En marzo del 2022, la Asociación Americana de Psiquiatría (APA) publicó la versión revisada de la quinta edición de su Manual Diagnóstico, DSM-V-TR.
Los cambios más importantes respecto al DSM-V
En azul lo que se ha agregado información o cambiado la información.
Trastorno de Identidad Disociativo
- Ningún cambio en los criterios principales.
- Aclaración de que no es necesario que los alters estén muy elaborados, sean evidentes y tengan diferentes nombres y presentación.
- Se agregó la explicación explícita de la presencia de síntomas de orden Schneiderian en forma de experiencias positivas y negativas (experiencias agregadas o eliminadas) como parte de la experiencia disociativa y postraumática, como alucinaciones de todos los sentidos.
- Se eliminó el comentario de que «un individuo puede haber sido poseído por un demonio o deidad«.
- Se agregó información de las presentaciones occidentales vs no occidentales de síntomas neurológicos, incluyendo esclerosis múltiple.
- Se agregaron rasgos de personalidad más prominentes, principalmente rasgos evitativos y en segundo lugar rasgos límite (TLP) pero muchos sin el factor de temor al abandono (más característica del TLP). Otros rasgos menos prominentes son los de personalidad obsesiva, y muchos menos los de personalidad histriónica, narcisista y antisocial.
- Se eliminaron los datos de que el TID sea más prevalente en hombres o mujeres. Se agregaron datos de un estudio de Turquía (lo que es bastante nuevo en el DSM puesto que sus estudios son principalmente por y para EE.UU. y nos preguntamos por qué agregaron solo de ese país y no de tantos otros)
- Se agregó más información de la disociación infantil y adolescente, dando a entender que es posible de cierta forma asignar este trastorno a menores de edad. Además de que se agregó, sin explicar a fondo la aparente contradicción de la nota del criterio D, que los niños pueden manifestar a sus alters como «compañeros imaginarios«. Sí, pero hay diferencias que no explicaron.
- Eliminaron también el lamentable comentario de que en adolescentes «pareciera ser solo una crisis adolescente«, y que, en cambio, llama la atención por conductas autodestructivas, cambios rápidos de comportamiento que podrían asociarse a TDAH o T. Bipolar infantil y que en niños podrían verse como agresivos o irritables.
- Se expandió la información de factores de riesgo para la aparición y empeoramiento de pronóstico como el seguir viviendo traumatización.
- Se cambió el término «female» por «women» y se agregó la distinción de género y sexo.
- Se expandió la información de suicidalidad asociado tanto al TEPT, trastornos comórbidos y la disociación misma como factor de riesgo.
- Se agregó manifestación en infancia y adolescencia sobre funcionalidad, que pueden ir muy mal en la escuela o, en cambio, pueden ir excelente porque lo ven como un respiro. Esto es congruente con lo que tantos hemos podido demostrar.
- Se agregaron diagnósticos diferenciales de la amnesia disociativa, despersonalización desrealización, se eliminó el diagnóstico diferencial del OTDE (OSDD) (algo extraño), expansión en algunos criterios y de nuevo la explicación de los síntomas de orden Schneiderian que antes se consideraban solo asociados a la esquizofrenia y se agregó también el diagnóstico diferencial de la amnesia postraumática debido a un traumatismo cerebral.
Nota: No ha sido publicada la versión oficial en español, así que pondremos el texto exacto en inglés en lugar de improvisar traducción.
Trastorno de Identidad Disociativo (TID) (F44.81)
- 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, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
- Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
- The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The disturbance is not a normal part of a broadly accepted cultural or religious practice.
- Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
- The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).
