276 Trauma- and Stressor-Related Disorders
caused by cars or trucks) and those not relate d to the traumatic event (e.g., being fearful of
suffering a heart attack) (Criterion E3). Individuals with PTSD may be very reactive to un-
expected stimuli, displaying a heightened startle response, or jumpiness, to loud noises or
unexpected movements (e.g., jumping markedly in response to a telephone ringing) (Cri-
terion E4). Concentration difficulties, includ ing difficulty remembering daily events (e.g.,
forgetting one’s telephone numb er) or attending to focused t asks (e.g., following a conver-
sation for a sustained period of time), are commonly reported (Criterion E5). Problems
with sleep onset and maintenance are commo n and may be associated with nightmares
and safety concerns or with generalized elevated  arousal that interferes with adequate sleep
(Criterion E6). Some in dividuals also experien ce persistent dissociative symptoms of de-
tachment from their bodies (depersonalization) or the world around them (derealization);
this is reflected in the “with di ssociative symptoms” specifier.
Associated Features Supporting Diagnosis
Developmental regression, such as loss of la nguage in young children, may occur. Audi-
tory pseudo-hallucinations, such as having  the sensory experience of hearing one’s
thoughts spoken in one or more different voic es, as well as paranoid ideation, can be pres-
ent. Following prolonged, repeated, and seve re traumatic events (e.g., childhood abuse,
torture), the individual may additionally experi ence difficulties in regulating emotions or
maintaining stable interpersonal relationship s, or dissociative symptoms. When the trau-
matic event produces violent death, symptoms of both problematic bereavement and PTSD
may be present.


may be present.
Prevalence
In the United States, projected lifetime risk for PTSD using DS M-IV criteria at age 75 years
is 8.7%. Twelve-month prevalence among U.S. adults is about 3.5%. Lower estimates are
seen in Europe and most Asian, African, an d Latin American countries, clustering around
0.5%–1.0%. Although different groups have di fferent levels of exposure to traumatic
events, the conditional probability of developi ng PTSD following a similar level of expo-
sure may also vary across cultural groups. Rates of PTSD are higher among veterans and
others whose vocation increases the risk of tr aumatic exposure (e.g., police, firefighters,
emergency medical personnel). Highest rates (r anging from one-third to more than one-
half of those exposed) are found among surv ivors of rape, military combat and captivity,
and ethnically or politically motivated intern ment and genocide. The prevalence of PTSD
may vary across development; children and adolescents, including preschool children,
generally have displayed lower prevalence following exposure to serious traumatic
events; however, this may be because previo us criteria were insufficiently developmen-
tally informed. The prevalence of full-thresh old PTSD also appears to be lower among
older adults compared with the general popu lation; there is eviden ce that subthreshold
presentations are more common th an full PTSD in later life and that these symptoms are
associated with substantial clinical impairme nt. Compared with U.S. non-Latino whites,
higher rates of PTSD have been reported among U.S. Latinos, African Americans, and
American Indians, and lower rates have been reported among Asian Americans, after ad-
justment for traumatic exposu re and demographic variables.
Development and Course


justment for traumatic exposu re and demographic variables.
Development and Course
PTSD can occur at any age, beginning after th e first year of life. Symptoms usually begin
within the first 3 months after the trauma, although there may be a delay of months, or
even years, before criteria for the diagnosis  are met. There is abundant evidence for what
DSM-IV called “delayed onset” but is now call ed “delayed expression,” with the recogni-
tion that some symptoms typically appear immediately and that the delay is in meeting


DSM-IV called “delayed onset” but is now call ed “delayed expression,” with the recogni-
tion that some symptoms typically appear immediately and that the delay is in meeting
full criteria.


Posttraumatic Stress Disorder 277
Frequently, an individual’s reaction to a tr auma initially meets cr iteria for acute stress
disorder in the immediate aftermath of the trauma. The symptoms of PTSD and the rela-
tive predominance of different symptoms may vary over time. Duration of the symptoms
also varies, with complete recovery within 3 months occurring in approximately one-half
of adults, while some individuals remain symptomatic for longer  than 12 months and
sometimes for more than 50 years. Symptom recurrence and intens ification may occur in
response to reminders of the original trauma, ongoing life stressors, or newly experienced
traumatic events. For older individuals, dec lining health, worsening cognitive function-
ing, and social isolation ma y exacerbate PTSD symptoms.
The clinical expression of reexperiencing can vary across development. Young children
may report new onset of frightening dreams wi thout content specific to the traumatic event.
Before age 6 years (see criteria for preschool su btype), young children are more likely to ex-
press reexperiencing symptoms through play th at refers directly or symbolically to the
trauma. They may not manifest fe arful reactions at the time of the exposure or during reex-
periencing. Parents may report a wide range of  emotional or behavioral changes in young
children. Children may focus on imagined interventions in their play or storytelling. In ad-
dition to avoidance, children  may become preoccupied with reminders. Because of young
children’s limitations in expressing thoughts or labeling emotions, negative alterations in
mood or cognition tend to involve primarily mood changes. Children may experience co-
occurring traumas (e.g., physical abuse, witnes sing domestic violence) and in chronic cir-
cumstances may not be able to identify onset of symptomatology. Avoidant behavior may


cumstances may not be able to identify onset of symptomatology. Avoidant behavior may
be associated with restricted play or explor atory behavior in youn g children; reduced par-
ticipation in new activities in school-age children; or reluctance to pursue developmental op-
portunities in adolescents (e.g ., dating, driving). Older children and adolescents may judge
themselves as cowardly. Adolescents may harb or beliefs of being changed in ways that
make them socially undesirable and estrange them from peers (e.g., “Now I’ll never fit in”)
and lose aspirations for the future. Irritable or aggressive behavior in children and adoles-
cents can interfere with peer relationships and sch ool behavior. Reckless behavior may lead
to accidental injury to self or  others, thrill-seeking, or high-risk behaviors. Individuals who
continue to experience PTSD into older ad ulthood may express fe wer symptoms of hy-
perarousal, avoidance, and ne gative cognitions and mood compared with younger adults
with PTSD, although adults ex posed to traumatic events duri ng later life may display more
avoidance, hyperarousal, sleep problems, and crying spells than do younger adults exposed
to the same traumatic events. In older individu als, the disorder is associated with negative
health perceptions, primary care ut ilization, and suicidal ideation.
Risk and Prognostic Factors
Risk (and protective) factors are generally divided into pretraumatic , peritraumatic, and
posttraumatic factors.
Pretraumatic factors
Temperamental. These include childhood emotional prob lems by age 6 years (e.g., prior
traumatic exposure, externalizing or anxiety problems) and prior me ntal disorders (e.g.,
panic disorder, depressive disorder, PTSD, or obsessive-compulsive disorder [OCD]).


panic disorder, depressive disorder, PTSD, or obsessive-compulsive disorder [OCD]).
Environmental. These include lower socioeconomic st atus; lower education; exposure to
prior trauma (especially during  childhood); childhood adversity (e.g., economic depriva-
tion, family dysfunction, parental separation or  death); cultural charac teristics (e.g., fatal-
istic or self-blaming coping strategies); lower intelligence; minority racial/ethnic status;


tion, family dysfunction, parental separation or  death); cultural charac teristics (e.g., fatal-
istic or self-blaming coping strategies); lower intelligence; minority racial/ethnic status;
and a family psychiatric history. Social suppo rt prior to event exposure is protective.
Genetic and physiological. These include female gender and younger age at the time of
trauma exposure (for adults). Certain genotypes may either be  protective or increase risk
of PTSD after exposure  to traumatic events.


278 Trauma- and Stressor-Related Disorders
Peritraumatic factors
Environmental. These include severity (dose) of th e trauma (the greater the magnitude
of trauma, the greater the likelihood of PTSD), perceived life threat, personal injury, in-
terpersonal violence (particularly trauma pe rpetrated by a caregiver or involving a wit-
nessed threat to a caregiver in children), and,  for military personnel, being a perpetrator,
witnessing atrocities, or killing the enemy. Fina lly, dissociation that occurs during the trauma
and persists afterward is a risk factor.
Posttraumatic factors
Temperamental. These include negative appraisals, inappropriate coping strategies,
and development of ac ute stress disorder.
Environmental. These include subsequent exposure to repeated upsetting reminders, subse-
quent adverse life events, and financial or other trauma-related losses. Social support (includ-
ing family stability, for children) is a protecti ve factor that moderate s outcome after trauma.
Culture-Related Diagnostic Issues
The risk of onset and severity of PTSD may differ  across cultural groups as a result of vari-
ation in the type of traumatic exposure (e.g., genocide), the impact on disorder severity of
the meaning attributed to the tr aumatic event (e.g., inability to  perform funerary rites after
a mass killing), the ongoing so ciocultural context (e.g., re siding among unpunished per-
petrators in postconflict settings), and other cultural factors (e.g., acculturative stress in
immigrants). The relative risk for PTSD of particular exposures (e .g., religious persecu-
tion) may vary across cultural groups. The clin ical expression of the symptoms or symp-
tom clusters of PTSD may vary culturally, particularly with respect to avoidance and


tom clusters of PTSD may vary culturally, particularly with respect to avoidance and
numbing symptoms, distressing dreams, and somatic symptoms (e.g., dizziness, short-
ness of breath, heat sensations).
Cultural syndromes and idioms of distress influence the expression of PTSD and the
range of comorbid disorders in  different cultures by providi ng behavioral and cognitive
templates that link traumatic exposures to specific symptoms. For example, panic attack
symptoms may be salient in PTSD among Cambodians and Latin Americans because of
the association of traumatic exposure with panic-like khyâl attacks and ataque de nervios.
Comprehensive evaluation of local expression s of PTSD should include assessment of cul-
tural concepts of distress (see the chapter “Cultural Formulation” in Section III).
Gender-Related Diagnostic Issues
PTSD is more prevalent among females than among males across the lifespan. Females in
the general population experience PTSD for a longer duration than do males. At least some
of the increased risk for PTSD in females appe ars to be attributable  to a greater likelihood
of exposure to traumatic events, such as rape, and other forms of interpersonal violence.
Within populations exposed specifically to such  stressors, gender differences in risk for
PTSD are attenuated or nonsignificant.
Suicide Risk
Traumatic events such as childhood abuse increa se a person’s suicide risk. PTSD is associated
with suicidal ideation and suicide attempts, an d presence of the disorder may indicate which
individuals with ideation even tually make a suicide plan or actually attempt suicide.
Functional Consequences of
Posttraumatic Stress Disorder
PTSD is associated with high levels of social , occupational, and physical disability, as well
as considerable economic costs and high leve ls of medical utilization. Impaired function-


