The differential diagnosis of epilepsy, pseudoseizures, dissociative identity disorder, and dissociative disorder not otherwise specified.

The authors review the co-occurrences of dissociative symptoms and disorders with epilepsy and pseudo-seizures and examine newer diagnostic instruments that assist in accurate diagnosis of persons with concomitant seizure behaviors and dissociative symptoms. They also review seizure behaviors and electroencephalographic findings in persons with dissociative identity disorder (DID) and dissociative disorder not otherwise specified (DDNOS) and dissociative symptoms in persons with epilepsy and with pseudoseizures. Dissociative symptoms in 15 patients with epilepsy and 15 with pseudo-seizures were examined using the Dissociative Experiences Scale (DES) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). On the SCID-D, pseudo-seizure patients had significantly higher dissociative symptom scores than epileptic patients, but DES scores did not reliably distinguish epileptic and pseudo-seizure patients. Misdiagnosis of persons with seizures and dissociative symptoms can be avoided by careful adherence to DSM dissociative disorder criteria, the use of video-EEG monitoring, and systematic assessment of dissociative symptoms with the SCID-D.

Psychogenic or dissociative fugue: a clinical investigation of five cases.

Dissociative fugue (formerly psychogenic fugue) is a rare and little understood dissociative disorder. Following a review of the pertinent literature, five cases of dissociative fugue are described. These cases were systematically studied with a comprehensive history, mental status examination, physical and neurological evaluation, review of previous medical and psychiatric records, and psychological testing including MMPI, WAIS-R, electroencephalogram, and Dissociative Experiences Scale. An unexpected finding was that, in some cases, associated criminal activity may allow the person with dissociative fugue to continue to function in spite of their loss of memory and original identity.

The dissociative disorders. Rarely considered and underdiagnosed.

A wide variety of dissociative disorders, including dissociative amnesia, dissociative fugue, depersonalization disorder, dissociative identity disorder, and various forms of dissociative disorder not otherwise specified. In many instances, these disorders are either underdiagnosed or misdiagnosed secondary to the clinician's mistaken belief that dissociative disorders are rare. Recent research shows that dissociative disorders may comprise 5% to 10% of psychiatric populations. This article reviews the epidemiology and clinical symptomatology of these disorders. In addition, various screening and diagnostic instruments, such as the DES, Structured Clinical Interview for Dissociative Disorders, and MMPI, are discussed.

Confirmation of childhood abuse in child and adolescent cases of multiple personality disorder and dissociative disorder not otherwise specified.

The diagnostic validity of multiple personality disorder (MPD) and its association to trauma have been questioned because corroboration of child abuse in studies of patients with MPD is scant. The purpose of this study was to determine on a retrospective basis whether external corroboration of child abuse could be found in a group of patients with MPD and dissociative disorder not otherwise specified. A group of child and adolescent psychiatric inpatients and outpatients was chosen because of the extensive number of collateral records collected on them in a tertiary care setting. This group was also chosen because of the intense interest paid by child protective services and courts to child abuse during the past 15 years. This retrospective chart review confirmed child abuse in eight of nine patients with MPD and in all 12 cases of dissociative disorder not otherwise specified. This study provides further evidence of the association of severe dissociative disorders with trauma, particularly child abuse. Future studies should be prospective and blinded to avoid the possibility of investigator bias, and should include a control group for comparison of base rate of child abuse.

Use of the MMPI to distinguish genuine from factitious multiple personality disorder.

MMPI special scales were repeatedly administered to several personality states of a woman alleging to have Multiple Personality Disorder. Her inability to produce a consistent response set on retesting helped to unmask a case of factitious multiple personality.

The use of electroconvulsive therapy in patients with dissociative disorders.

