoms are persistent or recurrent, and unless they impair functioning or cause pretty significant distress (this means something well beyond the bemused reflection, “Well, that was weird!”). In fact, depersonalization and derealization are much more commonly encountered as symptoms than as a diagnosis. For example, derealization or depersonalization is one of the qualifying symptoms for panic attack. Episodes of DDD are often precipitated by stress; they may begin and end suddenly. The disorder usually has its onset in the teens or early 20s; usually it is chronic. Although still not well studied, prevalence rates in the general population appear to be around 1–2%, with males and females nearly equal. Essential Features of Depersonalization/Derealization Disorder A patient experiences depersonalization or derealization, but reality testing remains intact throughout. (The definitions are provided in the previous section.). The Fine Print The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood or anxiety disorders, psychotic disorders, trauma- and stressor-related disorders, other dissociative disorders) Francine Parfit “It feels like I’m losing my mind.” Francine Parfit was only 20 years old, but she had already worked as a bank teller for nearly 2 years. Having received several raises during that time, she felt that she was good at her job—conscientious, personable, and reliable. And healthy, though she’d been increasingly troubled by her “out-of-body experiences,” as she called them. “I’ll be standing behind my counter and, all of a sudden, I’m also standing a couple of feet away. I seem to be looking over my own shoulder as I’m talking with my customer. And in my head I’m commenting to myself on my own actions, as if I were a different person I was watching. Stuff like ‘Now she’ll have to call the assistant manager to get approval for this transfer of funds.’ I came to the clinic because I saw something like this on television a few nights ago, and the person got shock treatments. That’s when I began to worry something really awful was wrong.” Francine denied that she had ever had blackout spells, convulsions, blows to the head, severe headaches, or dizziness. She had smoked pot a time or two in high school, but otherwise she was drug- and alcohol-free. Her physical health had been excellent; her only visits to physicians had been for immunizations, Pap smears, and a preemployment physical exam 2 years ago. Each episode began suddenly, without warning. First Francine would feel quite anxious; then she’d notice that her head seemed to bob up and down slightly, out of her control. Occasionally she felt a warm sensation on the top of her head, as if someone had cracked a half-cooked egg that was dribbling yolk down through her hairline. The episodes seldom lasted longer than a few minutes, but they were becoming more frequent—several times a week now. If they occurred while she was at work, she could often take a break until they passed. But several times it had happened when she was driving. She worried that she might lose control of her car. Francine had never heard voices or had hallucinations of other senses; she denied ever feeling talked about or plotted against in any way. She had never had suicidal ideas and didn’t really feel depressed. “Just scared,” she concluded. “It’s so spooky to feel that you’ve sort of died.” Evaluation of Francine Parfit The sensation of being an outside observer of yourself can be quite unsettling; it is one that many people who are not patients have had a time or two. What makes Francine’s experience stand out is the fact that it returned often enough (criterion A1) and forcibly enough to cause her considerable distress—enough to seek an evaluation, at any rate (C). (She was a little unusual in that her episodes didn’t seem to be precipitated by stress; in many people, they are.) Notice that she described her experience “as if I were a different person,” not “I am a different person.” This tells us that she retained contact with reality (B). Francine’s experiences and feelings were much like those of Shorty Rheinbold, except that his occurred as symptoms of panic disorder. A variety of other conditions include depersonalization as a symptom: posttraumatic stress disorder, anxiety, cognitive, mood, personality, and substance-related disorders; schizophrenia; and epilepsy (D, E). However, Francine did not complain of panic attacks or have symptoms of other disorders that could account for the symptoms. Note a new feature in DSM-5: Francine could also have received this diagnosis if she had experienced only symptoms of derealization. With a GAF score of 70, her diagnosis would be: F48.1 [300.6] Depersonalization/derealization disorder Though it goes unmentioned in DSM-5, a collection of symptoms called the phobic anxiety depersonalization syndrome sometimes occurs, especially in young women. In addition to depression, such patients, not surprisingly, have phobias, anxiety, and depersonalization. This