Posttraumatic Stress Disorder 279
ing is exhibited across social, interpersonal, develo pmental, educational, physical health,
and occupational domains. In community and veteran samples, PTSD is associated with
poor social and family relationships, absent eeism from work, lower income, and lower ed-
ucational and occupational success.
Differential Diagnosis
Adjustment disorders. In adjustment disorders, the st ressor can be of any severity or
type rather than that required by PTSD Crit erion A. The diagnosis of an adjustment dis-
order is used when the response to a stressor that meets PTSD Criterion A does not meet
all other PTSD criteria (or criteria for another mental disorder). An adjustment disorder is
also diagnosed when the symptom pattern of PTSD occurs in response to a stressor that
does not meet PTSD Criterion A (e .g., spouse leaving, being fired).
Other posttraumatic diso rders and conditions. Not all psychopathology that occurs in
individuals exposed to an extreme stressor sh ould necessarily be attributed to PTSD. The
diagnosis requires that trauma exposure prec ede the onset or exacer bation of pertinent
symptoms. Moreover, if the symptom response pattern to the extreme stressor meets cri-
teria for another mental disorder, these diagnoses should be given instead of, or in addi-
tion to, PTSD. Other diagnoses and conditions are excluded if they are better explained by
PTSD (e.g., symptoms of panic disorder that  occur only after exposure to traumatic re-
minders). If severe, symptom response patter ns to the extreme stressor may warrant a sep-
arate diagnosis (e.g., dissociative amnesia).
Acute stress disorder. Acute stress disorder is distin guished from PTSD because the
symptom pattern in acute stress disorder is restricted to a duration of 3 days to 1 month


following exposure to  the traumatic event.
Anxiety disorders and obsessive-compulsive disorder. In OCD, there are recurrent
intrusive thoughts, but these meet the definition  of an obsession. In addition, the intrusive
thoughts are not related to an experienced traumatic event, compulsions are usually pres-
ent, and other symptoms of PTSD or acute stre ss disorder are typically absent. Neither the
arousal and dissociative symptoms of panic di sorder nor the avoidance, irritability, and
anxiety of generalized anxiety disorder are associated with a specific traumatic event. The
symptoms of separation anxiety disorder are clearly related to separation from home or
family, rather than to a traumatic event.
Major depressive disorder. Major depression may or may not be preceded by a trau-
matic event and should be diagnosed if othe r PTSD symptoms are absent. Specifically, ma-
jor depressive disorder does not include any PTSD Criterion B or C symptoms. Nor does it
include a number of symptoms from PTSD Criterion D or E.
Personality disorders. Interpersonal difficulties that had their onset, or were greatly ex-
acerbated, after exposure to a traumatic event may be an indica tion of PTSD, rather than a
personality disorder, in which such difficulties would be expected independently of any
traumatic exposure.
Dissociative disorders. Dissociative amnesia, dissociative identity disorder, and de-
personalization-derealization disorder may or may not be preceded by exposure to a trau-
matic event or may or may not have co-occurri ng PTSD symptoms. When full PTSD criteria
are also met, however, the PTSD “with dissoci ative symptoms” subtype should be considered.
Conversion disorder (functional neurological symptom disorder). New onset of somatic
symptoms within the context of posttraumati c distress might be an indication of PTSD


symptoms within the context of posttraumati c distress might be an indication of PTSD
rather than conversion disorder (functional neurological symptom disorder).
Psychotic disorders. Flashbacks in PTSD must be di stinguished from illusions, halluci-
nations, and other perceptual disturbances that may occur in schizophrenia, brief psy-
chotic disorder, and other psychotic disord ers; depressive and bipolar disorders with


280 Trauma- and Stressor-Related Disorders
psychotic features; delirium; substance/medication-induced disorders; and psychotic dis-
orders due to another medical condition.
Traumatic brain injury. When a brain injury occurs in the context of a traumatic event (e.g.,
traumatic accident, bomb blast, acceleration/d eceleration trauma), symptoms of PTSD may
appear. An event causing head trauma may also  constitute a psychological traumatic event,
and tramautic brain injury (TBI)–related neurocognitive symptoms are not mutually exclusive
and may occur concurrently. Sy mptoms previously termed postconcussive  (e.g., headaches,
dizziness, sensitivity to light or  sound, irritability, concentration deficits) can occur in brain-
injured and non-brain-injured populations, in cluding individuals with PTSD. Because symp-
toms of PTSD and TBI-related neurocognitive symptoms can overlap, a differential diagnosis
between PTSD and neurocognitive disorder sy mptoms attributable to TBI may be possible
based on the presence of symptoms that are di stinctive to each presentation. Whereas reexpe-
riencing and avoidance are characteristic of PTSD  and not the effects of TBI, persistent disori-
entation and confusion are more specific to TBI (neurocognitive effects) than to PTSD.
Comorbidity
Individuals with PTSD are 80% more likely than those without PTSD to have symptoms
that meet diagnostic criteria for at least one other mental disorder (e.g., depressive, bipo-
lar, anxiety, or substance use disorders). Comorbid substance use disorder and conduct
disorder are more common among males than  among females. Among U.S. military per-
sonnel and combat veterans who have been de ployed to recent wars  in Afghanistan and


sonnel and combat veterans who have been de ployed to recent wars  in Afghanistan and
Iraq, co-occurrence of PTSD and mild TBI is  48%. Although most  young children with
PTSD also have at least one other diagnosis, the patterns of comorbidity are different than
in adults, with oppositional defiant disorder  and separation anxiety disorder predominat-
ing. Finally, there is considerable comorb idity between PTSD and major neurocognitive
disorder and some overlapping sy mptoms between these disorders.
Acute Stress Disorder
Diagnostic Criteria 308.3 (F43.0)
A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or
more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the event(s) occurred to a close family member or close friend.  Note:
In cases of actual or threatened death of a family member or friend, the event(s)
must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s) (e.g., first responders collecting human remains, police officers repeatedly
exposed to details of child abuse).
Note: This does not apply to exposure through electronic media, television, mov-
ies, or pictures, unless this exposure is work related.
B. Presence of nine (or more) of the following symptoms from any of the five categories
of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or wors-
ening after the traumatic event(s) occurred:
Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic


1. Recurrent, involuntary, and intrusive distressing memories of the traumatic
event(s).  Note: In children, repetitive play may occur in which themes or aspects of
the traumatic event(s) are expressed.


Acute Stress Disorder 281
2. Recurrent distressing dreams in which the content and/or affect of the dream are
related to the event(s). Note: In children, there may be frightening dreams without
recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if
the traumatic event(s) were recurring. (Such reactions may occur on a continuum,
with the most extreme expression being a complete loss of awareness of present
surroundings.) Note:  In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress or marked physiological reactions in re-
sponse to internal or external cues that symbolize or resemble an aspect of the
traumatic event(s).
Negative Mood
5. Persistent inability to experience positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).
Dissociative Symptoms
6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself
from another’s perspective, bein g in a daze, time slowing).
7. Inability to remember an important aspect of the traumatic event(s) (typically due to
dissociative amnesia and not to other factors such as head injury, alcohol, or
drugs).
Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about or closely asso-
ciated with the traumatic event(s).
9. Efforts to avoid external reminders (peopl e, places, conversations, activities, ob-
jects, situations) that arouse distressing memories, thoughts, or feelings about or
closely associated with the traumatic event(s).
Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).


10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
11. Irritable behavior and angry outbursts (with little or no provocation), typically ex-
pressed as verbal or physical aggression toward people or objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response.
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma
exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at
least 3 days and up to a month is needed to meet disorder criteria.
D. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g.,
medication or alcohol) or another medical c ondition (e.g., mild traumatic brain injury)
and is not better explained by brief psychotic disorder.
Diagnostic Features
The essential feature of acute stress disorder  is the development of characteristic symp-
toms lasting from 3 days to 1 month following exposure to one or more traumatic events.
Traumatic events that are expe rienced directly include, but are not limited to, exposure
to war as a combatant or civilia n, threatened or actual violen t personal assault (e.g., sexual


282 Trauma- and Stressor-Related Disorders
violence, physical attack, active combat, mugging, childhood physical and/or sexual vio-
lence, being kidnapped, being taken hostage, terrorist attack, tortur e), natural or human-
made disasters (e.g., earthquake, hurricane, airplane crash), and severe accident (e.g.,
severe motor vehicle, industrial accident). For children, sexually traumatic events may
include inappropriate sexual experiences with out violence or injury. A life-threatening
illness or debilitating medical condition is no t necessarily consider ed a traumatic event.
Medical incidents that qualify as traumatic even ts involve sudden, cata strophic events (e.g.,
waking during surgery, anaphylactic shock). St ressful events that do not possess the severe
and traumatic components of ev ents encompassed by Criterion A may lead to an adjust-
ment disorder but not to  acute stress disorder.
The clinical presentation of acute stress disorder may vary by individual but typically
involves an anxiety response that includes some  form of reexperiencing of or reactivity to
the traumatic event. In some individuals, a dissociative or detached presentation can pre-
dominate, although these individuals typically  will also display strong emotional or phys-
iological reactivity in response to trauma re minders. In other individuals, there can be a
strong anger response in which reactivity is characterized by irritable or possibly aggres-
sive responses. The full symptom picture must be  present for at least 3 days after the trau-
matic event and can be diagnosed only up to 1 month after the event. Symptoms that occur
immediately after the event but resolve in less than 3 days would not meet criteria for
acute stress disorder.
Witnessed events include, but are not limited  to, observing threatened or serious in-


