Mental Health Consultation
Prior to beginning work on this assignment, it is recommended that you read Chapter 1 in Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises and Chapters 1, 2, and 4 in The Psychiatric Interview: Evaluation and Diagnosis.
For this assignment, you will take on the role of a mental health professional providing a consultation to a colleague. Your colleague in this case happens to be a licensed clinical psychologist. Carefully review the PSY645 Fictional Mental Health Consultation Scenario (Links to an external site.) which provides information on your colleague’s patient and specific questions your colleague has posed to you as a consultant. Once you have reviewed the scenario, research a minimum of two peer-reviewed articles in the related to the situation(s) presented in the scenario and how these have been approached and treated in previous cases.
Write an evaluation of the patient’s symptoms and presenting problems within the context of one theoretical orientation (e.g., psychoanalytic, cognitive, behavioral, humanistic, etc.). Summarize views of these symptoms and presenting problems within the context of at least one historical perspective and two theoretical orientations different from the one used in your evaluation (e.g.:, cognitive, humanistic, psychodynamic, integrative) in order to provide alternative viewpoints. To conclude, justify the use of diagnostic manuals and handbooks besides the DSM-5 that might be used to assess this prospective patient.
The Mental Health Consultation:
- Must be two to three double-spaced pages in length (not including title and references pages) and must be formatted according to APA style
- Must include a separate title page with the following:
- Title of paper
- Student’s name
- Course name and number
- Instructor’s name
- Date submitted
- Must use at least two peer-reviewed sources in addition to the course text.
- Must document all sources in APA style
- Must include a separate references page
Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview: Evaluation and diagnosis.Chichester, England: John Wiley & Sons. Retrieved from http://www.ebrary.com“Dissociative Disorders Quick Guide to the Dissociative Disorders Dissociative symptoms are principally covered in this chapter, but there are some conditions (especially involving loss or lapse of memory) that are classified elsewhere. Yep, the link indicates where a more detailed discussion begins. Primary Dissociative Disorders Dissociative amnesia. The patient cannot remember important information that is usually of a personal nature. This amnesia is usually stress-related. Dissociative identity disorder. One or more additional identities intermittently seize control of the patient’s behavior. Depersonalization/derealization disorder. There are episodes of detachment, as if the patient is observing the patient’s own behavior from outside. In this condition, there is no actual memory loss. Other specified, or unspecified, dissociative disorder. Patients who have symptoms suggestive of any of the disorders above, but who do not meet criteria for any one of them, may be placed in one of these two categories. Other Causes of Marked Memory Loss When dissociative symptoms are encountered in the course of other mental diagnoses, a separate diagnosis of a dissociative disorder is not ordinarily given. Panic attack. Some patients panic may experience depersonalization or derealization as part of an acute panic attack. Posttraumatic stress disorder. A month or more following a severe trauma, the patient may not remember important aspects of personal history. Acute stress disorder. Immediately following a severe trauma, patients may not remember important aspects of personal history. Somatic symptom disorder. Patients who have a history of somatic symptoms that cannot be explained on the basis of known disease mechanisms can also forget important aspects of personal history. Non-rapid eye movement sleep arousal disorder, sleepwalking type. Sleepwalking resembles the dissociative disorders, in that there is amnesia for purposeful behavior. But it is classified elsewhere in order to keep all the sleep disorders together. Borderline personality disorder. When severely stressed, these people will sometimes experience episodes of dissociation, such as depersonalization. Malingering. Some patients consciously feign symptoms of memory loss. Their object is material gain, such as avoiding punishment or obtaining money or drugs. INTRODUCTION Dissociation occurs when one group of normal mental processes becomes separated from the rest. In essence, some of an individual’s thoughts, feelings, or behaviors are removed from conscious awareness and control. For example, an otherwise healthy college student cannot recall any of the events of the previous 2 weeks. As with so many other mental symptoms, you can have dissociation without disorder; if it’s mild, it can be entirely normal. (Perhaps, for example, while enduring a boring lecture, you once daydreamed about your weekend plans, unaware that you’ve been called on for a response?) There’s also a close connection between the phenomena of dissociation and hypnosis. Indeed, over half the people interviewed in some surveys have had some experience of a dissociative nature. Episodes of dissociation severe enough