condition may be a variant of major depressive disorder, with atypical features. F44.0 [300.12] Dissociative Amnesia There are two main requirements for dissociative amnesia (DA): (1) The patient has forgotten something important, and (2) other disorders have been ruled out. Of course, the central feature is the inability to remember significant events. Over 100 years ago, clinicians like Pierre Janet recognized several patterns in which this forgetting can occur: Localized (or circumscribed). The patient has recall for none of the events that occurred within a particular time frame, often during a calamity such as a wartime battle or a natural disaster. Selective. Certain portions of a time period, such as the birth of a child, have been forgotten. This type is less common. The next three types are much less common, and may eventually lead to a diagnosis of dissociative identity disorder (see below): Generalized. All of the experiences during the patient’s entire lifetime have been forgotten. Continuous. The patient forgets all events from a given time forward to the present. This is now extremely rare. Systematized. The patient has forgotten certain classes of information, such as that relating to family or to work. DA begins suddenly, usually following severe stress such as physical injury, guilt about an extramarital affair, abandonment by a spouse, or internal conflict over sexual issues. Sometimes the patient wanders aimlessly near home. Duration ranges widely, from minutes to perhaps years, after which the amnesia usually ends abruptly with complete recovery of memory. In some individuals, it may occur again, perhaps more than once. DA has still received insufficient study, so too little is known about demographic patterns, family occurrence, and the like. Beginning during early adulthood, it is most commonly reported in young women; it may occur in 1% or less of the general population, though recent surveys have pegged it somewhat higher. Many patients with DA have reported childhood sexual trauma, with a high percentage who cannot remember the actual abuse. Dissociative Fugue In the subtype of DA known as dissociative fugue, the amnesic person suddenly journeys from home. This often follows a severe stress, such as marital strife or a natural or human-made disaster. The individual may experience disorientation and a sense of perplexity. Some will assume a new identity and name, and for months may even work at a new occupation. However, in most instances the episode is a brief episode of travel, lasting a few hours or days. Occasionally, there may be outbursts of violence. Recovery is usually sudden, with subsequent amnesia for the episode. Dissociative fugue is another of those extraordinarily interesting, rare disorders—fodder for novels and motion pictures—about which there has been little in the way of recent research. For example, little is known about sex ratio or family history. This is a part of the reason (after its general rarity) that accounts for the demotion of dissociative fugue from an independent diagnosis in DSM-IV to a mere subtype of dissociative amnesia in DSM-5. DSM-5 notes, by the way, that the greatest prevalence of fugue states is among patients with dissociative identity disorder. Essential Features of Dissociative Amnesia Far beyond common forgetfulness, there is a loss of recall for important personal (usually distressing or traumatic) information. The Fine Print The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, cognitive disorders, trauma- and stressor-related disorders, dissociative identity disorder, somatic symptom disorder, ordinary forgetfulness) Coding Note If relevant, specify: F44.1 [300.13] With dissociative fugue Holly Kahn A mental health clinician presented the following dilemma to a medical center ethicist. A single 38-year-old woman had been seen several times in the outpatient clinic. She had complained of depression and anxiety, both of which were relatively mild. These symptoms seemed focused on the fact that she was 38 and unmarried, and “her biological clock was ticking.” She had had no problems with sleep, appetite, or weight gain or loss, and had not thought about suicide. For many months Holly Kahn had so longed for a child that she intentionally became pregnant by her boyfriend. When he discovered what she had done, he broke off contact with her. The following week she miscarried. Stuck in her boring, unrewarding job as a sales clerk in a store that specialized in teaching supplies, she said she’d come to the clinic for help in “finding meaning for her life.” The oldest girl in a Midwestern family, Holly had spent much of her adolescence caring for younger siblings. Although she had attended college for 2 years during her mid-20s, she had come away with neither degree nor career to show for it. In the last decade, she had lived with three different men; her latest relationship had lasted the longest and had seemed the most stable. She had no history