Witnessed events include, but are not limited  to, observing threatened or serious in-
jury, unnatural death, physical or sexual violence inflicted on another individual as a re-
sult of violent assault, severe domestic violen ce, severe accident, war, and disaster; it may
also include witnessing a medical catastrophe (e.g., a life-threatening hemorrhage) involv-
ing one’s child. Events experienced indirectly  through learning about the event are limited
to close relatives or close friends. Such even ts must have been violent or accidental—death
due to natural causes does not qualify—and in clude violent personal assault, suicide, se-
rious accident, or serious injury. The disorder may be especially severe when the stressor
is interpersonal and intentional (e .g., torture, rape). The like lihood of developing this dis-
order may increase as the intensity of and physical proximity to the stressor increase.
The traumatic event can be reexperienced in various wa ys. Commonly, the individual
has recurrent and intrusive recollections of the event (Criterion B1). The recollections are
spontaneous or triggered recurrent memories of the event that usua lly occur in response
to a stimulus that is reminiscent of the traumatic experience (e.g., the sound of a backfiring
car triggering memories of gunshots). Thes e intrusive memories often include sensory
(e.g., sensing the intense heat that was percei ved in a house fire), emotional (e.g., experi-
encing the fear of believing that one was about  to be stabbed), or physiological (e.g., expe-
riencing the shortness of breath that one su ffered during a near-drowning) components.
Distressing dreams may contain themes that are representative of or thematically re-
lated to the major threats involved in the trau matic event. (For example, in the case of a


motor vehicle accident surviv or, the distressing dreams may involve crashing cars gener-
ally; in the case of a combat soldier, the distressing dreams may involve being harmed in
ways other than combat.)
Dissociative states may last from a few seco nds to several hours, or even days, during
which components of the event are relived an d the individual behaves as though experi-


Dissociative states may last from a few seco nds to several hours, or even days, during
which components of the event are relived an d the individual behaves as though experi-
encing the event at that moment. While disso ciative responses are common during a trau-
matic event, only dissociative responses that  persist beyond 3 days after trauma exposure
are considered for the diagnosis of acute st ress d isord er. For youn g children, reenactment
of events related to trauma may appear in  play and may include dissociative moments
(e.g., a child who survives a motor vehicle accident may repe atedly crash toy cars during
play in a focused and distressing manner).  These episodes, often referred to as flashbacks,
are typically brief but involve a sense that th e traumatic event is oc curring in the present
rather than being remembered in the past and are associated with significant distress.


Acute Stress Disorder 283
Some individuals with the disorder do not ha ve intrusive memories of the event itself,
but instead experience intense psychological distress or physiological reactivity when
they are exposed to triggering events that re semble or symbolize an aspect of the traumatic
event (e.g., windy days for child ren after a hurricane, entering an elevator for a male or fe-
male who was raped in an elevator, seeing  someone who resembles one’s perpetrator).
The triggering cue could be a physical sensation (e.g., a sense of heat for a burn victim, diz-
ziness for survivors of head tr auma), particularly for individuals with highly somatic pre-
sentations. The individual may have a persistent  inability to feel positive emotions (e.g.,
happiness, joy, satisfaction, or emotions asso ciated with intimacy, tenderness, or sexual-
ity) but can experience negative emotions su ch as fear, sadness, anger, guilt, or shame.
Alterations in awareness can include depersonalization,  a detached sense of oneself (e.g.,
seeing oneself from the other side of the room), or derealization,  having a distorted view of
one’s surroundings (e.g., perceiving that thin gs are moving in slow motion, seeing things
in a daze, not being aware of events that on e would normally encode ). Some individuals
also report an inability to remember an impo rtant aspect of the tr aumatic event that was
presumably encoded. This symp tom is attributable to dissoc iative amnesia and is not at-
tributable to head inju ry, alcohol, or drugs.
Stimuli associated with the trauma are persistently avoided. The individual may refuse
to discuss the traumatic experience or may engage in avoidance strategies to minimize
awareness of emotional reactions (e.g., excessive alcohol use when reminded of the ex-


awareness of emotional reactions (e.g., excessive alcohol use when reminded of the ex-
perience). This behavioral avoidance may include avoiding watching news coverage of
the traumatic experience, refusing to return to a workplace where the trauma occurred, or
avoiding interacting with others who shared the same traumatic experience.
It is very common for indivi duals with acute stress disorder to experience problems
with sleep onset and maintenance, which may be associated with nightmares or with gen-
eralized elevated arou sal that prevents adequate sleep. Individuals with acute stress dis-
order may be quick tempered and may even en gage in aggressive verbal and/or physical
behavior with little provocation. Acute stress disorder is often characterized by a height-
ened sensitivity to potential th reats, including those that are related to the traumatic ex-
perience (e.g., a motor vehicle accident vict im may be especially sensitive to the threat
potentially caused by any cars or trucks) or those not related to the traumatic event (e.g.,
fear of having a heart attack). Concentration difficulties, including difficulty remembering
daily events (e.g., forg etting one’s telephone number) or attending to focused tasks (e.g.,
following a conversation for a sustained period  of time), are commonly reported. Individ-
uals with acute stress disorder may be very re active to unexpected stimuli, displaying a
heightened startle response or jumpiness to loud noises or unexpe cted movements (e.g.,
the individual may jump markedly in the response to a telephone ringing).
Associated Features Supporting Diagnosis
Individuals with acute stress disorder common ly engage in catastrophic or extremely neg-
ative thoughts about thei r role in the traumatic event, th eir response to the traumatic ex-
perience, or the likelihood of future harm. For example, an individual with acute stress
disorder may feel excessively guilty about not having prevented the traumatic event or


disorder may feel excessively guilty about not having prevented the traumatic event or
about not adapting to the experience more su ccessfully. Individuals with acute stress dis-
order may also interpret their symptoms in  a catastrophic manner, such that flashback
memories or emotional numbing may be interpreted as a sign of diminished mental ca-


order may also interpret their symptoms in  a catastrophic manner, such that flashback
memories or emotional numbing may be interpreted as a sign of diminished mental ca-
pacity. It is common for individuals with acute stress disorder to experience panic attacks
in the initial month after trauma exposure th at may be triggered by trauma reminders or
may apparently occur spontaneously. Addition ally, individuals with acute stress disorder
may display chaotic or impulsive behavior. For example, individuals may drive reck-
lessly, make irrational decisions, or gamble  excessively. In children, there may be sig-
nificant separation anxiety, possibly mani fested by excessive needs for attention from


284 Trauma- and Stressor-Related Disorders
caregivers. In the case of be reavement following a death that occurred in traumatic cir-
cumstances, the symptoms of acute stress di sorder can involve acute grief reactions. In
such cases, reexperiencing, dissociative, an d arousal symptoms ma y involve reactions to
the loss, such as intrusive memories of the ci rcumstances of the individual’s death, disbe-
lief that the individual has died, and ange r about the death. Po stconcussive symptoms
(e.g., headaches, dizziness, sensitivity to light or sound, irritability, concentration deficits),
which occur frequently following  mild traumatic brain injury, are also frequently seen in
individuals with acute stress disorder. Po stconcussive symptoms are equally common in
brain-injured and non–brain-injured populations, and the frequent occurrence of postcon-
cussive symptoms could be attributable  to acute stress disorder symptoms.
Prevalence
The prevalence of acute stress disorder in recently trauma-exposed populations (i.e.,
within 1 month of trauma exposure) varies ac cording to the nature of the event and the
context in which it is assessed. In both U.S. and non-U.S. population s, acute stress disorder
tends to be identified in less than 20% of ca ses following traumatic events that do not in-
volve interpersonal assault; 13%–21% of motor vehicle accidents, 14% of mild traumatic
brain injury, 19% of assault, 10% of severe burns, and 6%–12% of industrial accidents.
Higher rates (i.e., 20%–50%) are reported following interpersonal traumatic events, in-
cluding assault, rape, and witnessing a mass shooting.
Development and Course


cluding assault, rape, and witnessing a mass shooting.
Development and Course
Acute stress disorder cannot be diagnosed un til 3 days after a traumatic event. Although
acute stress disorder may prog ress to posttraumatic stress di sorder (PTSD) after 1 month,
it may also be a transient stress response th at remits within 1 month of trauma exposure
and does not result in PTSD. Approximately half of individuals who eventually develop
PTSD initially present with acute stress diso rder. Symptom worsenin g during the initial
month can occur, often as a result of ongoin g life stressors or further traumatic events.
The forms of reexperiencing can vary acro ss development. Unlike adults or adoles-
cents, young children may report frightening dreams without content that clearly reflects
aspects of the trauma (e.g., waki ng in fright in the aftermath of the trauma but being unable
to relate the content of the dream to the traumatic event). Ch ildren age 6 years and younger
are more likely than older children to expres s reexperiencing symptoms through play that
refers directly or symbolically to the trauma. For example, a very young child who sur-
vived a fire may draw pictures of flames. Yo ung children also do not necessarily manifest
fearful reactions at the time of the exposure or even during reexperiencing. Parents typi-
cally report a range of emotional expressions,  such as anger, shame, or withdrawal, and
even excessively bright positiv e affect, in young children who are traumatized. Although
children may avoid reminders of the trauma, they sometimes become preoccupied with
reminders (e.g., a young child bitten by a dog may talk about dogs constantly yet avoid go-
ing outside because of fear of coming into contact with a dog).


ing outside because of fear of coming into contact with a dog).
Risk and Prognostic Factors
Temperamental. Risk factors include prior mental diso rder, high levels of negative af-
fectivity (neuroticism), greater perceived seve rity of the traumatic event, and an avoidant
coping style. Catastrophic appraisals of th e traumatic experience, often characterized by
exaggerated appraisals of future harm, guilt, or hopelessness, are strongly predictive of
acute stress disorder.
Environmental. First and foremost, an individual must  be exposed to a traumatic event to
be at risk for acute stress disorder. Risk fact ors for the disorder include a history of prior
trauma.


