日本精神神経学会（日本語版用語監修）、高橋 三郎・大野 裕（監訳）：DSM-5精神疾患の診断・統計マニュアル、医学書院、2014.
Brad Foote, Yvette Smolin, Margaret Kaplan, Michael E Legatt, Deborah Lipschitz
Prevalence of dissociative disorders in psychiatric outpatients.
Am J Psychiatry. 2006 Apr;163(4):623-9. doi: 10.1176/appi.ajp.163.4.623.
Abstract/Text
OBJECTIVE: The purpose of the study was to assess the prevalence of DSM-IV dissociative disorders in an inner-city outpatient psychiatric population.
METHOD: Subjects were 231 consecutive admissions (84 men and 147 women, mean age=37 years) to an inner-city, hospital-based outpatient psychiatric clinic. The subjects completed self-report measures of dissociation (Dissociative Experiences Scale) and trauma history (Traumatic Experiences Questionnaire). Eighty-two patients (35%) completed a structured interview for dissociative disorders (Dissociative Disorders Interview Schedule).
RESULTS: The 82 patients who were interviewed did not differ significantly on any demographic measure or on the self-report measures of trauma and dissociation from the 149 patients who were not interviewed. Twenty-four (29%) of the 82 interviewed patients received a diagnosis of a dissociative disorder. Dissociative identity disorder was diagnosed in five (6%) patients. Compared to the patients without a dissociative disorder diagnosis, patients with a dissociative disorder were significantly more likely to report childhood physical abuse (71% versus 27%) and childhood sexual abuse (74% versus 29%), but the two groups did not differ significantly on any demographic measure, including gender. Chart review revealed that only four (5%) patients in whom a dissociative disorder was identified during the study had previously received a dissociative disorder diagnosis.
CONCLUSIONS: Dissociative disorders were highly prevalent in this clinical population and typically had not been previously diagnosed clinically. The high prevalence of dissociative disorders found in this study may be related to methodological factors (all patients were offered an interview rather than only those who had scored high on a screening self-report measure) and epidemiological factors (extremely high prevalence rates for childhood physical and sexual abuse were present in the overall study population).
V Sar, H Tutkun, B Alyanak, B Bakim, I Baral
Frequency of dissociative disorders among psychiatric outpatients in Turkey.
Compr Psychiatry. 2000 May-Jun;41(3):216-22. doi: 10.1016/S0010-440X(00)90050-6.
Abstract/Text
The aim of this study was to determine the frequency of dissociative disorders among psychiatric outpatients in Turkey. One hundred fifty consecutive outpatients admitted to the psychiatry clinic of a university hospital were screened with the Dissociative Experiences Scale (DES). Twenty-three patients (15.3%) with a DES score greater than 30 and a comparison group selected from the same outpatient population who scored less than 10 on the scale were then interviewed with the Dissociative Disorders Interview Schedule (DDIS) in a blind fashion. According to the DDIS, 18 patients (12.0%) received a diagnosis of dissociative disorder; 83.3% (n = 15) of the dissociative patients reported neglect, 72.2% (n = 13) emotional abuse, 50.0% (n = 9) physical abuse, and 27.8% (n = 5) sexual abuse during childhood. Dissociative disorders are not rare among psychiatric outpatients. Self-rating instruments and structured interviews can be used successfully for screening dissociative disorders, which are usually underrecognized. Neglect was the most frequently reported type of childhood trauma, suggesting the importance of other childhood experiences in addition to sexual and/or physical abuse in the development of dissociative psychopathology.
Jeffrey G Johnson, Patricia Cohen, Stephanie Kasen, Judith S Brook
Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity.
J Psychiatr Res. 2006 Mar;40(2):131-40. doi: 10.1016/j.jpsychires.2005.03.003. Epub 2005 Dec 6.
Abstract/Text
OBJECTIVE: To investigate the association of dissociative disorder (DD) with impaired functioning and co-occurring Axis I and personality disorders among adults in the community.