of drug abuse or alcoholism and was in good physical health. The clinician’s verbal description was of a plain, no longer young (and perhaps never youthful), heavy-set woman with a square jaw and stringy hair. “In fact, she looks quite a lot like this.” The clinician produced a drawing of a woman’s head and shoulders. It was somewhat indistinct and smudged, but the features did fit the verbal description. The ethicist recognized it as a flyer that had recently received wide distribution. The copy below the picture read: “Wanted by FBI on suspicion of kidnapping.” A day-old infant had been abducted from a local hospital’s maternity ward. The first-time mother, barely out of her teens, had handed the baby girl to a woman wearing an operating room smock. The woman had introduced herself as a nursing supervisor and said she needed to take the baby for a final weighing and examination before the mother could take her home. That was the last time anyone could remember seeing either the woman or the baby. The picture had been drawn by a police artist from a description given by the distraught mother. A reward was being offered by the baby’s grandparents. “The next-to-last time I saw my patient, we were trying to work on ways she could take control over her own life. She seemed quite a bit more confident, less depressed. The following week she came in late, looking dazed. She claimed to have no memory of anything she had done for the past several days. I asked her whether she’d been ill, hit on the head, that sort of thing. She denied all of it. I started probing backward to see if I could jog her memory, but she became more and more agitated and finally rushed out. She said she’d return the next week, but I haven’t seen her since. It wasn’t until yesterday that I noticed her resemblance to the woman in this picture.” The therapist sat gazing at the flyer for a few seconds, then said: “Here’s my dilemma. I think I know who committed this really awful crime, but I have a privileged relationship with the person I suspect. Just what is my ethical duty?” Evaluation of Holly Kahn Whether Holly took the baby is not the point here. At issue is the cause of her amnesia, which was her most pressing recent problem (criterion A). She had been under stress because of her desire to have a baby, and this could have provided the stimulus for her amnesia. The episode was itself evidently stressful enough that she broke off contact with her clinician (B). There is no information provided in the vignette that might support other (mostly biological) causes of amnesia (D). Specifically, there was no head trauma that might have induced a major neurocognitive disorder due to traumatic brain injury. Substance-induced neurocognitive disorder, persistent would be ruled out by Holly’s history of no substance use (C). Her general health had been good and there was no history of abnormal physical movements, reducing the likelihood of epilepsy. Although she had had a miscarriage, too much time had passed for a postabortion psychosis to be a possibility. Some patients with amnesia are also mute; they may be misdiagnosed as having another medical condition with catatonic symptoms. And, just to be complete, we should note that her loss of memory is far more striking and significant than ordinary forgetfulness, which is what we humans experience all the time. There was no history of a recent, massive trauma that might indicate acute stress disorder. If she was malingering, she did it without an obvious motive (had she been trying to avoid punishment for a crime, simply staying away from the medical center would have served her better). It certainly wouldn’t appear to be a case of normal daydreaming. Holly was clear about her personal identity, and she did not travel from home, so she would not qualify for the dissociative fugue subtype diagnosis. Although we must be careful not to make a diagnosis in a patient we have not personally interviewed and for whom we lack adequate collateral information, if what material we do have is borne out by subsequent investigation, her diagnosis would be as below. I’d give her GAF score as 31. F44.0 [300.12] Dissociative amnesia John Doe When the man first walked into the homeless shelter, he hadn’t a thing to his name, including a name. He’d been referred from a hospital emergency room, but he told the clinician on duty that he’d only gone there for a place to stay. As far as he was aware, his physical health was good. His problem was that he didn’t remember a thing about his life prior to waking up on a park bench at dawn that morning. Later, when filling out the paperwork, the clinician had penciled in “John Doe” as the patient’s name. Aside from the fact that he could give a history spanning only about 8 hours, John Doe’s mental status exam was remarkably normal. He appeared to be in his early 40s. He was dressed casually in slacks, a pink dress shirt, and a nicely fitting corduroy sports jacket with leather patches on the