Acute Stress Disorder 285
Genetic and physiological. Females are at greater risk for developing acute stress dis-
order.
Elevated reactivity, as reflected by acousti c startle response, prior to trauma exposure
increases the risk for developing acute stress disorder.
Culture-Related Diagnostic Issues
The profile of symptoms of acute stress disorder may vary cross-culturally, particularly
with respect to dissociative symptoms, ni ghtmares, avoidance, and somatic symptoms
(e.g., dizziness, shortness of breath, heat se nsations). Cultural sy ndromes and idioms of
distress shape the local symptom profiles of acute stress disorder. Some cultural groups
may display variants of dissociative response s, such as possession or trancelike behaviors
in the initial month after trauma exposure. Pa nic symptoms may be salient in acute stress
disorder among Cambodians because of the as sociation of traumatic exposure with panic-
like khyâl  attacks, and ataque de nervios  among Latin Americans may also follow a traumatic
exposure.
Gender-Related Diagnostic Issues
Acute stress disorder is more prevalent am ong females than among males. Sex-linked neu-
robiological differences in stre ss response may contribute to females’ increased risk for
acute stress disorder. The increased risk for the disorder in females may be attributable in
part to a greater likelihood of exposure to th e types of traumatic events with a high con-
ditional risk for acute stress  disorder, such as rape and other interpersonal violence.
Functional Consequences of Acute Stress Disorder
Impaired functioning in social, interpersona l, or occupational domains has been shown
across survivors of accidents, assault, and rape  who develop acute stress disorder. The ex-
treme levels of anxiety that may be associa ted with acute stress disorder may interfere


treme levels of anxiety that may be associa ted with acute stress disorder may interfere
with sleep, energy levels, and capacity to a ttend to tasks. Avoidance in acute stress dis-
order can result in generalized withdrawal from many situations that are perceived as
potentially threatening, which can lead to nonattendance of medical appointments, avoid-
ance of driving to important appointments, and absenteeism from work.
Differential Diagnosis
Adjustment disorders. In acute stress disorder, the stress or can be of any severity rather
than of the severity and type required by Criterion A of acute stress di sorder. The diagnosis of
an adjustment disorder is used when the response to a Criterion A event does not meet the cri-
teria for acute stress disorder (o r another specific mental diso rder) and when the symptom pat-
tern of acute stress disorder occurs in response to a stressor that does not meet Criterion A for
exposure to actual or threatened death, serious injury, or sexual  violence (e.g., spouse leaving,
being fired). For example, severe  stress reactions to life-threate ning illnesses that may include
some acute stress disorder symptoms may be more appropriately desc ribed as an adjustment
disorder. Some forms of acute stress response do not include acute stress disorder symptoms
and may be characterized by anger, depression, or guilt. These responses are more appro-
priately described as primarily an adjustment disorder. Depressive or anger responses in an
adjustment disorder may involve rumination ab out the traumatic event, as opposed to invol-
untary and intrusive distressing memories in acute stress disorder.
Panic disorder. Spontaneous panic attacks are very common in acute stress disorder.
However, panic disorder is diagnosed only if panic attacks are unexpected and there is
anxiety about future attacks or  maladaptive changes in behavior associated with fear of
dire consequences of the attacks.


286 Trauma- and Stressor-Related Disorders
Dissociative disorders. Severe dissociative responses (i n the absence of characteristic
acute stress disorder symptoms) may be di agnosed as derealization/depersonalization
disorder. If severe amnesia of the trauma persists in the ab sence of characteristic acute
stress disorder symptoms, the diagnosis of  dissociative amnesia may be indicated.
Posttraumatic stress disorder. Acute stress disorder is dist inguished from PTSD because
the symptom pattern in acute stre ss disorder must occur within 1 month of the traumatic event
and resolve within that 1-month period. If th e symptoms persist for more than 1 month and
meet criteria for PTSD, the diagnosis is ch anged from acute stre ss disorder to PTSD.
Obsessive-compulsive disorder. In obsessive-compulsive diso rder, there are recurrent
intrusive thoughts, but these meet the definition  of an obsession. In addition, the intrusive
thoughts are not related to an experienced traumatic event, compulsions are usually pres-
ent, and other symptoms of acute st ress disorder are typically absent.
Psychotic disorders. Flashbacks in acute stress disorder  must be distinguished from il-
lusions, hallucinations, and other perceptual disturbances that may occur in schizophre-
nia, other psychotic disorders, depressive or  bipolar disorder with psychotic features, a
delirium, substance/medication -induced disorders, and psychotic disorders due to an-
other medical condition. Acut e stress disorder flashbacks ar e distinguished from these
other perceptual disturbances by being direct ly related to the traumatic experience and by
occurring in the absence of other psychotic or substance-induced features.
Traumatic brain injury. When a brain injury occurs in the context of a traumatic event
(e.g., traumatic accident, bomb blast, acceleration/deceleration trauma), symptoms of


(e.g., traumatic accident, bomb blast, acceleration/deceleration trauma), symptoms of
acute stress disorder may appear. An event causing head trauma may also constitute a
psychological trau matic event, and tramautic brain injury (TBI)–related neurocognitive
symptoms are not mutually exclusive and ma y occur concurrently. Symptoms previously
termed postconcussive  (e.g., headaches, dizziness, sensitiv ity to light or sound, irritability,
concentration deficits) can occur in brain-injured and non–brain injured populations, in-
cluding individuals with acute stress disorder . Because symptoms of acute stress disorder
and TBI-related neurocognitive symptoms can overlap, a differential diagnosis between
acute stress disorder and neurocognitive di sorder symptoms attributable to TBI may be
possible based on the presence of symptoms that are distinctive to each presenta-
tion. Whereas reexperiencing and avoidance are characteristic of acut e stress disorder and
not the effects of TBI, persistent disorientation  and confusion are more specific to TBI (neu-
rocognitive effects) than to acute stress disord er. Furthermore, differential is aided by the
fact that symptoms of acute stress disorder persist for up to only 1 month following trauma
exposure.
Adjustment Disorders
Diagnostic Criteria
A. The development of emotional or behavioral symptoms in response to an identifiable
stressor(s) occurring within 3 months of the onset of the stressor(s).
B. These symptoms or behaviors are clinically significant, as evidenced by one or both of
the following:
1. Marked distress that is out of proportion to the severity or intensity of the stressor,
taking into account the external context and the cultural factors that might influence
symptom severity and presentation.
2. Significant impairment in social, occupational, or other important areas of functioning.


2. Significant impairment in social, occupational, or other important areas of functioning.
C. The stress-related disturbance does not meet  the criteria for another mental disorder
and is not merely an exacerbation of a preexisting mental disorder.


Adjustment Disorders 287
D. The symptoms do not represent normal bereavement.
E. Once the stressor or its consequences have terminated, the symptoms do not persist
for more than an additional 6 months.
Specify whether:
309.0 (F43.21) With depressed mood:  Low mood, tearfulness, or feelings of hope-
lessness are predominant.
309.24 (F43.22) With anxiety:  Nervousness, worry, jitteriness, or separation anxiety
is predominant.
309.28 (F43.23) With mixed anxiety and depressed mood:  A combination of de-
pression and anxiety is predominant.
309.3 (F43.24) With disturbance of conduct:  Disturbance of conduct is predominant.
309.4 (F43.25) With mixed disturba nce of emotions and conduct:  Both emotional
symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant.
309.9 (F43.20) Unspecified:  For maladaptive reactions that are not classifiable as one
of the specific subtypes of adjustment disorder.
Diagnostic Features
The presence of emotional or behavioral sympto ms in response to an identifiable stressor
is the essential feature of adju stment disorders (Criterion A) . The stressor may be a single
event (e.g., a termination of a romantic relati onship), or there may be multiple stressors
(e.g., marked business difficulties and marita l problems). Stressors may be recurrent (e.g.,
associated with seasonal busi ness crises, unfulfilling sexual relationships) or continuous
(e.g., a persistent painful illness with increasi ng disability, living in a crime-ridden neigh-
borhood). Stressors may affect a single individual, an entire family, or a larger group or


community (e.g., a natural disaster). Some st ressors may accompany specific developmen-
tal events (e.g., going to school, leaving a parental home, reentering a parental home, get-
ting married, becoming a parent, failing to attain occupational goals, retirement).
Adjustment disorders may be diagnosed follo wing the death of a loved one when the
intensity, quality, or persis tence of grief reactions exceeds what normally might be ex-
pected, when cultural, religious, or age-appr opriate norms are taken into account. A more
specific set of bereavement-relate d symptoms has been designated persistent complex be-
reavement disorder.
Adjustment disorders are associated with an increased risk of suicide attempts and
completed suicide.
Prevalence
Adjustment disorders ar e common, although prevalence may vary widely as a function of
the population studied and the assessment me thods used. The percentage of individuals
in outpatient mental health treatment with a principal diagnosis of an adjustment disorder
ranges from approximately 5% to 20%. In a hospital psychiatric consultation setting, it is
often the most common diagno sis, frequently reaching 50%.
Development and Course
By definition, the disturbance in adjustment disorders begins within  3 months of onset of
a stressor and lasts no longer than 6 months  after the stressor or its consequences have
ceased. If the stressor is an acute event (e.g., being fired from a job), the onset of the dis-
turbance is usually immediate (i.e., within a few days) and the durati on is relatively brief
(i.e., no more than a few mont hs). If the stressor or its co nsequences persist, the adjustment
disorder may also continue to be pr esent and become the persistent form.