The defining feature of dissociative identity disorder is the presence of two or more distinct personality states or an experience of possession (Criterion A). The overtness or covertness of these personality states varies as a function of psychological motivation, current level of stress, cultural context, internal conflicts and dynamics, and emotional resilience, among other factors. Sustained periods of identity confusion/alteration may occur when psychosocial pressures are severe and/or prolonged. In those cases of dissociative identity disorder that present as the individual being possessed by external identities (e.g., spirits, demons) (possession-form dissociative identity disorder), and in a small proportion of non-possession-form cases, manifestations of alternate identities are readily observable. Most individuals with non-possession-form dissociative identity disorder do not overtly display, or only subtly display, their discontinuity of identity, and only a minority present to clinical attention with discernible alternation of identities. The elaboration of dissociative personality states with different names, wardrobes, hairstyles, handwritings, accents, and so forth, occurs in only a minority of individuals with the non-possession-form dissociative identity disorder and is not essential to diagnosis. In those cases where alternate personality states cannot be directly observed, the presence of distinct personality states can be identified by sudden alterations or discontinuities in the individual’s sense of self and sense of agency (Criterion A), and recurrent dissociative amnesias (Criterion B).
Criterion A symptoms are related to discontinuities of experience that can affect any aspect of an individual’s functioning. Individuals 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 powerless to stop (i.e., impaired sense of self and impaired sense of agency). These individuals may also report perceptions of voices (e.g., a child’s voice, voices commenting on the individual’s thoughts or behavior, persecutory voices and command hallucinations). In some cases, hearing voices is specifically denied, but the individual reports multiple, perplexing, independent thought streams over which the individual experiences no control. Individuals with dissociative identity disorder may report hallucinations in all sensory modalities: auditory, visual, tactile, olfactory, and gustatory.
Strong emotions, impulses, thoughts, and even speech or other actions may suddenly materialize, without a sense of personal ownership or control (i.e., lack of sense of agency). Conversely, thoughts and emotions may unexpectedly vanish, and speech and actions are abruptly inhibited. These experiences are frequently reported as ego-dystonic and puzzling. Attitudes, outlooks, and personal preferences (e.g., about food, activities, gender identity) may suddenly shift. Individuals may report that their bodies feel different (e.g., like a small child, the opposite gender, different ages simultaneously). Alterations in sense of self and agency may be accompanied by a feeling that attitudes, emotions, and behaviors—even the individual’s own body—are “not mine” or are “not under my control.” Although most Criterion A symptoms are subjective, these sudden discontinuities in speech, affect, and behavior may be witnessed by family, friends, or the clinician.
In most individuals with dissociative identity disorder, switching/shifting of states is subtle and may occur with only subtle changes in overt presentation. State switching may be more overt in the possession form of dissociative identity disorder. In general, the individual with dissociative identity disorder experiences himself or herself as multiple, simultaneously overlapping and interfering states.
Dissociative amnesia (Criterion B) manifests in several major domains: 1) gaps in any aspect of autobiographical memory (e.g., important life events like getting married or giving birth, lack of recall of all school experiences before high school); 2) lapses in memory of recent events or well-learned skills (e.g., how to do one’s job, use a computer, cook or drive); and 3) discovery of possessions that the individual has no recollection of ever owning (e.g., clothing, weapons, tools, writings or drawings that he or she must have created).
Dissociative fugues, with amnesia for travel, are common. Individuals may report suddenly finding themselves in another city, at work, or even at home: in the closet, under the bed, or running out of the house. Amnesia in individuals with dissociative identity disorder is not limited to stressful or traumatic events; it can involve everyday events as well. Individuals may report major gaps in ongoing memory (e.g., experiencing “time loss,” “blackouts,” or “coming to” in the midst of doing something). Dissociative amnesia may be apparent to others (e.g., the individual does not recall something others witnessed that he or she did or said, cannot remember his or her own name, or may fail to recognize spouse, children, or close friends). Minimization or rationalization of amnesia is common.
Possession-form identities in dissociative identity disorder typically manifest behaviorally as if a “spirit,” supernatural being, or outside person has taken control, with the individual speaking or acting in a distinctly different manner. For example, an individual’s behavior may give the appearance that her identity has been replaced by the “ghost” of a girl who died by suicide in the same community years before, speaking and acting as though she were still alive. The identities that arise during possession-form dissociative identity disorder present recurrently, are unwanted and involuntary, and cause clinically significant distress or impairment (Criterion C). However, the majority of possession states that occur around the world are usually part of a broadly accepted cultural or religious practice and therefore do not meet criteria for dissociative identity disorder (Criterion D).
