Am J Psychiatry
155:6, June
1998
TUTKUN,
FREQUENCY
ŞAR,O YARGIÇ,
F DISSOCIATIVE
ET AL.
DISORDERS
Frequency of Dissociative Disorders Among Psychiatric
Inpatients in a Turkish University Clinic
Hamdi Tutkun, M.D., Vedat Şar, M.D., L. İ lhan Yargιç, M.D.,
Tuba Özpulat, M.D., Medaim Yanik, M.D., and Emre Kiziltan, M.D.
O bjective: T he aim of this study w as to determine the rate of dissociative disorders among
psychiatric inpatients in a university clinic in T urk ey. Method: T he Dissociative Ex periences
Scale w as used to screen 166 consecutive inpatients adm itted to the psychiatry clinic of a
university hospital. T he patients w ho had scores higher than 30 w ere matched for age and
gender w ith 19 of the patients w ho scored below 10 on the scale. T he patients in both groups
w ere then interview ed w ith the D issociative D isorders Interview Schedule by interview ers w ho
w ere blind to their diagnoses and scores on the D issociative Ex periences Scale. Patients w ho
w ere diagnosed as having a dissociative disorder according to the D issociative D isorders Interview Schedule w ere then interview ed by a clinician. R esults: T w enty-four (14.5% ) of the
166 patients had a score higher than 30 on the Dissociative Ex periences Scale; 17 patients
(10.2% ) w ere diagnosed as having a dissociative disorder according to the D issociative D isorders Interview Schedule. N ine patients (5.4% ) had clinically confirm ed dissociative identity
disorder. Conclusions: A considerable proportion of the psychiatric inpatients in a T urk ish
university psychiatry clinic had dissociative disorder. Clinicians w ho w ork in general psychiatric inpatient units should be alert for chronic complex dissociative disorders.
(Am J Psychiatry 1998; 155:800–805)
D
issociative disorders were first officially classified
as a separate diagnostic group in DSM -III. Until
the last decade, no standardized instrument had been
designed to yield uniform diagnoses of dissociative disorders. Structured diagnostic interviews developed for
other psychiatric categories did not include assessment
of dissociative disorders. The development of objective
screening instruments (1, 2) and structured interviews
(3, 4) filled this gap and promoted empirical research
leading to a change in opinions regarding the relevance
of dissociative disorders in psychiatry.
Dissociative identity disorder (DSM -IV), also known
as multiple personality disorder, has been the most extensively studied dissociative disorder in the last decade
(5, 6). It is considered the most severe manifestation of
dissociative psychopathology that is closely related to
child abuse (7). There is growing interest in this previously neglected diagnostic category among clinicians
and researchers in several countries (8–13). Studies conducted with standardized assessment measures in
Presented in part at the 13th Fall Conference of the International
Society for the Study of Dissociation, San Francisco, N ov. 8, 1996.
Received M arch 20, 1997; revision received Aug. 13, 1997; accepted
N ov. 14, 1997. From the Clinical Psychotherapy Unit and Dissociative Disorders Program, Department of Psychiatry, Istanbul M edical
Faculty, Istanbul University, Istanbul, Turkey. Address reprint requests to Dr. Şar, Istanbul Tip Fakültesi Psikiyatri Klinig^i, 34390
Çapa, Istanbul, Turkey; vsar@prizma.net.tr (e-mail).
800
N orth America (14), The N etherlands (15), and Turkey
(16) reported similar symptom profiles, supporting
cross-cultural consistency of the disorder.
Dissociative symptoms have traditionally been considered quite common in Turkey, especially in emergency psychiatric wards and emergency units of general
hospitals (17–19). Dissociative states were usually conceived of as acute and self-limited clinical conditions
that tend to be recurrent; an underlying, chronic, complex dissociative psychopathology was never taken into
consideration. Dissociative states have been linked to
developmental conditions characterized by restriction,
oppression, neglect, and even hostile rejection in the
family of origin (19–21); however, the relation to childhood traumata, especially sexual and physical abuse,
was not included as part of today’s trauma paradigm
(22). Consequently, the direct traumatic origins of current symptoms were not taken into consideration in the
psychotherapeutic treatment of these patients (23–25).