to constitute a disorder have several features in common: • They usually begin and end suddenly. • They are perceived as a disruption of information that is needed by the individual. They can be positive, in the sense of something added (for example, flashbacks) or negative (a period of time for which the person has no memory). • Although clinicians often disagree as to their etiology, many episodes are apparently precipitated by psychological conflict. • Although they are generally regarded as rare, their numbers may be increasing. • In most (except depersonalization/derealization disorder), there is a profound disturbance of memory. • Impaired functioning or a subjective feeling of distress is required only for dissociative amnesia and depersonalization/derealization disorder. Conversion symptoms (typical of the somatic symptom disorders) and dissociation tend to involve the same psychic mechanisms. Whenever you encounter a patient who dissociates, consider whether such a diagnosis is also warranted. F48.1 [300.6] Depersonalization/Derealization Disorder Depersonalization can be defined as a sense of being cut off or detached from oneself. This feeling may be experienced as viewing one’s own mental processes or behavior; some patients feel as though they are in a dream. When a patient is repeatedly distressed by episodes of depersonalization, and there is no other disorder that better accounts for the symptoms, you can diagnose depersonalization/derealization disorder (DDD). DSM-5 offers another route to that diagnosis: through the experience of derealization, a feeling that the exterior world is unreal or odd. Patients may notice that the size or shape of objects has changed, or that other people seem robotic or even dead. Always, however, the person retains insight that it is only a change in perception—that the world itself has remained the same. Because about half of all adults have had at least one such episode, we need to place some limits on who receives this diagnosis. It should not be made unless the symptoms are persistent or recurrent, and unless they impair functioning or cause pretty significant distress (this means something well beyond the bemused reflection, “Well, that was weird!”). In fact, depersonalization and derealization are much more commonly encountered as symptoms than as a diagnosis. For example, derealization or depersonalization is one of the qualifying symptoms for panic attack. Episodes of DDD are often precipitated by stress; they may begin and end suddenly. The disorder usually has its onset in the teens or early 20s; usually it is chronic. Although still not well studied, prevalence rates in the general population appear to be around 1–2%, with males and females nearly equal. Essential Features of Depersonalization/Derealization Disorder A patient experiences depersonalization or derealization, but reality testing remains intact throughout. (The definitions are provided in the previous section.). The Fine Print The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood or anxiety disorders, psychotic disorders, trauma- and stressor-related disorders, other dissociative disorders) Francine Parfit “It feels like I’m losing my mind.” Francine Parfit was only 20 years old, but she had already worked as a bank teller for nearly 2 years. Having received several raises during that time, she felt that she was good at her job—conscientious, personable, and reliable. And healthy, though she’d been increasingly troubled by her “out-of-body experiences,” as she called them. “I’ll be standing behind my counter and, all of a sudden, I’m also standing a couple of feet away. I seem to be looking over my own shoulder as I’m talking with my customer. And in my head I’m commenting to myself on my own actions, as if I were a different person I was watching. Stuff like ‘Now she’ll have to call the assistant manager to get approval for this transfer of funds.’ I came to the clinic because I saw something like this on television a few nights ago, and the person got shock treatments. That’s when I began to worry something really awful was wrong.” Francine denied that she had ever had blackout spells, convulsions, blows to the head, severe headaches, or dizziness. She had smoked pot a time or two in high school, but otherwise she was drug- and alcohol-free. Her physical health had been excellent; her only visits to physicians had been for immunizations, Pap smears, and a preemployment physical exam 2 years ago. Each episode began suddenly, without warning. First Francine would feel quite anxious; then she’d notice that her head seemed to bob up and down slightly, out of her control. Occasionally she felt a warm sensation on the top of her head, as if someone had cracked a half-cooked egg that was dribbling yolk down through her hairline. The episodes seldom lasted longer than a few minutes, but they were becoming more frequent—several times a week now. If they occurred while she was at work, she could often take a break until they passed. But several times it had happened when she was driving. She worried that she might lose control of her car. Francine had never heard voices or had hallucinations of other senses; she denied ever feeling talked about or plotted against in any way. She had never had suicidal ideas and didn’t really feel depressed. “Just