METHOD: Psychiatric interviews were administered to a sample of 658 adult participants in the Children in the Community Study, a community-based longitudinal study.
RESULTS: Depersonalization disorder (prevalence: 0.8%), dissociative amnesia (prevalence: 1.8%), dissociative identity disorder (prevalence: 1.5%), and dissociative disorder not otherwise specified (prevalence: 4.4%), evident within the past year, were each associated with impaired functioning, as assessed by the clinician-administered Global Assessment of Functioning Scale. These associations remained significant after controlling for age, sex, and co-occurring disorders. Individuals with anxiety, mood, and personality disorders were significantly more likely than individuals without these disorders were to have DD, after the covariates were controlled. Individuals with Cluster A (DD prevalence: 58%), B (DD prevalence: 68%), and C (DD prevalence: 37%) personality disorders were substantially more likely than those without personality disorders were to have DD.
CONCLUSIONS: DD is associated with clinically significant impairment among adults in the community. DD may be particularly prevalent among individuals with personality disorders.
Colin A. Ross. Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of Multiple Personality, 2nd edition, 1997, Wiley.
E M Bernstein, F W Putnam
Development, reliability, and validity of a dissociation scale.
J Nerv Ment Dis. 1986 Dec;174(12):727-35.
Abstract/Text
Dissociation is a lack of the normal integration of thoughts, feelings, and experiences into the stream of consciousness and memory. Dissociation occurs to some degree in normal individuals and is thought to be more prevalent in persons with major mental illnesses. The Dissociative Experiences Scale (DES) has been developed to offer a means of reliably measuring dissociation in normal and clinical populations. Scale items were developed using clinical data and interviews, scales involving memory loss, and consultations with experts in dissociation. Pilot testing was performed to refine the wording and format of the scale. The scale is a 28-item self-report questionnaire. Subjects were asked to make slashes on 100-mm lines to indicate where they fall on a continuum for each question. In addition, demographic information (age, sex, occupation, and level of education) was collected so that the connection between these variables and scale scores could be examined. The mean of all item scores ranges from 0 to 100 and is called the DES score. The scale was administered to between 10 and 39 subjects in each of the following populations: normal adults, late adolescent college students, and persons suffering from alcoholism, agoraphobia, phobic-anxious disorders, posttraumatic stress disorder, schizophrenia, and multiple personality disorder. Reliability testing of the scale showed that the scale had good test-retest and good split-half reliability. Item-scale score correlations were all significant, indicating good internal consistency and construct validity. A Kruskal-Wallis test and post hoc comparisons of the scores of the eight populations provided evidence of the scale's criterion-referenced validity.(ABSTRACT TRUNCATED AT 250 WORDS)
Brad Foote, Jane Park
Dissociative identity disorder and schizophrenia: differential diagnosis and theoretical issues.
Curr Psychiatry Rep. 2008 Jun;10(3):217-22.
Abstract/Text
Schizophrenia and dissociative identity disorder (DID) are typically thought of as unrelated syndromes--a genetically based psychotic disorder versus a trauma-based dissociative disorder--and are categorized as such by the DSM-IV. However, substantial data exist to document the elevated occurrence of psychotic symptoms in DID; awareness of these features is necessary to prevent diagnostic confusion. Recent research has also pointed out that schizophrenia and DID overlap not only in psychotic symptoms but also in terms of traumatic antecedents, leading to a number of suggestions for revision of our clinical, theoretical, and nosologic understanding of the relationship between these two disorders.
R P Kluft
First-rank symptoms as a diagnostic clue to multiple personality disorder.
Am J Psychiatry. 1987 Mar;144(3):293-8. doi: 10.1176/ajp.144.3.293.
Abstract/Text
Thirty patients with multiple personality disorder had one or more of Schneider's 11 first-rank symptoms at initial assessment (mean = 3.6; range = 1-8). The author describes these symptom categories, eight of which were noted in the patients he interviewed, and illustrates them from the patients' case material. He suggests that inquiry about first-rank symptom phenomena may be a valuable diagnostic clue to the presence of multiple personality disorder.
