Dissociative disorder not otherwise specified

Dissociative Disorders that do not fit into other categories in the DSM-5 include both dissociative disorder not otherwise specified (DDNOS, now known as other specified dissociative disorder (OSDD), and unspecified Dissociative Disorder meant to be used in emergency situations. DDNOS is a Dissociative Disorder that has been present for some time, where an individual reports distress impaired functioning due to symptoms. ^[1]

DDNOS was diagnosed when symptoms characteristic of a dissociative disorder predominate, but the symptoms do not fully meet the criteria for any other dissociative disorder. Symptoms must cause clinically significant distress and/or impaired functioning in at least one major area of life (e.g. social, occupational, etc.). The clinician needs to record a reason why the symptoms do not fully meet the criteria for another dissociative disorder, four presentations are described to aid diagnosis.^[2]:306-307

This was formally the DDNOS (dissociative disorder not otherwise specified) category, and many who had this diagnosis now have a diagnosis of dissociative identity disorder if they do experience time-loss (amnesia) and report this to their therapist. ^[3]:158

DSM-5 Criteria

As with all dissociative disorders, the condition must cause "clinically significant distress" and/or "impaired functioning in social, occupational, or other significant areas of life must predominate". The clinician must record a reason for this giving diagnosis. ^[3]:158

Example presentations include:

1. Chronic and recurrent syndromes of mixed dissociative symptoms. This category includes identity disturbance association with less than marked discontinuities in sense of self and agency, or alterations of identity or episodes of possession in an individual who reports no dissociative amnesia.
2. Identity disturbance due to prolonged and intense coercive persuasion: Individuals who have been subjected to intense coercive persuasion may present with prolonged changes in, or conscious questions of their identity.
3. Acute dissociative reactions to stressful events, these can last between a few hours and a month and may include a variety of dissociative symptoms such as micro-amnesias and depersonalization
4. Dissociative trance: characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifest as profound unresponsiveness or insensitivity to environmental stimuli. May may be accompanied by minor stereotyped behaviors of which the individual is unaware and/or that he or she cannot control, as well as transient paralysis or loss of consciousness. The dissociative trance is not a normal part of a broadly accepted collective cultural or religious practice.

ICD-10 Criteria

All dissociative [conversion] disorders must involve

1. No evidence of a physical disorder that can explain the symptoms that characterize the disorder (but physical disorders may be present that give rise to other symptoms).
2. Convincing associations in time between the symptoms of the disorder and stressful events, problems or needs. ^[4]

The ICD-10 describes a range of dissociative disorders which are all classified as DDNOS in the DSM-5 manual.

Dissociative Stupor

F44.2

• Profound diminution or absence of voluntary movements and speech, and of normal responsiveness to light, noise and touch.
• Maintenance of normal muscle tone, static posture, and breathing (and often limited coordinated eye movements).

Trance and Possession Disorders

F44.3 Either (1) or (2):

1. Possession disorder: Conviction that the individual has been taken over by a spirit, power, deity or other person.
2. Trance: Temporary alteration of the state of consciousness, shown by any two of:

• Loss of the usual sense of personal identity.
• Narrowing of awareness of immediate surroundings, or unusually narrow and selective focusing on environmental stimuli.
• Limitation of movements, postures, and speech to repetition of a small repertoire.

In addition both criterion 1. and 2. must be unwanted and troublesome, occurring outside or being a prolongation of similar states in religious or other culturally accepted situations. This must not occur at the same time as schizophrenia or related disorders, or mood [affective] disorders with hallucinations or delusions.

Dissociative motor disorders

F44.4 The commonest varieties of dissociative motor disorder are loss of ability to move the whole or a part of a limb or limbs. Paralysis may be partial, with movements being weak or slow, or complete. Various forms and variable degrees of in coordination (ataxia) may be evident, particularly in the legs, resulting in bizarre gait or inability to stand unaided (astasia-abasia). There may also be exaggerated trembling or shaking of one or more extremities or the whole body.

Either (1) or (2):

1. Complete of partial loss of the ability to perform movements that are normally under voluntary control (including speech).
2. Various or variable degrees of in coordination or ataxia or inability to stand unaided.

Dissociative convulsions

F44.5 These are pseudoseizures, they may mimic epileptic seizures but with some differences. Diagnostic criteria:

• Sudden and unexpected spasmodic movements, closely resembling any of the varieties of epileptic seizures, but not followed by loss of consciousness.
• this must not be accompanied by tongue-biting, serious bruising or laceration due to falling, or incontinence of urine.

Dissociative anesthesia and sensory loss

F44.6 Either (1) or (2):

1. Partial or complete loss of any or all of the normal cutaneous sensations over part or all of the body (specify: touch, pin prick, vibration, heat, cold).
2. Partial or complete loss of vision, hearing or smell (specify).