scared,” she concluded. “It’s so spooky to feel that you’ve sort of died.” Evaluation of Francine Parfit The sensation of being an outside observer of yourself can be quite unsettling; it is one that many people who are not patients have had a time or two. What makes Francine’s experience stand out is the fact that it returned often enough (criterion A1) and forcibly enough to cause her considerable distress—enough to seek an evaluation, at any rate (C). (She was a little unusual in that her episodes didn’t seem to be precipitated by stress; in many people, they are.) Notice that she described her experience “as if I were a different person,” not “I am a different person.” This tells us that she retained contact with reality (B). Francine’s experiences and feelings were much like those of Shorty Rheinbold, except that his occurred as symptoms of panic disorder. A variety of other conditions include depersonalization as a symptom: posttraumatic stress disorder, anxiety, cognitive, mood, personality, and substance-related disorders; schizophrenia; and epilepsy (D, E). However, Francine did not complain of panic attacks or have symptoms of other disorders that could account for the symptoms. Note a new feature in DSM-5: Francine could also have received this diagnosis if she had experienced only symptoms of derealization. With a GAF score of 70, her diagnosis would be: F48.1 [300.6] Depersonalization/derealization disorder Though it goes unmentioned in DSM-5, a collection of symptoms called the phobic anxiety depersonalization syndrome sometimes occurs, especially in young women. In addition to depression, such patients, not surprisingly, have phobias, anxiety, and depersonalization. This condition may be a variant of major depressive disorder, with atypical features. F44.0 [300.12] Dissociative Amnesia There are two main requirements for dissociative amnesia (DA): (1) The patient has forgotten something important, and (2) other disorders have been ruled out. Of course, the central feature is the inability to remember significant events. Over 100 years ago, clinicians like Pierre Janet recognized several patterns in which this forgetting can occur: Localized (or circumscribed). The patient has recall for none of the events that occurred within a particular time frame, often during a calamity such as a wartime battle or a natural disaster. Selective. Certain portions of a time period, such as the birth of a child, have been forgotten. This type is less common. The next three types are much less common, and may eventually lead to a diagnosis of dissociative identity disorder (see below): Generalized. All of the experiences during the patient’s entire lifetime have been forgotten. Continuous. The patient forgets all events from a given time forward to the present. This is now extremely rare. Systematized. The patient has forgotten certain classes of information, such as that relating to family or to work. DA begins suddenly, usually following severe stress such as physical injury, guilt about an extramarital affair, abandonment by a spouse, or internal conflict over sexual issues. Sometimes the patient wanders aimlessly near home. Duration ranges widely, from minutes to perhaps years, after which the amnesia usually ends abruptly with complete recovery of memory. In some individuals, it may occur again, perhaps more than once. DA has still received insufficient study, so too little is known about demographic patterns, family occurrence, and the like. Beginning during early adulthood, it is most commonly reported in young women; it may occur in 1% or less of the general population, though recent surveys have pegged it somewhat higher. Many patients with DA have reported childhood sexual trauma, with a high percentage who cannot remember the actual abuse. Dissociative Fugue In the subtype of DA known as dissociative fugue, the amnesic person suddenly journeys from home. This often follows a severe stress, such as marital strife or a natural or human-made disaster. The individual may experience disorientation and a sense of perplexity. Some will assume a new identity and name, and for months may even work at a new occupation. However, in most instances the episode is a brief episode of travel, lasting a few hours or days. Occasionally, there may be outbursts of violence. Recovery is usually sudden, with subsequent amnesia for the episode. Dissociative fugue is another of those extraordinarily interesting, rare disorders—fodder for novels and motion pictures—about which there has been little in the way of recent research. For example, little is known about sex ratio or family history. This is a part of the reason (after its general rarity) that accounts for the demotion of dissociative fugue from an independent diagnosis in DSM-IV to a mere subtype of dissociative amnesia in DSM-5. DSM-5 notes, by the way, that the greatest prevalence of fugue states is among patients with dissociative identity disorder. Essential Features of Dissociative Amnesia Far beyond common forgetfulness, there is a loss of recall for important personal (usually distressing or traumatic) information. The Fine Print The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, cognitive disorders, trauma- and stressor-related disorders, dissociative identity disorder, somatic symptom disorder, ordinary