Diagnostic Considerations

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.^[28]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. Schizophrenia and dissociation identity disorder overlap not only in psychotic symptoms but also in terms of traumatic antecedents.^[29]

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 dissociation identity disorder and schizophrenia can be made along several lines.

Patients with schizophrenia hear voices emanating from the external world, whereas patients with dissociation identity disorder 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 dissociation identity disorder 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.

Differential Diagnoses

Childhood-Onset Schizophrenia

Workup

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Author

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA Professor of Emergency Medicine and Clinical Pediatrics, Weill Cornell Medical College; Attending Physician, Departments of Emergency Medicine and Pediatrics, Lincoln Medical and Mental Health Center; Adjunct Professor of Emergency Medicine, Adjunct Professor of Pediatrics, St George's University School of Medicine, Grenada

Muhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Academy of Urgent Care Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, Association of Clinical Research Professionals, Public Responsibility in Medicine and Research, Society for Academic Emergency Medicine, Society for Simulation in Healthcare

Disclosure: Nothing to disclose.

Coauthor(s)

Muhammad Aslam, MD Professor of Pediatrics, University of California, Irvine, School of Medicine; Neonatologist, Division of Newborn Medicine, Department of Pediatrics, UC Irvine Medical Center

Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen 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, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Chief Editor

Acknowledgements

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.

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.