In studies using standardized instruments, we found
rates of dissociative identity disorder of 3.9% among
psychiatric outpatients (26) and 0.4% in the general
population in Turkey (27). We also found that dissociative symptoms are far from rare in studies conducted
among nonclinical populations in Turkey (27–29).
In the present study, we attempted to determine the
rate of dissociative disorders in psychiatric inpatients in
Turkey using standardized assessment instruments. To
A m J Psychiatry 155:6, June 1998
TUTKUN , ŞAR, YARGIÇ, ET AL.
M ETH O D
hood abuse and some psychiatric symptoms as part of a concurrent
study. Three psychiatry residents (T.Ö ., M .Y., and E.K.) administered the scale to the patients of their own gender.
In the second phase of the study, all subjects who had scores higher
than 30 on the Dissociative Experiences Scale were matched for age
and gender with 19 of the patients who scored below 10 on the scale.
The Dissociative Disorders Interview Schedule was administered to
patients in both groups. The interviewer was blind to the patients’
diagnoses and Dissociative Experiences Scale scores. All structured
interviews were conducted by two of us (H .T. and L. İ .Y.), both of
whom had extensive experience using this instrument before the initiation of the study.
In the third phase of the study, all subjects who were diagnosed as
having a dissociative disorder according to the Dissociative Disorders
Interview Schedule were interviewed for clinical confirmation. Personality switches were observed at least three times in patients who
were diagnosed as having dissociative identity disorder. Because we
were all working at the same institution, it was not possible to keep
the clinician in the third phase (H .T.) blind to the data obtained during the second phase. O ne of us (V.Ş.), a psychiatrist and director of
the Dissociative Disorders Program and the Clinical Psychotherapy
Unit, confirmed all of the clinical diagnoses either by direct consultation or supervision.
Subjects
D ata A nalysis
All patients admitted to two 30-bed general psychiatric inpatient
wards at the Istanbul M edical Faculty H ospital over a 7-month period (N ovember 1, 1994, to M ay 31, 1995) were considered for participation in the study. Patients who had previously been diagnosed
as having a dissociative disorder were excluded from the study. The
patients who agreed to participate in the study provided written informed consent after the study procedures had been fully explained.
All patients were approached for the study if their treating physician
felt that they could give informed consent and there were no other
clinical limitations on their participation. Some of the patients were
allowed to stabilize for 1 to 2 weeks before being asked to give informed consent. The comparison subjects were drawn from the same
patient population.
Subjects who completed the Dissociative Experiences Scale were
compared with those who did not complete the scale to determine
whether these two groups differed in gender or age. The frequency of
dissociative disorders was calculated on the basis of the number of
subjects who received a confirming clinical diagnosis from a clinician.
Characteristics of patients with diagnoses of a dissociative disorder
were compared with those of patients with no dissociative disorder.
Student’s two-tailed t tests were used to compare ordinal data. Chisquare analyses were used to compare nominal data. Bonferroni correction for multiple comparisons was used.
Instrum ents
During the research period, 261 consecutive patients
were admitted to the inpatient wards. Twenty patients
were excluded for the following reasons: six had been
previously diagnosed as having dissociative identity disorder, six had mental retardation, and eight were illiterate. O f the 241 remaining patients, 166 (68.9% ) completed the questionnaires (63.6% of all admissions).
The reasons for not completing the questionnaires included being hospitalized for too short a time, refusal
to participate, or being too psychotic to be invited.
There was no significant difference in the ages of
the patients who did not participate (mean=31.6 years,
SD=11.3) and those patients who did (mean=32.1 years,
SD =1 2 .0 ) (t =0 .3 3 , d f=2 3 1 , p>0.05). Twenty-one
(8.7% ) of the 241 patients were younger than 18. Women
made up 58.4% (N =97) of those who completed the
questionnaires and 53.3% (N =40) of those who did
not complete them; this difference was not significant (χ2 =1.25, df=2, p>0.05). The age range of the participating patients was 13–70 years. There was no significant difference in age between women (mean=32.0,
SD=12.2) and men (mean=32.3, SD=11.8) (t=0.16, df=
164, p>0.05).