forgetfulness) Coding Note If relevant, specify: F44.1 [300.13] With dissociative fugue Holly Kahn A mental health clinician presented the following dilemma to a medical center ethicist. A single 38-year-old woman had been seen several times in the outpatient clinic. She had complained of depression and anxiety, both of which were relatively mild. These symptoms seemed focused on the fact that she was 38 and unmarried, and “her biological clock was ticking.” She had had no problems with sleep, appetite, or weight gain or loss, and had not thought about suicide. For many months Holly Kahn had so longed for a child that she intentionally became pregnant by her boyfriend. When he discovered what she had done, he broke off contact with her. The following week she miscarried. Stuck in her boring, unrewarding job as a sales clerk in a store that specialized in teaching supplies, she said she’d come to the clinic for help in “finding meaning for her life.” The oldest girl in a Midwestern family, Holly had spent much of her adolescence caring for younger siblings. Although she had attended college for 2 years during her mid-20s, she had come away with neither degree nor career to show for it. In the last decade, she had lived with three different men; her latest relationship had lasted the longest and had seemed the most stable. She had no history of drug abuse or alcoholism and was in good physical health. The clinician’s verbal description was of a plain, no longer young (and perhaps never youthful), heavy-set woman with a square jaw and stringy hair. “In fact, she looks quite a lot like this.” The clinician produced a drawing of a woman’s head and shoulders. It was somewhat indistinct and smudged, but the features did fit the verbal description. The ethicist recognized it as a flyer that had recently received wide distribution. The copy below the picture read: “Wanted by FBI on suspicion of kidnapping.” A day-old infant had been abducted from a local hospital’s maternity ward. The first-time mother, barely out of her teens, had handed the baby girl to a woman wearing an operating room smock. The woman had introduced herself as a nursing supervisor and said she needed to take the baby for a final weighing and examination before the mother could take her home. That was the last time anyone could remember seeing either the woman or the baby. The picture had been drawn by a police artist from a description given by the distraught mother. A reward was being offered by the baby’s grandparents. “The next-to-last time I saw my patient, we were trying to work on ways she could take control over her own life. She seemed quite a bit more confident, less depressed. The following week she came in late, looking dazed. She claimed to have no memory of anything she had done for the past several days. I asked her whether she’d been ill, hit on the head, that sort of thing. She denied all of it. I started probing backward to see if I could jog her memory, but she became more and more agitated and finally rushed out. She said she’d return the next week, but I haven’t seen her since. It wasn’t until yesterday that I noticed her resemblance to the woman in this picture.” The therapist sat gazing at the flyer for a few seconds, then said: “Here’s my dilemma. I think I know who committed this really awful crime, but I have a privileged relationship with the person I suspect. Just what is my ethical duty?” Evaluation of Holly Kahn Whether Holly took the baby is not the point here. At issue is the cause of her amnesia, which was her most pressing recent problem (criterion A). She had been under stress because of her desire to have a baby, and this could have provided the stimulus for her amnesia. The episode was itself evidently stressful enough that she broke off contact with her clinician (B). There is no information provided in the vignette that might support other (mostly biological) causes of amnesia (D). Specifically, there was no head trauma that might have induced a major neurocognitive disorder due to traumatic brain injury. Substance-induced neurocognitive disorder, persistent would be ruled out by Holly’s history of no substance use (C). Her general health had been good and there was no history of abnormal physical movements, reducing the likelihood of epilepsy. Although she had had a miscarriage, too much time had passed for a postabortion psychosis to be a possibility. Some patients with amnesia are also mute; they may be misdiagnosed as having another medical condition with catatonic symptoms. And, just to be complete, we should note that her loss of memory is far more striking and significant than ordinary forgetfulness, which is what we humans experience all the time. There was no history of a recent, massive trauma that might indicate acute stress disorder. If she was malingering, she did it without an obvious motive (had she been trying to avoid punishment for a crime, simply staying away from the medical center would have served her better). It certainly wouldn’t appear to be a case of normal daydreaming. Holly was clear about her personal identity, and she did not travel from home, so she would not qualify for the dissociative fugue subtype diagnosis. Although we must be careful not to make a diagnosis in a patient we have not personally interviewed and for whom we