288 Trauma- and Stressor-Related Disorders
Risk and Prognostic Factors
Environmental. Individuals from disadvantaged lif e circumstances experience a high
rate of stressors and may be at increased risk for adjustment disorders.
Culture-Related Diagnostic Issues
The context of the individual’s cultural setting should be taken into account in making the
clinical judgment of whether the individual’s response to the stressor is maladaptive or
whether the associated distress is in excess of what would be expected. The nature, mean-
ing, and experience of the stressors and the ev aluation of the response to the stressors may
vary across cultures.
Functional Consequences of Adjustment Disorders
The subjective distress or impa irment in functioning associat ed with adjustment disorders
is frequently manifested as decreased perf ormance at work or school and temporary
changes in social relationships. An adjustment disorder may complicate the course of ill-
ness in individuals who have a general medica l condition (e.g., decreased compliance with
the recommended medical regimen; incr eased length of hospital stay).
Differential Diagnosis
Major depressive disorder. If an individual has symptoms that meet criteria for a major
depressive disorder in response  to a stressor, the diagnosis of an adjustment disorder is
not applicable. The symptom profile of major depressive disorder differentiates it from ad-
justment disorders.
Posttraumatic stress disorder and acute stress disorder. In adjustment disorders, the
stressor can be of any severity rather than of  the severity and type required by Criterion A
of acute stress disorder and posttraumatic st ress disorder (PTSD). In distinguishing ad-
justment disorders from thes e two posttraumatic diagnoses,  there are both timing and
symptom profile considerations. Adjustment disorders can be diagnosed immediately
and persist up to 6 months afte r exposure to the traumatic event, whereas acute stress dis-


order can only occur between 3 days and 1 month of exposure to the stressor, and PTSD
cannot be diagnosed until at least 1 month has passed since the occurrence of the traumatic
stressor. The required symptom profile for PT SD and acute stress disorder differentiates
them from the adjustment disorders. With re gard to symptom profiles, an adjustment dis-
order may be diagnosed following a traumatic event when an individu al exhibits symptoms
of either acute stress disorder or PTSD that do not meet or exceed the diagnostic threshold
for either disorder. An adjustment disorder should also be diagno sed for individuals who
have not been exposed to a tr aumatic event but who otherwise exhibit the full symptom pro-
file of either acute st ress disorder or PTSD.
Personality disorders. With regard to personality disorders, some personality features
may be associated with a vulnerability to situat ional distress that may resemble an adjust-
ment disorder. The lifetime hist ory of personality functionin g will help inform the in-
terpretation of distressed behaviors to aid in  distinguishing a long-standing personality
disorder from an adjustment d isorder. In addition to some personality disorders incurring
vulnerability to distress, stre ssors may also exacerbate pers onality disorder symptoms. In
the presence of a personality disorder, if the symptom criteria for an adjustment disorder
are met, and the stress-related disturbance exceeds what may be attributable to maladap-
tive personality disorder symptoms (i.e., Crit erion C is met), then the diagnosis of an ad-
justment disorder should be made.


Other Specified Trauma- and Stressor-Related Disorder 289
Psychological factors affecting other medical conditions. In psychological factors af-
fecting other medical conditions, specific psychological entities (e.g., psychological symp-
toms, behaviors, other factors) exacerbate  a medical condition. These psychological
factors can precipitate, exacerbate, or put an individual at risk for medical illness, or they
can worsen an existing condition. In contrast, an adjustment disorder is a reaction to the
stressor (e.g., having a medical illness).
Normative stress reactions. When bad things happen, most  people get upset. This is
not an adjustment disorder. The diagnosis should only be made when the magnitude of
the distress (e.g., alterations in mood, anxiet y, or conduct) exceed s what would normally
be expected (which may vary in different cu ltures) or when the adverse event precipitates
functional impairment.
Comorbidity
Adjustment disorders can accompany most mental disorders and an y medical disorder.
Adjustment disorders can be diagnosed in additi on to another mental disorder only if the
latter does not explain the partic ular symptoms that occur in reaction to the stressor. For
example, an individual may develop an adjustment disorder, with depressed mood, after
losing a job and at the same time have a di agnosis of obsessive-co mpulsive disorder. Or,
an individual may have a depressive or bipo lar disorder and an adjustment disorder as
long as the criteria for both are met. Adju stment disorders are common accompaniments
of medical illness and may be the major psychological response to a medical disorder.
Other Specified Trauma- and
Stressor-Related Disorder
309.89 (F43.8)
This category applies to presentations in which symptoms characteristic of a trauma- and


This category applies to presentations in which symptoms characteristic of a trauma- and
stressor-related disorder that cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning predominate but do not meet the full
criteria for any of the disorders in the trauma- and stressor-related disorders diagnostic
class. The other specified trauma- and stressor- related disorder category is used in situa-
tions in which the clinician chooses to communicate the specific reason that the presenta-
tion does not meet the criteria for any specific trauma- and stressor-related disorder. This
is done by recording “other specified trauma- and stressor-related disorder” followed by
the specific reason (e.g., “persistent complex bereavement disorder”).
Examples of presentations that can be specified using the “other specified” designation
include the following:
1.Adjustment-like disorders with delayed on set of symptoms that occur more than
3 months after the stressor.
2.Adjustment-like disorders with prolonged duration of more than 6 months with-
out prolonged duration of stressor.
3.Ataque de nervios:  See “Glossary of Cultural Concepts of Distress” in the Appendix.
4.Other cultural syndromes:  See “Glossary of Cultural Concepts of Distress” in the Ap-
pendix.
5.Persistent complex bereavement disorder:  This disorder is characterized by severe
and persistent grief and mourning reactions (see the chapter “Conditions for Further
Study”).


290 Trauma- and Stressor-Related Disorders
Unspecified Trauma- and
Stressor-Related Disorder
309.9 (F43.9)
This category applies to presentations in which symptoms characteristic of a trauma- and
stressor-related disorder that cause clinically significant distress or impairment in social, oc-
cupational, or other important areas of functioning predominate but do not meet the full cri-
teria for any of the disorders in the trauma- and stressor-related disorders diagnostic class.
The unspecified trauma- or stressor-related disord er category is used in  situations in which
the clinician chooses not to specify the reason that the criteria are not met for a specific
trauma- and stressor-related disorder, and includes  presentations in which there is insuffi-
cient information to make a more specific diagnosis (e.g., in emergency room settings).


291Dissociative
 Disorders
Dissociative disorders  are characterized by a disrup tion of and/or discontinuity
in the normal integration of consciousness, memory, identity, emotion, perception, body
representation, motor control, and behavior. Dissociative symptoms can potentially dis-
rupt every area of psychological functioning.  This chapter includes dissociative identity
disorder, dissociative amnesia, depersonalization/derealization disorder, other specified
dissociative disorder, and unspecified dissociative disorder.
Dissociative symptoms are experienced as a)  unbidden intrusions into awareness and
behavior, with accompanying losses of continuity  in subjective experience (i.e., ‘‘positive’’
dissociative symptoms such as fragmentation of identity, depersonalization, and dereal-
ization) and/or b) inability to access inform ation or to control ment al functions that nor-
mally are readily amenable to access or contro l (i.e., “negative’’ dissociative symptoms such
as amnesia).
The dissociative disorders are frequently found in the af termath of trauma, and many
of the symptoms, including embarrassment an d confusion about the symptoms or a desire
to hide them, are influenced by the proximity to trauma. In DSM-5, the dissociative disor-
ders are placed next to, but are not part of, the trauma- and stressor-r elated disorders, re-
flecting the close relationship between these di agnostic classes. Both  acute stress disorder
and posttraumatic stress disorder contain di ssociative symptoms, such as amnesia, flash-
backs, numbing, and depersonalization/derealization.
Depersonalization/derealization disorder is characterized by clinically significant persis-
tent or recurrent depersonalizat ion (i.e., experiences of unreality or detachment from one’s


mind, self, or body) and/or derealization (i.e ., experiences of unreality or detachment from
one’s surroundings). These alte rations of experience are accompanied by intact reality
testing. There is no evidence of any distin ction between individuals with predominantly
depersonalization versus derealization sympto ms. Therefore, individuals with this disor-
der can have depersonalizatio n, derealization, or both.
Dissociative amnesia  is characterized by an inability to recall autobiographical informa-
tion. This amnesia may be localized (i.e., an even t or period of time), selective (i.e., a specific
aspect of an event), or generali zed (i.e., identity and life history). Dissociative amnesia is fun-
damentally an inability to recall autobiographic al information that is inconsistent with nor-
mal forgetting. It may or may not involve purp oseful travel or bewildered wandering (i.e.,
fugue). Although some individual s with amnesia promptly notice  that they have “lost time”
or that they have a gap in their memory, most individuals with dissocia tive disorders are ini-
tially unaware of their amnesias. For them, aw areness of amnesia occu rs only when personal
identity is lost or when circumstances make  these individuals awar e that autobiographical
information is missing (e.g., wh en they discover evidence of events they cannot recall or
when others tell them or ask th em about events they cannot reca ll). Until and unless this hap-
pens, these individuals have “amnesia for their amnesia.” Amnesia is experienced as an es-
sential feature of dissociative amnesia; individuals may experience localized or selective


sential feature of dissociative amnesia; individuals may experience localized or selective
amnesia most commonly, or generalized amnesia rarely. Dissociative fugue is rare in per-
sons with dissociative am nesia but common in dissoc iative identity disorder.
Dissociative identity disorder is characterized by a) the presence of two or more distinct
personality states or an experi ence of possession and b) recurrent episodes of amnesia. The


292 Dissociative Disorders
fragmentation of identity may vary with culture (e.g., possession-form presentations) and cir-
cumstance. Thus, individuals ma y experience discontinuities in identity and memory that
may not be immediately evident to others or are obscured by attempts to hide dysfunction. In-
dividuals with dissociative identity disorder experience a) recurrent, inexplicable intrusions
into their conscious functioning and sense of se lf (e.g., voices; dissociated actions and speech;
intrusive thoughts, emotions, and im pulses), b) alterations of sense of  self (e.g., attitudes, pref-
erences, and feeling like one’s body or actions are not one’s own), c) odd changes of perception
(e.g., depersonalization or derealization, such as feeling deta ched from one’s body while cut-
ting), and d) intermittent functional neurolog ical symptoms. Stress often produces transient
exacerbation of dissociative symptoms that makes them more evident.
The residual category of other specified disso ciative disorder has seven examples: chronic
or recurrent mixed dissociative symptoms that approach, but fall  short of, the diagnostic cri-
teria for dissociative identity disorder; dissociative states secondary to brainwashing or
thought reform; two acute presentations, of less than 1 month’s duration, of mixed dissociative
symptoms, one of which is also marked by the presence of psychotic symptoms; and three sin-
gle-symptom dissociative presentations—dissociat ive trance, dissociative stupor or coma, and
Ganser’s syndrome (the giving of  approximate and vague answers).
Dissociative Identity Disorder
Diagnostic Criteria 300.14 (F44.81)
A. Disruption of identity characterized by two or more distinct personality states, which