The mean Dissociative Experiences Scale rating of the
original 166 patients was 17.8 (SD=14.9, range=0.0–
77.9, median=14.6). Twenty-four (14.5% ) of the 166
our knowledge, this is the first study scanning dissociative identity disorder among psychiatric inpatients in
our country. We also attempted to determine the differences between patients with the diagnosis of dissociative disorder and those who reported few dissociative
symptoms. An additional reason for using such a comparison group and interviewing the two groups in a
blind fashion was to eliminate bias in the assessment of
these patients. To eliminate any false positive findings,
all patients given the diagnosis of a dissociative disorder
according to results of the structured interview were
evaluated by a clinician. Additionally, information
about the frequency of childhood abuse, suicide attempts, and self-mutilative behavior was gathered by
using a self-report questionnaire; details of related results will be published elsewhere.
1. D issociative Ex periences Scale. The Dissociative Experiences
Scale (1) is a 28-item self-report instrument. It is not a diagnostic tool
but serves as a screening device for chronic dissociative disorders.
Possible scores range from 0 to 100. M edian scores on this scale have
been shown to differentiate patients with a chronic dissociative disorder from patients with other psychiatric conditions (1, 30). The Turkish version of the scale has reliability and validity (31) as high as those
of its original form.
2. D issociative D isorders Interview Schedule. The Dissociative
Disorders Interview Schedule (3) is a structured interview consisting
of 131 items. It is used to make DSM -III-R diagnoses of somatization
disorder, major depressive episode, borderline personality disorder,
and all the dissociative disorders. This schedule also inquires about
childhood physical and sexual abuse and a variety of features associated with dissociative identity disorder, including 11 Schneiderian
symptoms, 16 secondary features of dissociative identity disorder,
and 16 extrasensory experiences. Two items inquiring about childhood emotional abuse and neglect that are not included in the English
form of the schedule were added to the Turkish version. The schedule
has an overall interrater reliability of 0.68 (kappa), a sensitivity of
90% , and a specificity of 100% for the diagnosis of dissociative identity disorder (11). Information on the validity and reliability of the
Turkish version has been reported elsewhere (16, 32).
Procedure
The study consisted of three phases. In the first phase, all patients
were asked to complete the Dissociative Experiences Scale. They also
completed a self-report questionnaire gathering information on child-
A m J Psychiatry 155:6, June 1998
RESULTS
801
FREQ UEN CY O F DISSO CIATIVE DISO RDERS
tients had other diagnoses: one had posttraumatic stress
disorder (PTSD) and three had schizophrenic disorder.
N one of the patients with Dissociative Experiences
Scale scores below 10 had the diagnosis of a dissociative
Dissociative Disorder
Present According to
disorder (table 1). Sensitivity and specificity were 100%
Dissociative Disorders
and 83% , respectively, positive predictive power was
Interview Schedule
81% , and negative predictive power was 100% .
Yes
No
Total
Eleven (eight women and three men) of the 17 patients
(N =17)
(N =23)
(N =40)
Group
with a dissociative disorder had the diagnosis of dissociative identity disorder according to the Dissociative
Patients with Dissociative Experiences Scale score >30 (N =21)
17
4
21
Disorders Interview Schedule. The remaining six patients
Patients with Dissociative Experiwere diagnosed as having dissociative disorder not othences Scale score <10 (N =19)
0
19
19
erwise specified. Dissociative identity disorder and disa Yates-corrected χ2 =26.65, df=1, p<0.00001.
sociative disorder not otherwise specified were considered supraordinate diagnoses.
Any patient who met criteria for
TABLE 2 . Main Symptom Cluster Scores on the Dissociative Disorders Interview Schedule of Psydissociative amnesia, dissociaa
chiatric Inpatients With or Without Diagnoses of Dissociative Disorder
tive fugue, or depersonalization
Patients
Patients
disorder and also met criteria
With
Without
for dissociative identity disorDissociative
Dissociative
der or dissociative disorder not
Disorder
Disorder
(N =17)
(N =19)
Student’s t Test
otherwise specified received the
overall diagnosis of either dissoVariable
M ean
SD
M ean SD
t (df=34)
p
ciative identity disorder or disSymptom cluster
sociative disorder not otherwise
Secondary features of dissociative idenspecified.
tity disorder
9.4
3.8
0.8
1.1
11.28
<0.001
Nine patients (seven women
Extrasensory perceptions
4.5
2.3
1.3
1.7
4.74
<0.001
and two men) were diagnosed
Schneiderian symptoms
6.4
2.8
1.6
2.0
5.99
<0.001
Borderline personality disorder criteria
5.6
2.1
1.0
1.1
8.15
<0.001
as having dissociative identity
Somatic complaints
10.5
4.1
1.7
2.2
8.14
<0.001
disorder by clinical examinaDissociative Experiences Scale score
48.3
14.7
5.0
2.8
12.60
<0.001
tion. The remaining eight paAge (years)
24.7
11.6
29.4
8.7
1.37
n.s.