lack adequate collateral information, if what material we do have is borne out by subsequent investigation, her diagnosis would be as below. I’d give her GAF score as 31. F44.0 [300.12] Dissociative amnesia John Doe When the man first walked into the homeless shelter, he hadn’t a thing to his name, including a name. He’d been referred from a hospital emergency room, but he told the clinician on duty that he’d only gone there for a place to stay. As far as he was aware, his physical health was good. His problem was that he didn’t remember a thing about his life prior to waking up on a park bench at dawn that morning. Later, when filling out the paperwork, the clinician had penciled in “John Doe” as the patient’s name. Aside from the fact that he could give a history spanning only about 8 hours, John Doe’s mental status exam was remarkably normal. He appeared to be in his early 40s. He was dressed casually in slacks, a pink dress shirt, and a nicely fitting corduroy sports jacket with leather patches on the elbows. His speech was clear and coherent; his affect was generally pleasant, though he was obviously troubled at his loss of memory. He denied having hallucinations or delusions (“as far as I know”), though he pointed out logically enough that he “couldn’t vouch for what kind of crazy ideas I might have had yesterday.” John Doe appeared intelligent, and his fund of information was good. He could name five recent presidents in order, and he could discuss recent national and international events. He could repeat eight digits forward and six backwards. He scored 29 out of 30 on the MMSE, failing only to identify the county in which the shelter was located. Although he surmised (he wore a wedding ring) that he must be married, after half an hour’s conversation he could remember nothing pertaining to his family, occupation, place of residence, or personal identity. “Let me look inside your sports jacket,” the clinician said. John Doe looked perplexed, but unbuttoned his jacket and held it open. The label gave the name of a men’s clothing store in Cincinnati, some 500 miles away. “Let’s try there,” suggested the clinician. Several telephone calls later, the Cincinnati Police Department identified John Doe as an attorney whose wife had reported him missing 2 days earlier. The following morning John Doe was on a bus for home, but it was days before the clinician heard the rest of the story. A 43-year-old specialist in wills and probate, John Doe had been accused of mingling the bank accounts of clients with his own. He had protested his innocence and hired his own attorney, but the Ohio State Bar Association stood ready to proceed against him. The pressure to straighten out his books, maintain his law practice, and defend himself in court and against his own state bar had been enormous. Two days before he disappeared, he had told his wife, “I don’t know if I can take much more of this without losing my mind.” Evaluation of John Doe John Doe was classically unable to recall important autobiographical information—in fact, all of it (criterion A). It is understandable—and required (B)—that this troubled him. Neither at the time of evaluation nor at follow-up was there evidence of alternative disorders (D). John had not switched repeatedly between identities, which would rule out dissociative identity disorder (you wouldn’t diagnose the two disorders together). Other than obvious amnesia, there was no evidence of a cognitive disorder. At age 43, a new case of temporal lobe epilepsy would be unlikely, but a complete evaluation should include a neurological workup. Of course, any patient who has episodes of amnesia must be evaluated for substance-related disorders (especially as concerns alcohol, C). Conscious imitation of amnesia in malingering can be very difficult to discriminate from the amnesia involved in DA with dissociative fugue. However, although John Doe did have legal difficulties, these would not have been relieved by his feigning amnesia. (When malingering appears to be a possibility, collateral history from relatives or friends of previous such behavior or of antisocial personality disorder can help.) A history of lifelong multiple medical symptoms might suggest somatic symptom disorder. John had no cross-sectional features that would suggest either a manic episode or schizophrenia, in either of which wandering and other bizarre behaviors can occur. Epilepsy is always mentioned in the differential diagnosis of the dissociative disorders. However, epilepsy and dissociation should not be hard to tell apart in practice, even without the benefit of an EEG. Epileptic episodes usually last no longer than a few minutes and involve speech and motor behavior that are repetitive and apparently purposeless. Dissociative behavior, on the other hand, may last for days or longer and involves complex speech and motor behaviors that appear purposeful. Although John Doe’s case is not quite classical (he did not assume a new identity and adopt a new life), he did travel far from home and purposefully set about seeking shelter. That sets up the specifier for his diagnosis. And by the way, his GAF score would be 55. F44.1 [300.13] Dissociative amnesia, with dissociative fugue Z65.3 [V62.5] Investigation by state bar association Note that the fugue subtype has a different code