eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect: Dissociative Identity Disorder: Differential Diagnoses & Workup

Author: Muhammad Waseem, MD, Associate Professor of Emergency Medicine in Clinical Pediatrics, Weill Medical College of Cornell University; Consulting Staff, Department of Pediatrics, Bronx Lebanon Hospital; Consulting Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Coauthor(s): Muhammad Aslam, MD, Clinical Fellow, Department of Newborn Medicine, Children's Hospital Boston; Richard M Switzer, Jr, MD, Consulting Staff, Department of Pediatrics, Brooklyn Hospital Center; Orlando Perales, MD, Associate Director of Pediatric Emergency Services, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Contributor Information and Disclosures

Updated: Nov 28, 2007

Differential Diagnoses

Schizophrenia and Other Psychoses

Other Problems to Be Considered

Comorbidities are noted among patients with dissociative identity disorder. In a study by Tezcan et al, all patients with dissociative disorder also had other psychiatric disorders.15  A high prevalence of dissociative disorder is noted among patients admitted from emergency psychiatric departments. Comorbid major depression, somatization disorder, and borderline personality disorder is seen in most of these patients. Auditory hallucinations, psychogenic amnesia, flashback experiences, and childhood abuse and/or neglect are other features seen in patients with a dissociative disorder. Many patients receive different diagnoses because of lack of awareness of this condition.

Temporal lobe epilepsy

Dissociation is more common in patients with temporal lobe epilepsy than in any other neurologic disorder. The clinician should refer patients with dissociative symptoms for a thorough neurologic workup to rule out the presence of temporal lobe epilepsy or other organic processes. The standard EEG is of little help in distinguishing MPD from temporal lobe epilepsy because a high rate of nonspecific abnormalities has been detected in patients with MPD, most commonly bilateral temporal lobe slowing.

Schizophrenic disorders

The differentiation between MPD and schizophrenia can be made along several lines.

  • Patients with schizophrenia hear voices emanating from the external world, whereas patients with MPD hear voices originating from within the individual's own head.
  • Patients with schizophrenia may experience visual hallucinations, although they are less well formed than those observed with certain other brain disorders. Patients with MPD occasionally experience hypnagogic phenomena.
  • Poor reality testing is observed with schizophrenia, whereas patients with MPD have essentially intact reality testing.
  • Tangential or loose associations accompanied by inappropriate affect are commonly observed with schizophrenia. Patients with MPD may have circumstantial association with appropriate affect.

Borderline personality disorder

Borderline personality disorder has been diagnosed in 70% of a sample of 33 patients with dissociative disorder and in 23% of 70 patients with dissociative disorder. Putnam acknowledged that a large number of his cases resembled Briquet syndrome or somatization disorder, but, like other investigators, he proposed that once the diagnostic criteria for MPD are satisfied, MPD should be considered the superordinate diagnosis because working with the alternates can provide a therapeutic device that cannot be used in the unified individual.

Malingering

Malingering is said to be an important differential diagnosis in times when an obvious gain may result from mental health intervention. Malingering is the deliberate and fraudulent production of false and exaggerated symptoms to deceive observers for secondary gain that is recognizable with an understanding of the individual's circumstances.

Dissociative amnesic disorder

MPD may prove difficult to distinguish from other dissociative amnesic disorders. With other dissociative amnesic disorders, behavior may be complex, but recovery is often complete, recurrences are less common, and the onset of amnesic spells may be intimately related to stressful events or to ingestion or intoxication.

Workup

Laboratory Studies

Although no laboratory studies are specifically indicated for the diagnosis of dissociative disorder, studies can be performed to check for abuse.

  • Obtain screening tests in all cases of bruising to rule out a bleeding diathesis, but remember that children with bleeding problems may also be abused.
  • Screen urine and stool for blood if abdominal trauma is suspected.

Imaging Studies

As with laboratory studies, no imaging studies are indicated for the diagnosis of dissociative disorder; however, results of imaging studies can indicate abuse.

  • A bone survey consisting of multiple views of the skull, thorax, long bones, hands, feet, pelvis, and spine is necessary with children younger than 2 years if abuse is suspected. If suspicion is strong, repeat the survey in 7-10 days to examine for healing or fractures not observed on the initial radiographs.
  • Bone scanning may be of value in detecting new fractures of hands, feet, or ribs. They are not valuable in detecting skull fractures.
  • Perform head CT scanning if the child has been severely injured.
  • Abdominal CT scanning may reveal damage to internal organs.

More on Child Abuse & Neglect: Dissociative Identity Disorder

Overview: Child Abuse & Neglect: Dissociative Identity Disorder
Differential Diagnoses & Workup: Child Abuse & Neglect: Dissociative Identity Disorder
Treatment & Medication: Child Abuse & Neglect: Dissociative Identity Disorder
Follow-up: Child Abuse & Neglect: Dissociative Identity Disorder
References
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References

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Further Reading

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Keywords

dissociative identity disorder, DID, borderline personality disorder, posttraumatic stress disorder, PTSD, dissociative disorder, dissociation, dissociative psychopathology, child abuse, neglect, multiple personality disorder, MPD, auditory hallucinations, severe depression, suicidality, phobic anxiety, somatization, substance abuse, borderline features, passive disengagement, psychodynamic dividedness, pathological dissociation, conversion disorder, hypnosis, fugue states, sleepwalking, automatic writing, auditory hallucinations, detachment, compartmentalization, temporal lobe epilepsy, schizophrenia

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Contributor Information and Disclosures

Author

Muhammad Waseem, MD, Associate Professor of Emergency Medicine in Clinical Pediatrics, Weill Medical College of Cornell University; Consulting Staff, Department of Pediatrics, Bronx Lebanon Hospital; Consulting Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Muhammad Waseem, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Muhammad Aslam, MD, Clinical Fellow, Department of Newborn Medicine, Children's Hospital Boston
Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Medical Association, Massachusetts Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Richard M Switzer, Jr, MD, Consulting Staff, Department of Pediatrics, Brooklyn Hospital Center
Richard M Switzer, Jr, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: Nothing to disclose.

Orlando Perales, MD, Associate Director of Pediatric Emergency Services, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Orlando Perales, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center
Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation

Managing Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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