Rachel Yehuda, Charles W Hoge, Alexander C McFarlane, Eric Vermetten, Ruth A Lanius, Caroline M Nievergelt, Stevan E Hobfoll, Karestan C Koenen, Thomas C Neylan, Steven E Hyman
Post-traumatic stress disorder.
Nat Rev Dis Primers. 2015 Oct 8;1:15057. doi: 10.1038/nrdp.2015.57. Epub 2015 Oct 8.
Abstract/Text
Post-traumatic stress disorder (PTSD) occurs in 5-10% of the population and is twice as common in women as in men. Although trauma exposure is the precipitating event for PTSD to develop, biological and psychosocial risk factors are increasingly viewed as predictors of symptom onset, severity and chronicity. PTSD affects multiple biological systems, such as brain circuitry and neurochemistry, and cellular, immune, endocrine and metabolic function. Treatment approaches involve a combination of medications and psychotherapy, with psychotherapy overall showing greatest efficacy. Studies of PTSD pathophysiology initially focused on the psychophysiology and neurobiology of stress responses, and the acquisition and the extinction of fear memories. However, increasing emphasis is being placed on identifying factors that explain individual differences in responses to trauma and promotion of resilience, such as genetic and social factors, brain developmental processes, cumulative biological and psychological effects of early childhood and other stressful lifetime events. The field of PTSD is currently challenged by fluctuations in diagnostic criteria, which have implications for epidemiological, biological, genetic and treatment studies. However, the advent of new biological methodologies offers the possibility of large-scale approaches to heterogeneous and genetically complex brain disorders, and provides optimism that individualized approaches to diagnosis and treatment will be discovered.
Ruth A Lanius, Eric Vermetten, Richard J Loewenstein, Bethany Brand, Christian Schmahl, J Douglas Bremner, David Spiegel
Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype.
Am J Psychiatry. 2010 Jun;167(6):640-7. doi: 10.1176/appi.ajp.2009.09081168. Epub 2010 Apr 1.
Abstract/Text
In this article, the authors present evidence regarding a dissociative subtype of PTSD, with clinical and neurobiological features that can be distinguished from nondissociative PTSD. The dissociative subtype is characterized by overmodulation of affect, while the more common undermodulated type involves the predominance of reexperiencing and hyperarousal symptoms. This article focuses on the neural manifestations of the dissociative subtype in PTSD and compares it to those underlying the reexperiencing/hyperaroused subtype. A model that includes these two types of emotion dysregulation in PTSD is described. In this model, reexperiencing/hyperarousal reactivity is viewed as a form of emotion dysregulation that involves emotional undermodulation, mediated by failure of prefrontal inhibition of limbic regions. In contrast, the dissociative subtype of PTSD is described as a form of emotion dysregulation that involves emotional overmodulation mediated by midline prefrontal inhibition of the same limbic regions. Both types of modulation are involved in a dynamic interplay and lead to alternating symptom profiles in PTSD. These findings have important implications for treatment of PTSD, including the need to assess patients with PTSD for dissociative symptoms and to incorporate the treatment of dissociative symptoms into stage-oriented trauma treatment.
Ketil J Oedegaard, Dag Neckelmann, Franco Benazzi, Vigdis E G Syrstad, Hagop S Akiskal, Ole Bernt Fasmer
Dissociative experiences differentiate bipolar-II from unipolar depressed patients: the mediating role of cyclothymia and the Type A behaviour speed and impatience subscale.
J Affect Disord. 2008 Jun;108(3):207-16. doi: 10.1016/j.jad.2007.10.018. Epub 2008 Feb 20.
Abstract/Text
BACKGROUND: Dissociative symptoms are often seen in patients with mood disorders, but there is little information on possible association with subgroups and temperamental features of these disorders.