number than plain old dissociative amnesia. This reflects the fact that, in ICD-10 and in ICD-9, a fugue state is a diagnosis separate and apart from dissociative amnesia. So the number change isn’t a mistake. F44.81 [300.14] Dissociative Identity Disorder In dissociative identity disorder (DID), which previously achieved fame as multiple personality disorder, the person possesses at least two distinct identities. Ranging up to 200 in number, these identities may have their own names; they don’t even have to be of the patient’s own gender. Some may be symbolic, such as “The Worker.” They can vary widely in age and style: If the patient is normally shy and quiet, one identity may be outgoing or even boisterous. The identities may be aware of one another to some degree, though only one interacts with the environment at a time. The transition from one to another is usually sudden, often precipitated by stress. Most of them are aware of the loss of time that occurs when another identity is in control. However, some patients aren’t aware of their peculiar state until a close friend points out the alterations in character with time. Of particular diagnostic note are states of pathological possession, which can have characteristics similar to DID. They may be characterized by the patient as a spirit or other external being that has taken over the person’s functioning. If this behavior is part of a recognized, accepted religious practice, it will not usually qualify for diagnosis as DID. However, a person who has recurrent possession states that cause distress and otherwise conform to DSM-5 criteria may well qualify for diagnosis. Of course, we would not diagnose DID in a child on the basis of having an imaginary playmate. Affecting up to 1% of the general population, DID is diagnosed much more commonly by clinicians in North America than in Europe. This fact has engendered a long-running dispute. European clinicians (naturally) claim that the disorder is rare, and that by paying so much attention to patients who dissociate, New World clinicians actually encourage the development of cases. At this writing, the dispute continues unresolved. The onset of this perhaps too-fascinating disorder is usually in childhood, though it is not commonly recognized then. Most of the patients are female, and many may have been sexually abused. DID tends toward chronicity. It may run in families, but the question of genetic transmission is also unresolved. Essential Features of Dissociative Identity Disorder A patient appears to have at least two clearly individual personalities, each with unique attributes of mood, perception, recall, and control of thought and behavior. The result: a person with memory gaps for personal information that common forgetfulness cannot begin to explain. The Fine Print The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood or anxiety disorders, psychotic disorders, trauma- and stressor-related disorders, other dissociative disorders, religious possession states accepted in non-Western cultures, childhood imaginary playmates/fantasy play) Effie Jens On her first visit to the mental health clinic, Effie cried and talked about her failing memory. At age 26—too young for Alzheimer’s—she felt senile on some days. For several months she had noticed “holes in her memory,” which sometimes lasted 2 or 3 days. Her recall wasn’t just spotty; for all she knew about her activities on those days, she might as well have been under anesthesia. However, from telltale signs—such as food that had disappeared from her refrigerator and recently arrived letters that had been opened—she knew she must have been awake and functioning during these times. On the proceeds of the property settlement from her recent divorce, Effie lived alone in a small apartment; her family lived in a distant state. She enjoyed quiet pastimes, such as reading and watching television. She was shy and had trouble meeting people; there was no one she saw often enough to help her account for the missing time. For that matter, Effie wasn’t all that clear about the details of her earlier life. She was the second of three daughters of an itinerant preacher; her early childhood memories were a jumble of labor camps, cheap hotel rooms, and Bible-thumping sermons. By the time she reached age 13, she had attended 15 different schools. Late in the interview, she revealed that she had virtually no memory of the entire year she was 13. Her father’s preaching had been moderately successful, and they had settled for a while in a small town in southern Oregon—the only time she had started and finished a year in the same school. But what had happened to her during the intervening months? Of that time, she recalled nothing whatsoever. The following week Effie came back, but she was different. “Call me Liz,” she said as she dropped her shoulder bag onto the floor and leaned back in her chair. Without further prompting, she launched into a long, detailed, and dramatic recounting of her activities of the last 3 days. She had gone out for dinner and dancing with a man she had met in the grocery store, and afterwards they had hit a couple of bars together. “But I only had ginger ale,” she said, smiling and crossing her legs. “I never drink. It’s terrible for the figure.” “Are there any parts of last week you can’t