tients were diagnosed as having
a Patients with dissociative disorder had scores greater than 30 on the Dissociative Experiences Scale
dissociative disorder not otherand were given the diagnosis on the basis of the Dissociative Disorders Interview Schedule; patients
wise specified. In six of these pawithout dissociative disorder had scores less than 10 on the Dissociative Experiences Scale.
tients, some personality states
were observed repeatedly, but
they were not considered sufficiently distinct and sepapatients had a score higher than 30, and 56 (33.7% )
rate to diagnose a dissociative identity disorder at this
had a score higher than 20. Women (mean=19.7, SD=
stage of the evaluation. A 45-year-old male patient from
16.9) had a higher score than men (mean=15.0, SD=11.0)
this group had the diagnosis of dissociative identity dis(t=2.04, df=164, p<0.05). Age correlated negatively with
order according to the Dissociative Disorders Interview
scale score (r=–0.27, N=166, p<0.001). Six of the patients
Schedule, but he declared that he did not want his alter
with a score higher than 30 were men and 18 were women.
personalities to be evaluated.
However, there was no difference in gender between
Findings from the main symptom clusters of the Dissopatients with a score higher than 30 and those with a
ciative Disorders Interview Schedule and the Dissociative
score of 30 or lower (χ2 =3.17, df=1, p>0.05). Patients
Experiences Scale scores for the two groups are presented
with scores above 30 (mean age=27.0, SD=11.4) were
in table 2. The patients with a dissociative disorder had
younger than those with scores of 30 or lower (mean
significantly higher scores in all main symptom clusters
age=33.0, SD=12.0) (t=2.28, df=164, p<0.05).
and on the Dissociative Experiences Scale.
Twenty-one of the 24 patients with scores above 30
Table 3 indicates the Dissociative Disorders Intercould be evaluated with the Dissociative Disorders Inview Schedule diagnoses that the patients in both
terview Schedule. Two patients were hospitalized for
groups received. All patients in the dissociative disortoo short a period, and one refused to participate in the
ders group met DSM -III-R criteria for a dissociative disinterview. This sole refusing patient told the interviewer
order. M ost of them had comorbid psychiatric disorthat he was deeply affected by the content of the Dissoders. There were high rates of comorbid borderline
ciative Experiences Scale and was afraid that a further
personality disorder, current or past episode of major
evaluation “ might elicit something” in him.
depression, and somatization disorder.
Seventeen of the 21 patients with Dissociative ExpeTable 4 shows some findings concerning mental health
riences Scale scores above 30 were diagnosed as having
history derived from the Dissociative Disorders Interview
a dissociative disorder according to the Dissociative
Schedule. Significantly more patients in the dissociative
Disorders Interview Schedule. The remaining four paTABLE 1 . Relation of Dissociative Disorder Diagnosis Made With Dissociative Disorders Interview Schedule to Scores on Dissociative Experiences Scale for 4 0 Psychiatric Inpatientsa
802
A m J Psychiatry 155:6, June 1998
TUTKUN , ŞAR, YARGIÇ, ET AL.
disorders group than in the comparison group reported physical
abuse and sexual abuse (table 4).
More of the patients with dissociative disorder than patients in
the comparison group also reported emotional abuse.
Sixteen of the 17 patients in the
dissociative disorders group had
contacted a psychiatrist previously. The mean interval between
their first psychiatric contact and
the study interview was 4.6 years
(SD=4.6, range=3 months–15
years). Seven of these patients had
been hospitalized at least once
(range=1–6 times). Nine had been
given diagnoses of depression,
one mania, two schizophrenic
disorder, and two anxiety disorder. Eleven had been prescribed
psychotropic medication. Two of
the subjects had received ECT;
nine had received antipsychotic
medication, 13 had received an
antidepressant, and two had received lithium. Fourteen of the
subjects said that they had received ineffective treatment at
some time. Only five of the subjects had received courses of psychotherapy. For all but one of
them the psychotherapeutic intervention ceased in fewer than 10
sessions. The only exception was
an incest victim with the diagnosis of depressive disorder who
had received both biological and
psychotherapeutic treatment for
6 years; her care was covered by
a women’s shelter in Istanbul
(Mor Cati [Purple Roof]).