elbows. His speech was clear and coherent; his affect was generally pleasant, though he was obviously troubled at his loss of memory. He denied having hallucinations or delusions (“as far as I know”), though he pointed out logically enough that he “couldn’t vouch for what kind of crazy ideas I might have had yesterday.” John Doe appeared intelligent, and his fund of information was good. He could name five recent presidents in order, and he could discuss recent national and international events. He could repeat eight digits forward and six backwards. He scored 29 out of 30 on the MMSE, failing only to identify the county in which the shelter was located. Although he surmised (he wore a wedding ring) that he must be married, after half an hour’s conversation he could remember nothing pertaining to his family, occupation, place of residence, or personal identity. “Let me look inside your sports jacket,” the clinician said. John Doe looked perplexed, but unbuttoned his jacket and held it open. The label gave the name of a men’s clothing store in Cincinnati, some 500 miles away. “Let’s try there,” suggested the clinician. Several telephone calls later, the Cincinnati Police Department identified John Doe as an attorney whose wife had reported him missing 2 days earlier. The following morning John Doe was on a bus for home, but it was days before the clinician heard the rest of the story. A 43-year-old specialist in wills and probate, John Doe had been accused of mingling the bank accounts of clients with his own. He had protested his innocence and hired his own attorney, but the Ohio State Bar Association stood ready to proceed against him. The pressure to straighten out his books, maintain his law practice, and defend himself in court and against his own state bar had been enormous. Two days before he disappeared, he had told his wife, “I don’t know if I can take much more of this without losing my mind.” Evaluation of John Doe John Doe was classically unable to recall important autobiographical information—in fact, all of it (criterion A). It is understandable—and required (B)—that this troubled him. Neither at the time of evaluation nor at follow-up was there evidence of alternative disorders (D). John had not switched repeatedly between identities, which would rule out dissociative identity disorder (you wouldn’t diagnose the two disorders together). Other than obvious amnesia, there was no evidence of a cognitive disorder. At age 43, a new case of temporal lobe epilepsy would be unlikely, but a complete evaluation should include a neurological workup. Of course, any patient who has episodes of amnesia must be evaluated for substance-related disorders (especially as concerns alcohol, C). Conscious imitation of amnesia in malingering can be very difficult to discriminate from the amnesia involved in DA with dissociative fugue. However, although John Doe did have legal difficulties, these would not have been relieved by his feigning amnesia. (When malingering appears to be a possibility, collateral history from relatives or friends of previous such behavior or of antisocial personality disorder can help.) A history of lifelong multiple medical symptoms might suggest somatic symptom disorder. John had no cross-sectional features that would suggest either a manic episode or schizophrenia, in either of which wandering and other bizarre behaviors can occur. Epilepsy is always mentioned in the differential diagnosis of the dissociative disorders. However, epilepsy and dissociation should not be hard to tell apart in practice, even without the benefit of an EEG. Epileptic episodes usually last no longer than a few minutes and involve speech and motor behavior that are repetitive and apparently purposeless. Dissociative behavior, on the other hand, may last for days or longer and involves complex speech and motor behaviors that appear purposeful. Although John Doe’s case is not quite classical (he did not assume a new identity and adopt a new life), he did travel far from home and purposefully set about seeking shelter. That sets up the specifier for his diagnosis. And by the way, his GAF score would be 55. F44.1 [300.13] Dissociative amnesia, with dissociative fugue Z65.3 [V62.5] Investigation by state bar association Note that the fugue subtype has a different code number than plain old dissociative amnesia. This reflects the fact that, in ICD-10 and in ICD-9, a fugue state is a diagnosis separate and apart from dissociative amnesia. So the number change isn’t a mistake. F44.81 [300.14] Dissociative Identity Disorder In dissociative identity disorder (DID), which previously achieved fame as multiple personality disorder, the person possesses at least two distinct identities. Ranging up to 200 in number, these identities may have their own names; they don’t even have to be of the patient’s own gender. Some may be symbolic, such as “The Worker.” They can vary widely in age and style: If the patient is normally shy and quiet, one identity