METHODS: The Dissociative Experience Scale was administered to 85 patients with a DSM-IV Major Depressive Disorder (MDD) or Bipolar-II Disorder (BP-II). Both broad-spectrum dissociation (DES total score) and clearly pathological forms of dissociation (DES-Taxon) were assessed. Temperament was assessed using Akiskal and Mallya;s criteria of Affective Temperaments and the Jenkins Activity Survey (JAS) for Type A Behaviour.
RESULTS: Sixty-five patients gave valid answers to DES. The mean DES and DES-T scores were higher in BP-II (16.8 and 12.7 respectively) compared to MDD (9.0 and 5.7); DES odds ratio (OR)=1.58 (95% CI 1.15-2.18) and DES-T OR=1.60 (95% CI 1.14-2.25) using univariate logistic regression analyses. There was no significant difference in DES score in patients with (n=30) and without an affective temperament (n=35): mean (95% CI), 13.5 vs. 10.5 (-7.8 to 1.9), p=0.224. However the subgroup with a cyclothymic temperament (n=18) had higher DES scores (mean (95% CI): 17.8 vs. 9.7 (2.9-13.3), p=0.003), compared to patients without such a temperament. There was no significant difference in DES scores for patients with (n=35) or without (n=28) a Type A behaviour pattern (JAS>0): mean (95% CI) 12. 7 vs. 10.9 (-6.8 to 3.3), p=0.491), but a positive JAS factor S score (speed and impatience subscale) was associated with significantly higher DES scores than a negative S-score: mean (95% CI) 14.9 vs. 9.0 (1.1-10.7), p=0.017), and this was still significant (p=0.005) using multiple linear regression of DES scores vs. the JAS subscale scores. DES-T scores were significantly higher in patients with OCD (n=9) (mean (95% CI) 18.4 vs. 6.6 (6.0-17.7), p<0.001); eating disorder (n=13) (14.0 vs. 6.8 (1.8-12.6), p=0.009), psychotic symptoms during depressions (n=9) (16.6 vs. 6.9 (3.7-15.8), p=0.002), and in those with a history of suicide attempt (n=28) (11.9 vs. 5.4 (2.2-10.8), p=0.003), but only OCD was an independent predictor after multiple linear regression of DES-T scores vs. all co-morbid disorders (p=0.043).
LIMITATIONS: The major limitation of the present study is a non-blind evaluation of affective diagnosis and temperaments, and assessment in a non-remission clinical status.
CONCLUSIONS: Dissociative symptoms measured with the Dissociative Experience Scale are associated with bipolar features, using formal DSM-IV criteria, cyclothymic temperament and the speed and impatience subscale of the JAS.
V J Felitti, R F Anda, D Nordenberg, D F Williamson, A M Spitz, V Edwards, M P Koss, J S Marks
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
Am J Prev Med. 1998 May;14(4):245-58. doi: 10.1016/s0749-3797(98)00017-8.
Abstract/Text
BACKGROUND: The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described.
METHODS: A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life.
RESULTS: More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life.
CONCLUSIONS: We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.
Julie P Gentile, Kristy S Dillon, Paulette Marie Gillig
Psychotherapy and pharmacotherapy for patients with dissociative identity disorder.
Innov Clin Neurosci. 2013 Feb;10(2):22-9.
Abstract/Text
There is a wide variety of what have been called "dissociative disorders," including dissociative amnesia, dissociative fugue, depersonalization disorder, dissociative identity disorder, and forms of dissociative disorder not otherwise specified. Some of these diagnoses, particularly dissociative identity disorder, are controversial and have been questioned by many clinicians over the years. The disorders may be under-diagnosed or misdiagnosed, but many persons who have experienced trauma report "dissociative" symptoms. Prevalence of dissociative disorders is unknown, but current estimates are higher than previously thought. This paper reviews clinical, phenomenological, and epidemiological data regarding diagnosis in general, and illustrates possible treatment interventions for dissociative identity disorder, with a focus on psychotherapy interventions and a review of current psychopharmacology recommendations as part of a comprehensive multidisciplinary treatment plan.