DISCUSSIO N
TABLE 3 . Dissociative Disorders Interview Schedule Diagnoses of Psychiatric Inpatients With or
Without Diagnoses of Dissociative Disordera
Patients
With
Dissociative
Disorder
(N =17)
Patients
Without
Dissociative
Disorder
(N =19)
Chi-Square
Analysisb
Diagnosis
N
%
N
%
χ2 (df=1)
p
Major depression (current or past)
Borderline personality disorder
Somatization disorder
Any comorbid disorder
Dissociative amnesia
Depersonalization disorder
Dissociative fugue
Dissociative disorder not otherwise
specified
Dissociative identity disorder
14
12
6
16
14
14
5
82.4
70.6
35.3
94.1
82.4
82.4
29.4
9
0
0
9
0
1
0
47.4
0.0
0.0
47.4
0.0
5.3
0.0
4.76
20.12
17.70
9.24
25.60
21.94
—c
n.s.
<0.00005
<0.00005
<0.005
<0.00001
<0.00001
n.s.
3
14
17.6
82.4
0
0
0.0
0.0
—c
25.60
n.s.
<0.00001
a Patients
with dissociative disorder had scores greater than 30 on the Dissociative Experiences
Scale and were given the diagnosis on the basis of the Dissociative Disorders Interview Schedule;
patients without dissociative disorder had scores less than 10 on the Dissociative Experiences
Scale.
b The adapted level of alpha is p=0.005 when the Bonferroni method is applied.
cFisher’s exact test.
TABLE 4 . Gender and Dissociative Disorders Interview Schedule Mental Health History Items of
Psychiatric Inpatients With or Without Diagnoses of Dissociative Disordera
Patients
With
Dissociative
Disorder
(N =17)
Patients
Without
Dissociative
Disorder
(N =19)
Chi-Square
Analysisb
Variable
N
%
N
%
χ2 (df=1)
p
Gender (female)
Dissociative Disorders Interview
Schedule mental health history items
Self-mutilation
Suicide attempt
Substance abuse
H eadache
Trance
Childhood imaginary companionship
Somnambulism
Sexual abuse
Sexual and/or physical abuse
Physical abuse
Emotional abuse
N eglect
Any type of abuse
13
76.5
13
68.4
0.28
n.s.
15
14
5
14
17
5
5
10
14
14
12
10
15
88.2
82.4
29.4
82.4
100.0
29.4
29.4
58.8
82.4
82.4
70.6
58.8
88.2
4
6
0
4
6
0
2
1
5
4
2
4
6
21.1
31.6
0.0
21.1
31.6
0.0
10.5
5.3
26.3
21.1
10.5
21.1
31.6
16.15
9.36
—c
13.49
18.20
—c
—c
13.20
11.30
15.35
16.70
7.20
11.85
<0.0001
n.s.
n.s.
n.s.
<0.00005
n.s.
n.s.
<0.0005
<0.001
<0.0001
<0.00005
n.s.
<0.001
a Patients
with dissociative disorder had scores greater than 30 on the Dissociative Experiences
O f all consecutively admitted
Scale and were given the diagnosis on the basis of the Dissociative Disorders Interview Schedule;
patients without dissociative disorder had scores less than 10 on the Dissociative Experiences
patients to an inpatient psychiatScale.
ric unit, 63.6% could be recruited
b The adapted level of alpha is p=0.003 when the Bonferroni method is applied.
for the present study. This rate is
cFisher’s exact test.
similar to those of Ross et al. (33)
and Saxe et al. (34) and higher
To our knowledge, there are few studies using a structhan those of Latz et al. (35) and Modestin et al. (36). On
tured interview to determine the rate of dissociative disthe basis of our findings in the current study, the conserorders among psychiatric inpatients (13, 33–36). Table
vative estimate of the frequency of new cases of dissocia5 presents the results from several studies. The rates in
tive disorders among psychiatric inpatients is 10.2% , inour study are in agreement with those of studies in
cluding 5.4% with dissociative identity disorder. These
N orth America and N orway despite the higher cutoff
are the percentages of subjects who received the diagnosis
score in our first phase. A study on a Swiss sample (36)
from both the Dissociative Disorders Interview Schedule
found lower rates. Whether this difference depends on
and the study clinician.