A. Disruption of identity characterized by two or more distinct personality states, which
may be described in some cultures as an experience of possession. The disruption in
identity involves marked discontinuity in sense of self and sense of agency, accompa-
nied by related alterations in affect, behavior, consciousness, memory, perception,
cognition, and/or sensory-motor functioning. These signs and symptoms may be ob-
served by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/
or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
D. The disturbance is not a normal part of a broadl y accepted cultural or religious practice.
Note:  In children, the symptoms are not better explained by imaginary playmates or
other fantasy play.
E. The symptoms are not attributable to the physiological effects of a substance (e.g.,
blackouts or chaotic behavior during alcohol intoxication) or anot her medical condition
(e.g., complex partial seizures).
Diagnostic Features
The defining feature of dissocia tive identity disorder is the presence of two or more dis-
tinct personality states or an experience of  possession (Criterion  A). The overtness or
covertness of these personality states, howeve r, varies as a function of psychological
motivation, current level of st ress, culture, internal conflicts and dynamics, and emotional
resilience. Sustained periods of identity di sruption may occur when psychosocial pres-
sures are severe and/or prolonged. In many possession-form cases of  dissociative identity
disorder, and in a small proportion of non-po ssession-form cases, manifestations of alter-


nate identities are highly ove rt. Most individuals with non-possession-for m dissociative
identity disorder do not overtly display their discontinuity of identity for long periods of
time; only a small minority present to clinical attention wi th observable alternation of


Dissociative Identity Disorder 293
identities. When alternate personality states are not directly observ ed, the disorder can be
identified by two clusters of symptoms: 1) sudden alterations or discontinuities in sense of
self and sense of agency (Criterion A), and 2)  recurrent dissociative amnesias (Criterion B).
Criterion A symptoms are related to disconti nuities of experience that can affect any
aspect of an individual’s functioning. Indivi duals with dissociative identity disorder may
report the feeling that they have suddenly  become depersonalized observers of their
“own” speech and actions, which they may feel po werless to stop (sense of self). Such in-
dividuals may also report perceptions of voices (e.g., a child’s voice; crying; the voice of a
spiritual being). In some case s, voices are experienced as multiple, perplexing, indepen-
dent thought streams over which the individual  experiences no contro l. Strong emotions,
impulses, and even speech or other actions ma y suddenly emerge, without a sense of per-
sonal ownership or control (sense of agency).  These emotions and impulses are frequently
reported as ego-dystonic and puzzling. Atti tudes, outlooks, and personal preferences
(e.g., about food, activities, dress) may sudde nly shift and then shift back. Individuals may
report that their bodies feel different (e.g.,  like a small child, like the opposite gender, huge
and muscular). Alterations in sense of self and loss of personal agency may be accompa-
nied by a feeling th at these attitudes, emotions, an d behaviors—even  one’s body—are
“not mine” and/or are “not under my control.” Although most Criterion A symptoms are


“not mine” and/or are “not under my control.” Although most Criterion A symptoms are
subjective, many of these sudden discontinuitie s in speech, affect, and behavior can be wit-
nessed by family, friends, or the clinician.  Non-epileptic seizures and other conversion
symptoms are prominent in some presentation s of dissociative identity disorder, espe-
cially in some non-Western settings.
The dissociative amnesia of in dividuals with dissociative id entity disorder manifests in
three primary ways: as 1) gaps in remote me mory of personal life events (e.g., periods of
childhood or adolescence; some important lif e events, such as the death of a grandparent,
getting married, giving birth); 2) lapses in  dependable memory (e.g., of what happened
today, of well-learned skills such as how to do  their job, use a computer, read, drive); and
3) discovery of evidence of their everyday ac tions and tasks that they do not recollect do-
ing (e.g., finding unexplained objects in thei r shopping bags or am ong their possessions;
finding perplexing writings or drawings that they must have created; discovering injuries;
“coming to” in the midst of doing something). Dissociative fugues, wherein the person
discovers dissociated travel, are common. Thus, individuals with dissociative identity dis-
order may report that they have suddenly found themselves at the beach, at work, in a night-
club, or somewhere at home (e.g., in the clos et, on a bed or sofa, in the corner) with no
memory of how they came to be there. Amnesia in individuals with dissociative identity dis-
order is not limited to stressful or traumati c events; these individuals often cannot recall


order is not limited to stressful or traumati c events; these individuals often cannot recall
everyday events as well.
Individuals with dissociative identity disorder vary in their awareness and attitude to-
ward their amnesias. It is common for these in dividuals to minimize their amnestic symp-
toms. Some of their amnestic behaviors may be  apparent to others—as when these persons
do not recall somethin g they were witnessed to have done or said, when they cannot
remember their own name, or when they do no t recognize their spouse, children, or close
friends.
Possession-form identities in dissociative identity  disorder typically manifest as be-
haviors that appear as if a “spirit,” supernatur al being, or outside person has taken control,


friends.
Possession-form identities in dissociative identity  disorder typically manifest as be-
haviors that appear as if a “spirit,” supernatur al being, or outside person has taken control,
such that the individual begins speaking or acting in a distinctly different manner. For ex-
ample, an individual’s beha vior may give the appearance  that her identity has been
replaced by the “ghost” of a girl who co mmitted suicide in the same community years
before, speaking and acting as though she were  still alive. Or an individual may be “taken
over” by a demon or deity, re sulting in profound impairment , and demanding that the in-
dividual or a relative be punished for a past act, followed by more su btle periods of iden-
tity alteration. However, the majority of possession states around the world are normal,
usually part of spiritual practice, and do not meet criteria for dissociative identity disor-


294 Dissociative Disorders
der. The identities that arise during possessio n-form dissociative identity disorder present
recurrently, are unwanted and involuntary, cause clinically significant distress or impair-
ment (Criterion C), and are not a normal part  of a broadly accepted cultural or religious
practice (Criterion D).
Associated Features Supporting Diagnosis
Individuals with di ssociative identity disorder typically present with comorbid depression,
anxiety, substance abuse, self-injury, non-epileptic seizures, or another common symp-
tom. They often conceal, or are not fully aw are of, disruptions in consciousness, amnesia,
or other dissociative symptoms. Many individu als with dissociative identity disorder re-
port dissociative flashbacks during which they undergo a sensory reliving of a previous
event as though it were occurring in the presen t, often with a change of identity, a partial
or complete loss of contact wi th or disorientation to current  reality during the flashback,
and a subsequent amnesia for the content of the flashback. Individuals with the disorder
typically report multiple types of interpersonal maltreatment during childhood and adult-
hood. Nonmaltreatment forms of overwhelming early life events, such as multiple long,
painful, early-life medical pr ocedures, also may be reported. Self-mutilation and suicidal
behavior are frequent. On standardized meas ures, these individuals report higher levels
of hypnotizability and dissociativity compared with other clinical groups and healthy con-
trol subjects. Some individuals experience transient psychotic phenomena or episodes.
Several brain regions have been implicated in the pathophysiology of dissociative identity
disorder, including the orbito frontal cortex, hippocampus, parahippocampal gyrus, and
amygdala.
Prevalence
The 12-month preval ence of dissociative id entity disorder among adults in a small U.S.


community study was 1.5%. The prevalence ac ross genders in that study was 1.6% for
males and 1.4% for females.
Development and Course
Dissociative identity disorder is associated  with overwhelming experiences, traumatic
events, and/or abuse oc curring in childhood. The full disorder may first manifest at al-
most any age (from earliest childhood to late life). Dissociation in children may generate
problems with memory, concentration, attach ment, and traumatic play . Nevertheless, chil-
dren usually do not present with  identity changes; instead they present primarily with over-
lap and interference among mental states (Cri terion A phenomena), with symptoms related
to discontinuities of experience. Sudden changes in identity during adolescence may ap-
pear to be just adolescent turmoil or the ea rly stages of another mental disorder. Older
individuals may present to treatment with what appear to be late-life mood disorders, ob-
sessive-compulsive disorder, paranoia, psycho tic mood disorders, or even cognitive dis-
orders due to dissociative amnesia. In some  cases, disruptive affects and memories may
increasingly intrude into aw areness with advancing age.
Psychological decompensation and overt change s in identity may be triggered by 1) re-
moval from the traumatizing situation (e.g.,  through leaving home); 2) the individual’s
children reaching the same age at which the in dividual was originally abused or trauma-
tized; 3) later traumatic experiences, even seemingly inconsequential ones, like a minor
motor vehicle accident; or 4) th e death of, or the onset of a fatal illness in, their abuser(s).
Risk and Prognostic Factors
Environmental. Interpersonal physical and sexual abus e is associated with an increased


Environmental. Interpersonal physical and sexual abus e is associated with an increased
risk of dissociative identity disorder. Prev alence of childhood abuse and neglect in the


Dissociative Identity Disorder 295
United States, Canada, and Europe among th ose with the disorder is about 90%. Other
forms of traumatizing experiences, includin g childhood medical and surgical procedures,
war, childhood prostitution, and terrorism, have been reported.
Course modifiers. Ongoing abuse, later-life retrauma tization, comorbid ity with mental
disorders, severe medical illness, and delay in appropriate treatment are associated with
poorer prognosis.
Culture-Related Diagnostic Issues
Many features of dissociative identity disord er can be influenced by the individual’s cul-
tural background. Individuals with this disorder may pres ent with prominent medically
unexplained neurological symptoms, such as no n-epileptic seizures, paralyses, or sensory
loss, in cultural settings where such symptoms are common. Similarly, in settings where
normative possession is common (e.g., rural areas in the developing world, among certain
religious groups in the United States and Euro pe), the fragmented identities may take the
form of possessing spirits, de ities, demons, animals, or myth ical figures. Acculturation or
prolonged intercultural contact may shape the characteristics of  the other identities (e.g.,
identities in India may speak English exclu sively and wear Western clothes). Possession-
form dissociative identity diso rder can be distinguished from  culturally accepted posses-
sion states in that the former is involunta ry, distressing, uncontro llable, and often recur-
rent or persistent; involves conflict between  the individual and his or her surrounding
family, social, or work milieu; and is manifest ed at times and in places that violate the
norms of the culture or religion.
Gender-Related Diagnostic Issues
Females with dissociative identity disorder pr edominate in adult clinical settings but not