Individuals with dissociative identity disorder typically present with comorbid depression, anxiety, substance abuse, self-injury, or another common symptom. Nonepileptic seizures and other functional neurological symptoms are prominent in some presentations of dissociative identity disorder, especially in some non-Western settings. Some individuals, especially in Western settings, may present with apparently refractory neurological symptoms, such as headaches, seizures, or symptoms suggestive of multiple sclerosis.
Individuals with dissociative identity disorder often conceal, or are not fully aware of, disruptions in consciousness, amnesia, or other dissociative symptoms. Many individuals with dissociative identity disorder report dissociative flashbacks during which they experience a sensory reliving of a previous event as though it were occurring in the present, often with a change of identity, a partial or complete loss of contact with 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 adulthood. Other overwhelming early life events, such as multiple long, painful, early-life medical procedures, also may be reported. Nonsuicidal self-injury is frequent. On standardized measures, these individuals report higher levels of hypnotizability and dissociative symptoms compared with other clinical groups and healthy control subjects. Some individuals experience transient psychotic phenomena or episodes. Some individuals experience transient psychotic phenomena or episodes.
Among personality features, avoidant personality features most often rate highest in individuals with dissociative identity disorder, and some individuals with dissociative identity disorder are so avoidant that they prefer to be alone. When decompensated, some individuals with dissociative identity disorder display features of borderline personality disorder (i.e., self-destructive high-risk behaviors, and mood instability). Many individuals with dissociative identity disorder display attachment problems but typically do not exhibit frantic activity to avoid being abandoned. Some have stable long-term relationships, albeit frequently dysfunctional and/or abusive ones, from which they may have difficulty extricating themselves. Obsessional personality features are common in dissociative identity disorder, more so than histrionic personality features. A subgroup of individuals with dissociative identity disorder have narcissistic and/or antisocial personality features.
The 12-month prevalence of dissociative identity disorder among adults in a small U.S. community study was 1.5%. Lifetime prevalence of dissociative identity disorder was 1.1% in a representative sample of community-based women in mid-eastern Turkey.
Development and Course
The disorder may first manifest at almost any age from early childhood to late life. Children usually do not present with identity shifting, instead presenting primarily with independently acting, imaginary companions, or as personified “mood” states (Criterion A phenomena). Dissociation in children may generate problems with memory, concentration, and attachment, and may be associated with traumatic play. In adolescents, dissociative identity disorder commonly comes to clinical attention because of externalizing symptoms, suicidal/self-destructive behavior, or rapid behavioral shifts often ascribed to other disorders such as attention deficit/ hyperactivity disorder or childhood bipolar disorder. Some children with dissociative identity disorder can also be quite aggressive and irritable. Older individuals with dissociative identity disorder may present with symptoms that appear to be late-life mood disorders, obsessive-compulsive disorder, paranoia, psychotic mood disorders, or even cognitive disorders attributable to dissociative amnesia.
Overt identity alteration/confusion may be triggered by many factors, such as later traumatic experiences (e.g., sexual assault), or even seemingly inconsequential stressors, like a minor motor vehicle accident. The experience of other major or cumulative life stressors may also worsen symptoms, including life events such as the individual’s children reaching the same age at which the individual was significantly abused or traumatized. The death of, or the onset of a fatal illness in, the individual’s abuser(s) is another example of an event that may worsen symptoms. Individuals with dissociative identity disorder are at high risk for adult interpersonal trauma such as rape, intimate partner violence, and sexual exploitation, including ongoing incestuous abuse into adulthood, as well as adult trafficking.