A m J Psychiatry 155:6, June 1998
803
FREQ UEN CY O F DISSO CIATIVE DISO RDERS
TABLE 5 . Studies of Dissociative Disorder Among Psychiatric Inpatients
Study
N umber
of
Subjects
Present study
166
Modestin et al. (36)
207
Knudsen et al. (13)
101
Latz et al. (35)
176
c
Saxe et al. (34)
110
Ross et al. (33)
299
a
Clinically confirmed diagnosis.
Diagnostic Instrument
Cutoff on
Dissociative
Experiences
Scale
Dissociative Disorders
Interview Schedule
Dissociative Disorders
Interview Schedule
Structured Clinical
Interview for
Dissociative
Disorders
Dissociative Disorders
Interview Schedule
Dissociative Disorders
Interview Schedule
Dissociative Disorders
Interview Schedule
b
Data not given.
cultural influences or is caused by different inpatient
sample characteristics is not yet known.
M ost of the patients with dissociative disorders in our
study group had comorbid psychiatric disorders according to the structured interview. There were high
rates of comorbid borderline personality disorder, current or past episode of major depression, and somatization disorder. Approximately two-thirds of our study
group met criteria for borderline personality disorder.
This finding is in agreement with that of Saxe et al. (34).
However, in a case series of mostly outpatients with
dissociative identity disorder (16), we found that the
rate of borderline personality disorder was much lower,
suggesting that patients fitting these criteria are hospitalized more frequently.
It is not uncommon for patients with dissociative
identity disorder to meet DSM -IV criteria for several
other disorders at the same time (14–16). Although
dissociative identity disorder and borderline personality disorder have their own diagnostic features,
there is a wide phenomenological overlap. O n the
other hand, M odestin et al. (36) determined that Dissociative Experiences Scale scores correlated positively with a number of features of practically all personality disorder subtypes.
Significantly higher rates of childhood traumatic experiences were found in our patients with a dissociative
disorder than in the comparison group. This finding
supports the notion that traumatic childhood experiences play a major role in the development of dissociative disorders (7, 22). Saxe et al. (34) found that
PTSD was also frequent among inpatients with a dissociative disorder. Self-destructive behavior such as
self-mutilation, suicide attempts, and substance abuse
were also common in our dissociative disorder group.
This type of behavior also has been linked to childhood
trauma (37).
The Dissociative Experiences Scale ratings of our in-
804
Rate of
Dissociative
Identity
Disorder (% )
Dissociative Experiences
Scale Score
Rate of
Dissociative
Disorder (% )
Mean
SD
Patients
With Score
>30 (% )
30
5.4
a
10.2
a
17.8
14.9
14.5
20
0.4
5.0
13.7
13.5
12.0
30
3.0
6.0
—
N one
12.0
—
b
b
—
b
—
—
b
b
15.0
b
34.7
b
b
25
4.0
15.0
—
—
—
20
3.3
a
20.7
14.6
14.2
15.4
c
Subjects included only females.
patients are similar to those obtained in comparable
study groups in N orth America (33–35, 38) and Europe
(13, 37). Among patients with Dissociative Experiences
Scale scores higher than 30, 81.0% of evaluated patients suffered from a clinically confirmed, chronic,
complex dissociative disorder; this finding confirms
that high scores on the scale are highly suggestive of a
dissociative disorder.
In our study, women had a higher mean Dissociative
Experiences Scale score than men. That Dissociative
Experiences Scale scores of men and women do not differ in the general population (27, 39) and among patients with different psychiatric disorders (35) suggests
that women with dissociative symptoms are hospitalized more frequently. Results reported by Chu and Dill
(38) and Latz et al. (35) support this idea. Because these
studies had few (38) or no (35) male subjects, their results are not comparable with ours. Some of the previous studies (40, 41) pointed out that childhood traumata are more common among women.
CO N CLUSIO N S
There is accumulating evidence suggesting that dissociative disorders are frequent among psychiatric inpatients. We found that approximately 10% of the psychiatric patients in a Turkish university hospital met the
criteria for a chronic complex dissociative disorder.