may be outgoing or even boisterous. The identities may be aware of one another to some degree, though only one interacts with the environment at a time. The transition from one to another is usually sudden, often precipitated by stress. Most of them are aware of the loss of time that occurs when another identity is in control. However, some patients aren’t aware of their peculiar state until a close friend points out the alterations in character with time. Of particular diagnostic note are states of pathological possession, which can have characteristics similar to DID. They may be characterized by the patient as a spirit or other external being that has taken over the person’s functioning. If this behavior is part of a recognized, accepted religious practice, it will not usually qualify for diagnosis as DID. However, a person who has recurrent possession states that cause distress and otherwise conform to DSM-5 criteria may well qualify for diagnosis. Of course, we would not diagnose DID in a child on the basis of having an imaginary playmate. Affecting up to 1% of the general population, DID is diagnosed much more commonly by clinicians in North America than in Europe. This fact has engendered a long-running dispute. European clinicians (naturally) claim that the disorder is rare, and that by paying so much attention to patients who dissociate, New World clinicians actually encourage the development of cases. At this writing, the dispute continues unresolved. The onset of this perhaps too-fascinating disorder is usually in childhood, though it is not commonly recognized then. Most of the patients are female, and many may have been sexually abused. DID tends toward chronicity. It may run in families, but the question of genetic transmission is also unresolved. Essential Features of Dissociative Identity Disorder A patient appears to have at least two clearly individual personalities, each with unique attributes of mood, perception, recall, and control of thought and behavior. The result: a person with memory gaps for personal information that common forgetfulness cannot begin to explain. The Fine Print The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood or anxiety disorders, psychotic disorders, trauma- and stressor-related disorders, other dissociative disorders, religious possession states accepted in non-Western cultures, childhood imaginary playmates/fantasy play) Effie Jens On her first visit to the mental health clinic, Effie cried and talked about her failing memory. At age 26—too young for Alzheimer’s—she felt senile on some days. For several months she had noticed “holes in her memory,” which sometimes lasted 2 or 3 days. Her recall wasn’t just spotty; for all she knew about her activities on those days, she might as well have been under anesthesia. However, from telltale signs—such as food that had disappeared from her refrigerator and recently arrived letters that had been opened—she knew she must have been awake and functioning during these times. On the proceeds of the property settlement from her recent divorce, Effie lived alone in a small apartment; her family lived in a distant state. She enjoyed quiet pastimes, such as reading and watching television. She was shy and had trouble meeting people; there was no one she saw often enough to help her account for the missing time. For that matter, Effie wasn’t all that clear about the details of her earlier life. She was the second of three daughters of an itinerant preacher; her early childhood memories were a jumble of labor camps, cheap hotel rooms, and Bible-thumping sermons. By the time she reached age 13, she had attended 15 different schools. Late in the interview, she revealed that she had virtually no memory of the entire year she was 13. Her father’s preaching had been moderately successful, and they had settled for a while in a small town in southern Oregon—the only time she had started and finished a year in the same school. But what had happened to her during the intervening months? Of that time, she recalled nothing whatsoever. The following week Effie came back, but she was different. “Call me Liz,” she said as she dropped her shoulder bag onto the floor and leaned back in her chair. Without further prompting, she launched into a long, detailed, and dramatic recounting of her activities of the last 3 days. She had gone out for dinner and dancing with a man she had met in the grocery store, and afterwards they had hit a couple of bars together. “But I only had ginger ale,” she said, smiling and crossing her legs. “I never drink. It’s terrible for the figure.” “Are there any parts of last week you can’t remember?” “Oh, no. She’s the one who has amnesia.” “She” was Effie Jens, whom Liz clearly regarded as a person quite different from her own self. Liz was happy, carefree, and sociable; Effie was introspective and preferred solitude. “I’m not saying that she isn’t a decent human being,” Liz conceded, “but you’ve met her—don’t you think she’s