Risk and Prognostic Factors
Environmental. In the context of family and attachment pathology, early life trauma (e.g., neglect and physical, sexual, and emotional abuse, usually before ages 5–6 years) represents a risk factor for dissociative identity disorder. In studies from diverse geographic regions, about 90% of the individuals with the disorder report multiple types of early neglect and childhood abuse, often extending into late adolescence. Some individuals report that maltreatment primarily occurred outside the family, in school, church, and/or neighborhoods, including being bullied severely. Other forms of repeated early-life traumatic experiences include multiple, painful childhood medical and surgical procedures; war; terrorism; or being trafficked beginning in childhood. Onset has also been described after prolonged and often transgenerational exposure to dysfunctional family dynamics (e.g., overcontrolling parenting, insecure attachment, emotional abuse) in the absence of clear neglect or sexual or physical abuse.
Genetic and physiological. Twin studies suggest that genetics account for around 45%–50% of the interindividual variance in dissociative symptoms, with nonshared, stressful, and traumatic environmental experiences accounting for most of the additional variance. Several brain regions have been implicated in the pathophysiology of dissociative identity disorder, including the orbitofrontal cortex, hippocampus, parahippocampal gyrus, and amygdala.
Course modifiers. Ongoing sexual, physical, and emotional trauma often leads to significant difficulties in later functioning. Poorer outcome in adults is commonly related to severe psychosocial stressors, revictimization, ongoing sexual or physical abuse or exploitation, intimate partner violence, refractory substance use, eating disorders, severe medical illness, enmeshment with the individual’s abusive family of origin, or ongoing involvement in criminal subgroups. Poorer functioning may also be related to perpetration of child maltreatment or intimate partner violence by individuals with dissociative identity disorder.
Culture-Related Diagnostic Issues
Many features of dissociative identity disorder can be influenced by the individual’s sociocultural background. In settings where possession symptoms are common (e.g., rural areas in low- and middle-income countries, among certain religious groups in the United States and Europe), all or some of the fragmented identities may take the form of possessing spirits, deities, demons, animals, or mythical figures. Acculturation or prolonged intercultural contact may shape the presentation of the other identities (e.g., identities in India may speak English exclusively and wear Western clothes). Possession-form dissociative identity disorder can be distinguished from culturally accepted possession states in that the former is involuntary, distressing, and uncontrollable; involves conflict between the individual and his or her surrounding family, social, or work milieu; and is manifested at times and in places that violate cultural or religious norms. Combined dissociative-psychosis episodes may be more common in
cultural contexts with marked communal violence or oppression and limited opportunity for redress.
Sex and Gender Related Diagnostic Issues
Women with dissociative identity disorder predominate in adult clinical settings but not in child/adolescent clinical settings or in general population studies. Few differences in symptom profiles, clinical history, and childhood trauma history have been found in comparisons between men and women with dissociative identity disorder, except that women may have higher rates of somatization.
Association with Suicidal Thoughts or Behavior
Suicidal behavior is frequent. Over 70% of outpatients with dissociative identity disorder have attempted suicide; multiple attempts are common, and other self-injurious and high-risk behaviors are highly prevalent. Individuals with dissociative identity disorder have multiple interacting risk factors for self-destructive and/or suicidal behavior. These include cumulative, severe early- and later-life trauma; high rates of comorbid posttraumatic stress disorder (PTSD), depressive disorders, and substance use disorders; and personality disorder features. Dissociation itself is an independent risk factor for multiple suicide attempts. Greater severity of dissociative symptom scores is associated with a higher frequency of suicide attempts and nonsuicidal self-injury among individuals with dissociative disorders.
Functional Consequences of Dissociative Identity Disorder
Some children and adolescents with dissociative identity disorder may function poorly in school and in relationships. Others do well in school, experiencing it as a respite. In adults impairment varies widely, from apparently minimal (e.g., in high-functioning professionals) to profound. The symptoms of higher-functioning individuals may impair their relational, marital, family, and parenting functions more than their occupational and professional life, although the latter also may be affected. Many impaired individuals show improvement in occupational and personal functioning over time, while some individuals with dissociative identity disorder may be impaired in most activities of living and function at the level of chronic and persistent mental illness.