remember?” “Oh, no. She’s the one who has amnesia.” “She” was Effie Jens, whom Liz clearly regarded as a person quite different from her own self. Liz was happy, carefree, and sociable; Effie was introspective and preferred solitude. “I’m not saying that she isn’t a decent human being,” Liz conceded, “but you’ve met her—don’t you think she’s just a tad mousy?” Although for many years she had “shared living space” with Effie, it wasn’t until after the divorce that Liz had begun to “come out,” as she put it. At first this had happened for only an hour or two, especially when Effie was tired or depressed and “needed a break.” Recently Liz had taken control for longer and longer periods of time; once she had done so for 3 days. “I’ve tried to be careful, it frightens her so,” Liz said with a worried frown. “I’ve begun to think seriously about taking control for all time. I think I can do a better job. I certainly have a better social life.” Besides being able to recount her activities during the blank times that had driven Effie to seek care, Liz could give an eyewitness account of all of Effie’s conscious activities as well. She even knew what had gone on during Effie’s “lost” year, when she was 13. “It was Daddy,” she said with a curl of her lip. “He said it was part of his religious mission to ‘practice for a reenactment of the Annunciation.’ But it was really just another randy male groping his own daughter, and worse. Effie told Mom. At first, Mom wouldn’t believe her. And when she finally did, she made Effie promise never to tell. She said it would break up the family. All these years, I’m the only other one who’s known about it. No wonder she’s losing her grip—it even makes me sick.” Evaluation of Effie Jens Effie’s two personalities (criterion A) are fairly typical of DID: One was quiet and unassuming, almost mousy, whereas the other was much more assertive. (Effie’s history was atypical in that more personalities than two are the rule.) What happened when Liz was in control was unknown to Effie, who experienced these episodes as amnesia. This difficulty with recall was vastly more extensive than you’d expect of common forgetfulness (B). It was distressing enough to send Effie to the clinic (C). Several other causes of amnesia should be considered in the differential diagnosis of this condition. Of course, any possible medical condition must first be ruled out, but Effie/Liz had no history suggestive of either a seizure disorder or substance use (we’re thinking of alcoholic blackouts and partial seizures here). Even though Effie (or Liz) had a significant problem with amnesia, it was not her main problem, as would be the case with dissociative amnesia, which is less often recurrent and does not involve multiple, distinct identities. Note, too, the absence of any information that Effie belonged to a cultural or religious group whose practices included trances or other rituals that could explain her amnesia (D). Schizophrenia has often been confused with DID, primarily by laypeople who equate “split personality” (which is how many have come to characterize schizophrenia) with multiple personality disorder, the old name for DID. However, although bizarre behavior may be encountered in DID, none of the identities is typically psychotic. As with other dissociative disorders, discrimination from malingering can be difficult; information from others about possible material gain provides the most valuable data. Effie’s history was not typical for either of these diagnoses. Some patients with DID will also have borderline personality disorder. The danger is that only the latter will be diagnosed by a clinician who mistakes alternating personae for the unstable mood and behavior typical of borderline personality disorder. Substance-related disorders sometimes occur with DID; neither Effie nor Liz drank alcohol (E). Her GAF score would be 55. F44.81 [300.14] Dissociative identity disorder Z63.5 [V61.03] Divorce F44.89 [V300.15] Other Specified Dissociative Disorder This category is for patients whose symptoms represent a change in the normally integrative function of identity, memory, or consciousness, but who do not meet criteria for one of the specific dissociative disorders listed above. Here are some examples; a particular condition should be stated after the other specified diagnosis is given. Identity disturbance due to prolonged and intense coercive persuasion. People who have been brainwashed or otherwise indoctrinated may develop mixed dissociative states. Acute dissociative reactions to stressful events. DSM-5 mentions that these often last just a few hours, though less than a month, and are characterized by mixed dissociative symptoms (depersonalization, derealization, amnesia, disruptions of consciousness, stupor). Dissociative trance. Here the person loses focus on the here and now, and may behave automatically. (A person’s engaging in an accepted religious or cultural ritual would not qualify as an example of dissociative trance.) F44.9 [V300.15] Unspecified Dissociative Disorder This diagnosis will serve to categorize those patients for whom there are evident dissociative symptoms, but who don’t fulfill criteria for any of the standard diagnoses already mentioned above, and for whom you do not care to specify the reasons why the criteria are not fulfilled.”