just a tad mousy?” Although for many years she had “shared living space” with Effie, it wasn’t until after the divorce that Liz had begun to “come out,” as she put it. At first this had happened for only an hour or two, especially when Effie was tired or depressed and “needed a break.” Recently Liz had taken control for longer and longer periods of time; once she had done so for 3 days. “I’ve tried to be careful, it frightens her so,” Liz said with a worried frown. “I’ve begun to think seriously about taking control for all time. I think I can do a better job. I certainly have a better social life.” Besides being able to recount her activities during the blank times that had driven Effie to seek care, Liz could give an eyewitness account of all of Effie’s conscious activities as well. She even knew what had gone on during Effie’s “lost” year, when she was 13. “It was Daddy,” she said with a curl of her lip. “He said it was part of his religious mission to ‘practice for a reenactment of the Annunciation.’ But it was really just another randy male groping his own daughter, and worse. Effie told Mom. At first, Mom wouldn’t believe her. And when she finally did, she made Effie promise never to tell. She said it would break up the family. All these years, I’m the only other one who’s known about it. No wonder she’s losing her grip—it even makes me sick.” Evaluation of Effie Jens Effie’s two personalities (criterion A) are fairly typical of DID: One was quiet and unassuming, almost mousy, whereas the other was much more assertive. (Effie’s history was atypical in that more personalities than two are the rule.) What happened when Liz was in control was unknown to Effie, who experienced these episodes as amnesia. This difficulty with recall was vastly more extensive than you’d expect of common forgetfulness (B). It was distressing enough to send Effie to the clinic (C). Several other causes of amnesia should be considered in the differential diagnosis of this condition. Of course, any possible medical condition must first be ruled out, but Effie/Liz had no history suggestive of either a seizure disorder or substance use (we’re thinking of alcoholic blackouts and partial seizures here). Even though Effie (or Liz) had a significant problem with amnesia, it was not her main problem, as would be the case with dissociative amnesia, which is less often recurrent and does not involve multiple, distinct identities. Note, too, the absence of any information that Effie belonged to a cultural or religious group whose practices included trances or other rituals that could explain her amnesia (D). Schizophrenia has often been confused with DID, primarily by laypeople who equate “split personality” (which is how many have come to characterize schizophrenia) with multiple personality disorder, the old name for DID. However, although bizarre behavior may be encountered in DID, none of the identities is typically psychotic. As with other dissociative disorders, discrimination from malingering can be difficult; information from others about possible material gain provides the most valuable data. Effie’s history was not typical for either of these diagnoses. Some patients with DID will also have borderline personality disorder. The danger is that only the latter will be diagnosed by a clinician who mistakes alternating personae for the unstable mood and behavior typical of borderline personality disorder. Substance-related disorders sometimes occur with DID; neither Effie nor Liz drank alcohol (E). Her GAF score would be 55. F44.81 [300.14] Dissociative identity disorder Z63.5 [V61.03] Divorce F44.89 [V300.15] Other Specified Dissociative Disorder This category is for patients whose symptoms represent a change in the normally integrative function of identity, memory, or consciousness, but who do not meet criteria for one of the specific dissociative disorders listed above. Here are some examples; a particular condition should be stated after the other specified diagnosis is given. Identity disturbance due to prolonged and intense coercive persuasion. People who have been brainwashed or otherwise indoctrinated may develop mixed dissociative states. Acute dissociative reactions to stressful events. DSM-5 mentions that these often last just a few hours, though less than a month, and are characterized by mixed dissociative symptoms (depersonalization, derealization, amnesia, disruptions of consciousness, stupor). Dissociative trance. Here the person loses focus on the here and now, and may behave automatically. (A person’s engaging in an accepted religious or cultural ritual would not qualify as an example of dissociative trance.) F44.9 [V300.15] Unspecified Dissociative Disorder This diagnosis will serve to categorize those patients for whom there are evident dissociative symptoms, but who don’t fulfill criteria for any of the standard diagnoses already mentioned above, and for whom you do not care to specify the reasons why the criteria are not fulfilled.”