Dissociative amnesia. Both dissociative identity disorder and dissociative amnesia are characterized by gaps in the recall of everyday events, important personal information, or traumatic events that are inconsistent with ordinary forgetting. Dissociative identity disorder is distinguished from dissociative amnesia by the additional presence of identity disruption characterized by two or more distinct personality states.
Depersonalization/derealization disorder. The essential feature of depersonalization/derealization disorder is persistent or recurrent episodes of depersonalization, derealization, or both. Individuals with depersonalization/derealization disorder do not experience the presence of personality/identity states with alterations of self and agency, nor do they typically report dissociative amnesia.
Major depressive disorder. Most individuals with dissociative identity disorder endorse a lifelong negative posttraumatic emotional state, often with childhood onset, and their symptoms may appear to meet the criteria for a major depressive episode. Moreover, posttraumatic reactivity to times of year when trauma occurred (anniversary reactions), primarily manifesting with more despondency, distress, and suicidal ideation, may also appear to be major depressive disorder, with seasonal pattern. However, individuals with major depressive disorder or persistent depressive disorder do not experience dissociative fluctuations in self and agency and dissociative amnesia. It is important to assess if all or most identity states are experiencing the adverse mood state, since mood disorder symptoms may fluctuate because they are experienced in some identity states, but not others.
Bipolar disorders. Dissociative identity disorder is commonly misdiagnosed as bipolar disorder, typically bipolar II disorder, with mixed features. The relatively rapid shifts in behavioral state in individuals with dissociative identity disorder—usually within minutes or hours—are atypical for even the most rapid-cycling individuals with bipolar disorders. These state alterations are due to rapidly shifting dissociative states and/or fluctuating posttraumatic intrusions. Sometimes these shifts are accompanied by rapid changes in levels of activation, but these usually last minutes to hours, not days, and are associated with activation of specific identity states. Elevated or depressed mood may be experienced as loculated in specific identities, through overlap/interference phenomena. Usually, the individual with dissociative identity disorder does not have a classic bipolar sleep disturbance (e.g., reduced need for sleep), instead suffering from chronic, severe nightmares and nocturnal flashbacks that interrupt sleep.
Posttraumatic stress disorder. A majority of individuals with dissociative identity disorder will have symptoms that meet diagnostic criteria for comorbid PTSD. Dissociative symptoms characteristic of dissociative identity disorder should be differentiated from the dissociative amnesia, dissociative flashbacks, and depersonalization/derealization characteristic of acute stress disorder, PTSD, or the dissociative subtype of PTSD. Dissociative amnesia in PTSD typically manifests only for specific traumatic events or aspects of traumatic events, as opposed to the chronic, complex dissociative amnesia characteristic of dissociative identity disorder. Depersonalization/derealization symptoms in the dissociative subtype of PTSD are related to specific posttraumatic reminders. Depersonalization/derealization symptoms in dissociative identity disorder may occur not only in response to posttraumatic reminders, but also in an ongoing fashion in daily life, including in response to stressful interpersonal interactions and when there is overlap/interference between states.