Females with dissociative identity disorder pr edominate in adult clinical settings but not
in child clinical settings. Adult males with dissociative identity disorder may deny their
symptoms and trauma  histories, and this can lead to el evated rates of false negative di-
agnosis. Females with dissociative identity di sorder present more frequently with acute
dissociative states (e.g., flashb acks, amnesia, fugue, function al neurological [conversion]
symptoms, hallucinations, self-mutilation). Ma les commonly exhibit more criminal or vi-
olent behavior than females; among males, comm on triggers of acute dissociative states in-
clude combat, prison conditions, and physical or sexual assaults.
Suicide Risk
Over 70% of outpatients with dissociative id entity disorder have attempted suicide; mul-
tiple attempts are common, and other self-inj urious behavior is frequent. Assessment of
suicide risk may be complicated when there is amnesia for past suicid al behavior or when
the presenting identity does no t feel suicidal and is unaware that other dissociated iden-
tities do.
Functional Consequences of
Dissociative Identity Disorder
Impairment varies widely, from apparently minimal (e.g., in high-functioning profession-
als) to profound. Regardless of level of disability, individuals with dissociative identity
disorder commonly minimize the impact of their dissociative an d posttraumatic symp-
toms. The symptoms of higher-functioning in dividuals may impair their relational, mar-
ital, family, and parenting functions more th an their occupational and professional life
(although the latter also may be affected). With appropriate treatment, many impaired in-
dividuals show marked improvement in occupational and personal functioning. How-
ever, some remain highly impaired in most ac tivities of living. These individuals may only


ever, some remain highly impaired in most ac tivities of living. These individuals may only
respond to treatment very slowly, with gr adual reduction in or improved tolerance of


296 Dissociative Disorders
their dissociative and posttraumatic sympto ms. Long-term supportive treatment may
slowly increase these individuals’ ability to  manage their symptoms  and decrease use of
more restrictive levels of care.
Differential Diagnosis
Other specified dissociative disorder. The core of dissociative identity disorder is the
division of identity, with recurrent disruption of conscious functioning and sense of self.
This central feature is sh ared with one form of other specified dissociative disorder, which
may be distinguished from dissociative identity disorder by the presence of chronic or re-
current mixed dissociative symptoms that do not meet Criterion A for dissociative identity
disorder or are not accomp anied by recurrent amnesia.
Major depressive disorder. Individuals with dissociative identity disorder are often de-
pressed, and their symptoms may appear to m eet the criteria for a major depressive episode.
Rigorous assessment indicates that this depression in some cases does not meet full criteria for
major depressive disorder. Othe r specified depressive disorder  in individual s with dissocia-
tive identity disorder often has an importan t feature: the depressed mood and cognitions fluc-
tuate  because they are experienced in some identity states but not others.
Bipolar disorders. Individuals with dissociative iden tity disorder are often misdiag-
nosed with a bipolar disorder, mo st often bipolar II disorder. The relatively rapid shifts in
mood in individuals with this disorder—typica lly within minutes or hours, in contrast to
the slower mood changes typically seen in individuals with bipolar disorders—are due to
the rapid, subjective shifts in  mood commonly reported acro ss dissociative states, some-
times accompanied by fluctuation in levels of activation. Furtherm ore, in dissociative
identity disorder, elevated or depressed mood  may be displayed in conjunction with overt


identity disorder, elevated or depressed mood  may be displayed in conjunction with overt
identities, so one or the other mood may pred ominate for a relatively  long period of time
(often for days) or may shift within minutes.
Posttraumatic stress disorder. Some traumatized individua ls have both posttraumatic
stress disorder (PTSD) and dissociative identity disorder. Accordingly, it is crucial to dis-
tinguish between individuals with PTSD only an d individuals who have both PTSD and
dissociative identity disorder. This different ial diagnosis requires that the clinician estab-
lish the presence or absence of dissociative sy mptoms that are not characteristic of acute
stress disorder or PTSD. Some individuals wi th PTSD manifest diss ociative symptoms that
also occur in dissociative identity disorder: 1) amnesia for some aspe cts of trauma, 2) dis-
sociative flashbacks (i.e., reliving of the trauma, with reduced awareness of one’s current
orientation), and 3) symptoms of intrusion an d avoidance, negative alterations in cogni-
tion and mood, and hyperarousal that are focu sed around the traumatic event. On the other
hand, individuals with dissociative identity disorder manifest dissociative symptoms that
are not a manifestation of PTSD: 1) amnesias for many everyday (i.e., nontraumatic) events,
2) dissociative flashbacks that may be followe d by amnesia for the content of the flashback,
3) disruptive intrusions (unrelated to trau matic material) by dissociated identity states
into the individual’s sense of self and agency, and 4) infrequent, full-blown changes
among different identity states.
Psychotic disorders. Dissociative identity disorder may be confused with schizophre-


Psychotic disorders. Dissociative identity disorder may be confused with schizophre-
nia or other psychotic disorders. The personified, internally communicative inner voices
of dissociative identity di sorder, especially of a child (e.g., “I hear a little girl crying in a
closet and an angry man yelling at her”), may be mistaken for psychotic hallucinations.
Dissociative experiences of identity fragmentat ion or possession, and of perceived loss of


closet and an angry man yelling at her”), may be mistaken for psychotic hallucinations.
Dissociative experiences of identity fragmentat ion or possession, and of perceived loss of
control over thoughts, feelings, impulses, and acts, may be confused with signs of formal
thought disorder, such as thought insertion or withdrawal. Individu als with dissociative
identity disorder may also report visual, tact ile, olfactory, gustatory, and somatic halluci-
nations, which are usually related to posttrau matic an d dissociative factors, such as partial


Dissociative Identity Disorder 297
flashbacks. Individuals with dissociative iden tity disorder experience these symptoms as
caused by alternate identities, do not have  delusional explanations for the phenomena,
and often describe the symptoms in a personified way (e.g., “I feel like someone else wants
to cry with my eyes”). Persecutory and derogato ry internal voices in dissociative identity
disorder associated with depressive symptoms  may be misdiagnosed as major depression
with psychotic features. Chaotic identity change and acute intrusions that disrupt thought
processes may be distinguished from brief psychotic disorder by the predominance of dis-
sociative symptoms and amnesia for the episode,  and diagnostic evaluation after cessation
of the crisis can help confirm the diagnosis.
Substance/medication-induced disorders. Symptoms associated with the physiological
effects of a substance can be distinguished from dissociative identity disorder if the sub-
stance in question is judged to be et iologically related to the disturbance.
Personality disorders. Individuals with dissociative identity disorder often present identi-
ties that appear to encapsulat e a variety of severe personality disorder features, suggesting a
differential diagnosis of personality disorder, especially of the borderline type. Importantly,
however, the individual’s longitudinal variabi lity in personality style (due to inconsistency
among identities) differs from the pervasive an d persistent dysfunctio n in affect management
and interpersonal relationships typical of those with personality disorders.
Conversion disorder (functional neurological symptom disorder). This disorder may be
distinguished from dissociative identity disord er by the absence of an identity disruption
characterized by two or more distinct personality states or an experience of possession.
Dissociative amnesia in conver sion disorder is more  limited and circumscribed (e.g., am-
nesia for a non-epileptic seizure).


nesia for a non-epileptic seizure).
Seizure disorders. Individuals with dissociative identity disorder may present with sei-
zurelike symptoms and behaviors that resemb le complex partial seizures with temporal
lobe foci. These include déjà vu, jamais vu, de personalization, derea lization, out-of-body
experiences, amnesia, disruptions of consci ousness, hallucinations, and other intrusion
phenomena of sensation, affect, and thought . Normal electroencep halographic findings,
including telemetry, differenti ate non-epileptic seiz ures from the seizurelike symptoms of
dissociative identity disorder. Also, individua ls with dissociative identity disorder obtain
very high dissociation scores, whereas indivi duals with complex partial seizures do not.
Factitious disorder and malingering. Individuals who feign dissociative identity disor-
der do not report the subtle symptoms of intr usion characteristic of the disorder; instead
they tend to overreport well-publicized symp toms of the disorder, such as dissociative
amnesia, while underreporting less-publicized  comorbid symptoms, such as depression.
Individuals who feign dissociative identity d isorder tend to be relatively undisturbed by
or may even seem to enjoy “having” the diso rder. In contrast, individuals with genuine
dissociative identity disorder tend to be ashamed of and overwhelmed by their symptoms
and to underreport their symptoms or deny th eir condition. Sequential observation, cor-
roborating history, and intensive psycho metric and psychological assessment may be
helpful in assessment.
Individuals who malinger dissociative identity  disorder usually create limited, stereo-
typed alternate identities, with feigned amnesia, related to the events for which gain is


typed alternate identities, with feigned amnesia, related to the events for which gain is
sought. For example, they may present an “all-good” identity and an “all-bad” identity in
hopes of gaining exculpation for a crime.
Comorbidity
Many individuals with dissociative identity disorder present with a comorbid disorder. If


hopes of gaining exculpation for a crime.
Comorbidity
Many individuals with dissociative identity disorder present with a comorbid disorder. If
not assessed and treated specifically for the dissociative disorder, these individuals often
receive prolonged treatment for the comorbid diagnosis only, with limited overall treat-
ment response and resultant demoralization, and disability.


298 Dissociative Disorders
Individuals with dissociative identity disorder usually ex hibit a large number of co-
morbid disorders. In particular, most develo p PTSD. Other disorders that are highly co-
morbid with dissociative identity disorder include depressive di sorders, trauma- and
stressor-related disorders, personality diso rders (especially avoidant and borderline per-
sonality disorders), conversion disorder (functional neurological symptom disorder),
somatic symptom disorder, eating disorders,  substance-related disorders, obsessive-
compulsive disorder, and sleep disorders. Dissociative alterations in identity, memory,
and consciousness may affect the sympto m presentation of comorbid disorders.
Dissociative Amnesia
Diagnostic Criteria 300.12 (F44.0)
A. An inability to recall important autobiographical information, usually of a traumatic or
stressful nature, that is inconsistent with ordinary forgetting.
Note:  Dissociative amnesia most often consists of localized or selective amnesia for a
specific event or events; or generalized amnesia for identity and life history.
B. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a substance (e.g., al-
cohol or other drug of abuse, a medication) or a neurological or other medical condition
(e.g., partial complex seizures, transient global amnesia, sequelae of a closed head in-
jury/traumatic brain injury, other neurological condition).
D. The disturbance is not better explained by dissociative identity disorder, posttraumatic
stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neu-
rocognitive disorder.
Coding note: The code for dissociative amnesia without dissociative fugue is 300.12