Anesthetic areas of skin often have boundaries which make it clear that they are associated more with the patient's ideas about bodily functions than with medical knowledge. There may also be differential loss between the sensory modalities which cannot be due to a neurological lesion. Sensory loss may be accompanied by complaints of paraesthesia.

Loss of vision is rarely total in Dissociative Disorders, and visual disturbances are more often a loss of acuity, general blurring of vision, or "tunnel vision". In spite of complaints of visual loss, the patient's general mobility and motor performance are often surprisingly well preserved. Dissociative deafness and anosmia (loss of smell) are far less common than loss of sensation or vision.

Mixed dissociative [conversion] disorders

F44.7 Any mix of the Dissociative Disorders, possibly including Dissociative Amnesia and Dissociative Fugue.

Ganser's syndrome

F44.80 Giving approximate answers to questions, for example 2+2 equals 5.

Transient dissociative [conversion] disorders occurring in childhood and adolescence

F44.82 No description is given for this in the ICD-10 manual.

Other specified dissociative [conversion] disorders

F44.88 Specific research criteria are not given for all disorders mentioned above, since these other dissociative states are rare and not well described. Research workers studying these conditions in detail will wish to specify their own criteria according to the purposes of their study. This includes psychogenic confusion and twilight state.

Dissociative [conversion] disorder, unspecified

F44.9 This has no description but must meet the two dissociative disorder criteria described at the top.^[5]

Other Specified Dissociative Disorder compared to Dissociative Identity Disorder in the DSM-5

OSDD example 1 of the DSM-5 states this is:

Chronic and recurrent syndromes of mixed dissociative symptoms. This category includes identity disturbance association with less than marked discontinuities in sense of self and agency, or alterations of identity or episodes of possession in an individual who reports no dissociative amnesia.

This common presentation of Other Specified Dissociative Disorder bears some similarities to Dissociative Identity Disorder, meeting some but not all the diagnostic criteria of Dissociative Identity Disorder.^[1] The DSM-5 states that OSDD is a differential diagnosis for Dissociative Identity Disorder, explaining that "division of identity is the core feature of Dissociative Identity Disorder," and this feature is also present in OSDD. OSDD can be "distinguished by the presence of chronic or recurrent mixed dissociative symptoms which do not meet Criterion A for Dissociative Identity Disorder, or are not accompanied by recurrent amnesia".^[2]:265,292 Dissociative identity disorder may initially be diagnosed as Other Specified Dissociative Disorder if there is not enough evidence that each of the criteria for Dissociative Identity Disorder has been fully met; for example, this diagnosis may made when the Apparently Normal Part (host identity) has amnesia for many of the symptoms. However, OSDD cannot develop into Dissociative Identity Disorder.

A person with Other Specified Dissociative Disorder may experience different parts of their personality which do not physically take over their body but instead strongly influence their thoughts and actions, and some amnesia is present.^[1] Alternatively, a person may experience different parts of their personality, and those parts may physically take over their body but there is no amnesia for the past or present, so the full criteria for dissociative identity disorder is not met. ^[6]

Understanding Other Specified Dissociative Disorder

This section uses the terms Apparently Normal Part of the personality (ANP) and Emotional Part of the Personality (EP) from structural dissociation, in order more accurately describe the different parts of the personality within OSDD.

Diagnosis and treatment

The ISSTD treatment guidelines for dissociative identity disorder also apply to presentations 1 of Other Specified Dissociative Disorder, and the same diagnostic tests should be used. ^[7] See the dissociative identity disorder page for further details.

The ISTSS treatment guidelines for Complex Posttraumatic Stress Disorder will also be useful.

Dr. Alison Miller (2012) describes a few differences in treatment and states between dissociative identity disorder and OSDD, stating that OSDD is often the intended result of ritual abuse, rather than dissociative identity disorder. ^[6]

References

1. ^ a b c Spiegel, David; Loewenstein, Richard J. Lewis-Fernández, Roberto, Sar, Vedat, Simeon, Daphne, Vermetten, Eric, Cardeña, Etzel, Dell, Paul F. (2011). Dissociative disorders in DSM‐5. Depression and anxiety, volume 28, issue 9, page 824-852 also cited as Depression and Anxiety 28(12) E17-E45. (doi:10.1002/da.20874)
2. ^ a b American Psychiatric Association, (2013). . APA.
3. ^ a b American Psychiatric Association, (2013). . APA.
4. ^ ICD-10 Classification of Mental and Behavioural Disorders" (PDF). World Health Organization
5. ^ ISSTD International Society for the Study of Trauma and Dissociation.
6. ^ a b Miller, Alison (2012). Healing the Unimaginable: Treating Ritual Abuse and Mind Control. Karnac Books.827.
7. ^ International Society for the Study. Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal of Trauma & Dissociation, volume 12, issue 2, 28 February 2011, page 115–187. (doi:10.1080/152947)