Schizophrenia and other psychotic disorders. Individuals with dissociative identity disorder may experience symptoms that can superficially appear similar to those of psychotic disorders. These include auditory hallucinations and symptoms characteristic of intrusions of personality states into the individual’s awareness; these symptoms can seemingly resemble some of the Schneiderian first-rank symptoms formerly considered indicative of schizophrenia (e.g., thought broadcasting, thought insertion, thought withdrawal, hearing voices keeping up a running commentary about the individual). For example, hearing different personality states discussing the individual can resemble auditory hallucinations of voices arguing in schizophrenia. The individual with dissociative identity disorder may also experience the thoughts or emotions of an intruding personality state, which can resemble thought insertion in schizophrenia, as well as experience the sudden disappearance of these thoughts or emotions, which can resemble thought withdrawal. Such experiences in an individual with schizophrenia are usually accompanied by delusional beliefs about the cause of those symptoms (i.e., thoughts being inserted by an outside force), whereas individuals with dissociative identity disorder typically experience these symptoms as ego-alien and frightening. Individuals with dissociative identity disorder may also report a range of visual, tactile, olfactory, gustatory, and somatic hallucinations, which are usually related to autohypnotic, posttraumatic, and dissociative factors, such as partial flashbacks, in contrast to individuals with schizophrenia, whose hallucinations are primarily auditory and less commonly visual. Dissociative identity disorder and psychotic disorders are therefore distinguished by symptoms characteristic of one of these conditions and not the other (e.g., dissociative amnesia in dissociative identity disorder and not in psychotic disorders). Finally, individuals with schizophrenia have low hypnotic capacity, whereas individuals with dissociative identity disorder have the highest hypnotic capacity among all clinical groups.
Substance/medication-induced disorders. Individuals with dissociative identity disorder frequently have a current or past history of substance use disorders. Symptoms associated with the physiological effects of a substance (e.g., blackouts) should be distinguished from dissociative amnesia in dissociative identity disorder if the substance in question is judged to be etiologically related to the memory loss.
Personality disorders. Individuals with dissociative identity disorder often present identities that appear to encapsulate 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 variability in personality style (attributable to inconsistency among identities) differs from the pervasive and persistent dysfunction in affect management and interpersonal relationships typical of those with personality disorders.
Posttraumatic amnesia due to brain injury. Both dissociative identity disorder and traumatic brain injury (TBI) are characterized by gaps in memory. Other characteristics of TBI include loss of consciousness, disorientation and confusion, or, in more severe cases, neurological signs and symptoms. A neurocognitive disorder due to TBI manifests either immediately after brain injury occurs or immediately after the individual recovers consciousness after the injury, and persists past the acute postinjury period. The cognitive presentation of a neurocognitive disorder following TBI is variable and includes difficulties in the domains of complex attention, executive function, and learning and memory, as well as slowed speed of information processing and disturbances in social cognition. While depersonalization is not uncommon following TBI, the additional neurocognitive features noted above help distinguish it from dissociative amnesia that is part of dissociative identity disorder. Moreover, dissociative amnesia occurring in the context of dissociative identity disorder is accompanied by a marked discontinuity in sense of self and sense of agency, which are not features of TBI.
Functional neurological symptom disorder (conversion disorder). Functional neurological symptom disorder may be distinguished from dissociative identity disorder by the absence of identity alteration characterized by two or more distinct personality states or an experience of possession. Dissociative amnesia in functional neurological symptom disorder is more limited and circumscribed (e.g., amnesia for a nonepileptic seizure).
Factitious disorder and malingering. Individuals who feign dissociative identity disorder usually do not report the subtle symptoms of intrusion characteristic of the disorder; instead they tend to overreport media-based symptoms of the disorder, such as dramatic dissociative amnesia and melodramatic switching behaviors, while underreporting less-publicized comorbid symptoms, such as depression. Individuals who feign dissociative identity disorder tend to be relatively undisturbed by or may even seem to enjoy “having” the disorder, or may ask clinicians to “find” traumatic memories. In contrast, most individuals with genuine dissociative identity disorder are ashamed of and overwhelmed by their symptoms, deny the diagnosis, underreport their symptoms, and display minimization and avoidance of their trauma history. Individuals who feign the symptoms of dissociative identity disorder usually create limited, stereotyped alternate identities, with feigned amnesia related only to the events for which gain is sought, with apparent switching behaviors and amnesia only displayed while being observed. They may present an “all-good” identity and an “all-bad” identity in hopes of gaining exculpation for a crime.
Te recordamos que los criterios diagnósticos tanto del DSM como del CIE son apenas una descripción básica y no son un instrumento diagnóstico. Hay muchos síntomas y signos que deben buscarse para diagnosticar correctamente.