(F44.0). The code for dissociative amnesia with dissociative fugue is 300.13 (F44.1).
Specify if:
300.13 (F44.1) With dissociative fugue:  Apparently purposeful travel or bewildered
wandering that is associated with amnesia for identity or for other important autobio-
graphical information.
Diagnostic Features
The defining characteristic of dissociative amnesia is an inability to recall important auto-
biographical information that 1) should be su ccessfully stored in me mory and 2) ordinar-
ily would be readily remembered (Criterion  A). Dissociative amnesia differs from the
permanent amnesias due to neurob iological damage or toxicity that prevent memory stor-
age or retrieval in that it is always potentially reversible because the memory has been suc-
cessfully stored.
Localized amnesia,  a failure to recall events during a circumscribed period of time, is the
most common form of dissocia tive amnesia. Localized amnesi a may be broader than am-
nesia for a single traumatic event (e.g., months or years associated with child abuse or in-
tense combat). In selective amnesia,  the individual can recall some , but not all, of the events
during a circumscribed period of time. Thus, the individual may remember part of a trau-
matic event but not other parts. Some individu als report both localized and selective am-
nesias.
Generalized amnesia,  a complete loss of memory for one’ s life history, is rare. Individuals
with generalized amnesia may forget personal  identity. Some lose previous knowledge
about the world (i.e., semantic knowledge) and can no longer access well-learned skills


Dissociative Amnesia 299
(i.e., procedural knowledge). Generalized amnesia has an acute onset; the perplexity, dis-
orientation, and purposeless wandering of individuals with generalized amnesia usually
bring them to the attention of the police or psychiatric emergency services. Generalized
amnesia may be more common among combat veterans, sexual  assault victims, and indi-
viduals experiencing extreme emotional stress or conflict.
Individuals with dissociative amnesia are fr equently unaware (or only partially aware)
of their memory problems. Many, especially those with localized am nesia, minimize the
importance of their memory loss and may be come uncomfortable when prompted to ad-
dress it. In systematized amnesia,  the individual loses memory for a specific category of in-
formation (e.g., all memories relating to on e’s family, a particular person, or childhood
sexual abuse). In continuous amnesia,  an individual forgets each new event as it occurs.
Associated Features Supporting Diagnosis
Many individuals with dissociative amnesia are chronically impaired in their ability to
form and sustain satisfactory relationships. Histories of trauma, child abuse, and victim-
ization are common. Some indivi duals with dissociative amnesia report dissociative flash-
backs (i.e., behavioral reexperiencing of trau matic events). Many have a history of self-
mutilation, suicide attempts, and other high -risk behaviors. Depressive and functional
neurological symptoms are common, as are depersonalization, auto-hypnotic symptoms,
and high hypnotizability. Sexual dysfunctions are common. Mild traumatic brain injury
may precede dissociative amnesia.
Prevalence
The 12-month prevalence for dissociative amnesia among ad ults in a small U.S. commu-


nity study was 1.8% (1.0% fo r males; 2.6% for females).
Development and Course
Onset of generalized amnesia is usually sudden . Less is known about the onset of localized
and selective amnesias because these amnesias ar e seldom evident, even to the individual.
Although overwhelming or intolerable events typically precede localized amnesia, its on-
set may be delayed for ho urs, days, or longer.
Individuals may report multiple episodes of dissociative amnesia. A single episode
may predispose to future episodes. In between episodes of amnesia, the individual may or
may not appear to be acutely symptomatic. Th e duration of the forgotten events can range
from minutes to decades. Some episodes of  dissociative amnesia resolve rapidly (e.g.,
when the person is removed from combat or some other stressful situation), whereas other
episodes persist for long periods of time. So me individuals may grad ually recall the dis-
sociated memories years later. Dissociative capacities may decline with age, but not al-
ways. As the amnesia remits, there may be considerable distress, su icidal behavior, and
symptoms of posttraumatic stress disorder (PTSD).
Dissociative amnesia has been observed in young children, adolescents, and adults.
Children may be the most difficult to evaluate because they often have difficulty under-
standing questions about amnesia, and interviewers may find it difficult to formulate child-
friendly questions about memory and amnesia. Observations of apparent dissociative am-
nesia are often difficult to differentiate from inattention, absorption , anxiety, oppositional
behavior, and learning disorders. Reports fr om several different sources (e.g., teacher,
therapist, case worker) may be needed  to diagnose amnesia in children.


therapist, case worker) may be needed  to diagnose amnesia in children.
Risk and Prognostic Factors
Environmental. Single or repeated traumatic experiences (e.g., war, childhood maltreat-
ment, natural disaster, internment in conc entration camps, genocide) are common ante-


300 Dissociative Disorders
cedents. Dissociative amnesia is more likely to  occur with 1) a greater number of adverse
childhood experiences, particularly physical and/or sexual abuse, 2) interpersonal vio-
lence; and 3) increased severity, frequency, and violence of the trauma.
Genetic and physiological. There are no genetic studies of  dissociative amnesia. Stud-
ies of dissociation report significant genetic an d environmental factors in both clinical and
nonclinical samples.
Course modifiers. Removal from the traumatic circumstances underlying the dissociative
amnesia (e.g., combat) may bring about a rapid re turn of memory. The memory loss of indi-
viduals with dissociative fugue may be particularly refractory. Onset of PTSD symptoms may
decrease localized, selective, or systematized amnesia. The returning memory, however, may
be experienced as flashbacks that alternate wi th amnesia for the content of the flashbacks.
Culture-Related Diagnostic Issues
In Asia, the Middle East, and Latin America, non-epileptic seizures and other functional
neurological symptoms may accompany dissociat ive amnesia. In cultur es with highly re-
strictive social traditions, th e precipitants of dissociative  amnesia often do not involve
frank trauma. Instead, the amnesia is preceded by severe psychological stresses or con-
flicts (e.g., marital conflict, other family d isturbances, attachment problems, conflicts due
to restriction or oppression).
Suicide Risk
Suicidal and other self-destructive behavior s are common in individuals with dissociative
amnesia. Suicidal behavior may be a particular risk when the amnesia remits suddenly
and overwhelms the individual  with intolerable memories.
Functional Consequences of Dissociative Amnesia


Functional Consequences of Dissociative Amnesia
The impairment of individuals with localized, selective, or systemat ized dissociative am-
nesia ranges from limited to severe. Individu als with chronic generalized dissociative am-
nesia usually have impairment in all aspects of functioning. Even when these individuals
“re-learn” aspects of their life history, au tobiographical memory remains very impaired.
Most become vocationally an d interpersonally disabled.
Differential Diagnosis
Dissociative identity disorder. Individuals with dissociati ve amnesia may report de-
personalization and auto-hypnotic symptoms. In dividuals with dissociative identity dis-
order report pervasive disconti nuities in sense of self and agency, accompanied by many
other dissociative symptoms. The amnesias of individuals with localized, selective, and/
or systematized dissociative amnesias are relatively stable. Amnesias in dissociative iden-
tity disorder include amnesia for everyday events, finding of unexplained possessions,
sudden fluctuations in skills and knowledge, ma jor gaps in recall of life history, and brief
amnesic gaps in interpersonal interactions.
Posttraumatic stress disorder. Some individuals with PTSD cannot recall part or all of
a specific traumatic event (e.g., a rape victim  with depersonalization and/or derealization
symptoms who cannot recall most events for the entire day of the rape). When that amne-
sia extends beyond the immediat e time of the trauma, a comorbid diagnosis of dissociative
amnesia is warranted.
Neurocognitive disorders. In neurocognitive disorders, memory loss for personal infor-
mation is usually embedded in cognitive, lingu istic, affective, atte ntional, and behavioral


Dissociative Amnesia 301
disturbances. In dissociative amnesia, memory  deficits are primarily for autobiographical
information; intellectual and co gnitive abilities are preserved.
Substance-related disorders. In the context of repeated intoxication with alcohol or
other substances/medications, there may be episod es of “black outs” or periods for which the
individual has no memory. To aid in distingu ishing these episodes from dissociative am-
nesia, a longitudinal history noting that the amnestic episodes occur only in the context of
intoxication and do no t occur in other situations would help identify the source as sub-
stance-induced; however the distinction may be difficult when the individual with dis-
sociative amnesia may also misuse alcohol or other substances in the context of stressful
situations that may also exac erbate dissociative symptoms. Some individuals with comor-
bid dissociative amnesia and substance use disorders will at tribute their memory prob-
lems solely to the substance use. Prolonged us e of alcohol or other substances may result in
a substance-induced neurocognitive disorder that may be associated with impaired cog-
nitive function, but in this co ntext the protracted history of  substance use and the persis-
tent deficits associated with the neurocognitive disorder would serve to distinguish it
from dissociative amnesia, wher e there is typically no evidence of persistent impairment in
intellectual functioning.
Posttraumatic amnesia due to brain injury. Amnesia may occur in th e context of a trau-
matic brain injury (TBI) when th ere has been an impact to th e head or other mechanisms of
rapid movement or displacement of the brain within the skull TBI. Other characteristics of
TBI include loss of consciousness, disorientati on and confusion, or, in more severe cases,


neurological signs (e.g., abnormalities on neuroimaging, a new onset of seizures or a marked
worsening of a preexisting seizure disorder, visual field cuts, anos mia). A neurocognitive
disorder attributable to TBI must present either  immediately after brain injury occurs or im-
mediately after the individual recovers consciousness after th e injury, and persist past the
acute post-injury period. The cognitive presenta tion of a neurocognitive disorder following
TBI is variable and includes difficulties in the domains of complex attention, executive func-
tion, learning and memory as well as slowed speed of information processing and distur-
bances in social cognition. Th ese additional features help di stinguish it from dissociative
amnesia.
Seizure disorders. Individuals with seizure disorders may exhibit complex behavior dur-
ing seizures or post-ictally wi th subsequent amnesia. Some individuals with a seizure disorder
engage in nonpurposive wandering that is lim ited to the period of seizure activity. Con-
versely, behavior during a di ssociative fugue is usually purposeful, complex, and goal-
directed and may last for days, weeks, or long er. Occasionally, individuals with a seizure dis-
order will report that earlier autobiographical me mories have been “wiped out” as the seizure
disorder progresses. Such  memory loss is not associated with traumatic circumstances and ap-
pears to occur randomly. Serial electroencepha lograms usually show abnormalities. Telemet-
ric electroencephalographic monitoring usually shows an association between the episodes of
amnesia and seizure activity. Dissociativ e and epileptic amnesias may coexist.
Catatonic stupor. Mutism in catatonic stupor may sugg est dissociative amnesia, but fail-