The psychiatric literature generally discourages the use of electroconvulsive therapy (ECT) to treat depression in dissociative disorder patients, but contains little data on outcome. This prospective study of ECT in three dissociative disorder patients demonstrates that ECT is indicated for severe treatment-resistant depression in such patients. Their Hamilton Depression Scale scores fell by 50%, they were remarkably clinically improved, and they maintained their gains for at least 4 months. The ECT proved helpful when depression was felt by most of the active alters rather than just by one depressed personality. Mini-Mental State Examination scores and clinical observation revealed no unusual confusion or side effects from ECT. These patients' dissociated condition was not altered by ECT, which indicates that ECT neither treats nor impairs treatment of dissociation. Electroconvulsive therapy can be helpful in the overall treatment of dissociative disorders by alleviating severe depressions which block utilization of psychotherapy.

Iatrogenesis and malingering of multiple personality disorder in the forensic evaluation of homicide defendants.

In this article I have addressed the possibility of iatrogenesis and/or malingering of MPD in 19 individuals who were charged with homicide. Due to the fragmentary nature of most of these case reports, it is not possible to state definitively who had genuine MPD and who did not. There is a strong possibility that a substantial proportion were malingering, however, because of their rather atypical presentations. Data from other sources suggest that the use of hypnosis in individuals accused of homicide may iatrogenically produce MPD-like phenomena when coupled with the defendant's desire to escape criminal responsibility. Finally, I have offered guidelines for the forensic evaluation of homicide defendants in whom MPD is suspected. Although hypnosis should generally be avoided in such defendants if it is used, rather strict guidelines should be followed. Clinicians using hypnosis with such individuals should be forewarned that such use will be strongly challenged in court and could pose an extreme threat to the defense position.

The use of hypnosis in a deaf patient with multiple personality disorder: a case report.

We present the first report of multiple personality disorder (MPD) in a prelingually deaf patient and the first description of alter personalities as the source of auditory hallucinations in a nonpsychotic deaf person. This young woman's history and clinical symptoms of MPD did not differ from those of hearing patients. A hypnotic trance was induced by instructing the patient in muscle relaxation, modeling relaxation with exhalation, and having the patient focus her gaze on the hypnotist repeatedly fingerspelling R-E-L-A-X. Hypnosis facilitated automatic handwriting, allowed the first meeting with an alter personality, and speeded the diagnostic process. Fingerspelling has not previously been reported in hypnosis of the deaf. It is a practical means of induction for a therapist who lacks fluent signing skills. It provides a narrow fix of gaze and avoids induction by physical stimulation, a process that some abused patients find upsetting.

Accuracy of the MMPI in identifying multiple personality disorder.

A number of previous studies have delineated Minnesota Multiphasic Personality Inventory (MMPI) characteristics in patients with multiple personality. To test the accuracy of the MMPI in identifying such patients, the authors blindly rated 63 MMPIs as being either multiple personality or not. The over-all hit rate for the entire sample was 71.4%, with a 68% hit rate for correctly identified patients with multiple personality. These hit rates compare favorably with the hit rates in similar studies of other psychiatric disorders and further demonstrate the clinical usefulness of the MMPI in the diagnosis of multiple personality.

Post-traumatic aspects of the treatment of victims of sexual abuse and incest.

This study assesses the frequency of childhood abuse and adult traumatization and the presence of symptomatology of post-traumatic stress and dissociation across different DSM-III diagnostic categories including affective disorder, schizophrenia, eating disorders, PTSD, borderline personality disorder, and multiple personality disorder. Findings revealed high levels of child abuse among patients with dissociative disorder and borderline personality disorder. The patients with dissociative disorders were found to have an increased incidence of rape and wife battery in adulthood. Patients with dissociative and post-traumatic stress disorders were found to experience similar symptomatology. The findings from this study highlight the need to assess all psychiatric patients for a history of physical and sexual trauma. Major treatment issues in patients who suffer from either type of trauma include the development of trust and the abreaction and working through of traumatic memories. Conjoint sessions with concerned others may be beneficial.