H alf of these patients met the criteria for dissociative
identity disorder. Patients who have chronic complex
dissociative disorder are very likely to fit the criteria for
borderline personality disorder, somatization disorder,
and at least one major episode of major depression as
well. These individuals are also very likely to have had
a history of childhood abuse and neglect. They present
a challenge for psychiatrists working in inpatient units.
Q uasi-psychotic posttraumatic symptoms of these pa-
A m J Psychiatry 155:6, June 1998
TUTKUN , ŞAR, YARGIÇ, ET AL.
tients can easily lead to diagnostic errors. An accurate
diagnosis is crucial for better intervention and management. Dissociative disorders should be investigated
routinely in psychiatric assessments. The use of structured instruments is helpful for this purpose.
22.
REFEREN CES
23.
1. Bernstein EM , Putnam FW: Development, reliability, and validity of a dissociation scale. J N erv M ent Dis 1986; 174:727–735
2. Vanderlinden J, Van Dyck R, Vandereycken W, Vertommen H :
The Dissociation Q uestionnaire (DIS-Q ): development and characteristics of a new self-reporting questionnaire. Clin Psychol
Psychotherapy 1991; 1:21–27
3. Ross CA, H eber S, N orton GR, Anderson D, Anderson G,
Burchet P: The Dissociative Disorders Interview Schedule: a
structured interview. Dissociation 1989; 2:169–189
4. Steinberg M , Rounsaville B, Cicchetti DV: The Structured Clinical Interview for DSM -III-R Dissociative Disorders: preliminary
report on a new diagnostic instrument. Am J Psychiatry 1990;
147:76–82
5. Putnam FW, Guroff JJ, Silberman EK, Barban L, Post RM : The
clinical phenomenology of multiple personality disorder: review
of 100 recent cases. J Clin Psychiatry 1986; 47:285–293
6. Ross CA, N orton GR, Wozney K: M ultiple personality disorder:
an analysis of 236 cases. Can J Psychiatry 1989; 34:413–418
7. Kluft RP: M ultiple personality disorder, in American Psychiatric
Press Review of Psychiatry, vol 10. Edited by Tasman A, Goldfinger SM . Washington DC, American Psychiatric Press, 1991,
pp 161–188
8. Adityanjee, Raju GSP, Khandelwal SK: Current status of multiple personality disorder in India. Am J Psychiatry 1989; 146:
1607–1610
9. Takahashi Y: Is multiple personality disorder really rare in Japan? Dissociation 1990; 3:57–59
10. M artinez-Taboas A: M ultiple personality in Puerto Rico: an
analysis of fifteen cases. Dissociation 1991; 4:189–192
11. Modestin J: M ultiple personality disorder in Switzerland. Am J
Psychiatry 1992; 149:88–92
12. Tutkun H , Yargιç Lİ , Şar V: Dissociative identity disorder: clinical investigation of 20 cases from Turkey. Dissociation 1995;
8:3–9
13. Knudsen H , H aslerud J, Boe T, Draijer N , Boon S: Prevalence of
dissociative disorders in a N orwegian general psychiatric department (inpatients and daycare), in Proceedings of the Fifth Annual
M eeting of the International Society for the Study of Dissociation. Edited by van der H art O , Boon S, Draijer N . Amsterdam,
International Society for the Study of Dissociation, 1995, p 79
14. Ross CA, M iller SD, Reagor P, Bjornson L, Fraser GA, Anderson
G: Structured interview data on 102 cases of multiple personality
disorder from four centers. Am J Psychiatry 1990; 147:596–601
15. Boon S, Draijer N : M ultiple personality disorder in The N etherlands: a clinical investigation of 71 patients. Am J Psychiatry
1993; 150:489–494
16. Şar V, Yargιç Lİ , Tutkun H : Structured interview data on 35
cases of dissociative identity disorder in Turkey. Am J Psychiatry
1996; 153:1329–1333
17. Ö ztürk O M , Volkan VD: The theory and practice of psychiatry
in Turkey. Am J Psychother 1971; 15:240–271
18. Salgirtay A: [An Evaluation of Emergency Admissions to Ankara
University Psychiatry Clinic] (doctoral dissertation). Ankara,
Turkey, Ankara University M edical Faculty, Department of Psychiatry, 1979 (Turkish)
19. Ö ztürk O M , GöG^üş A: [H ysterical psychosis presenting with severe regressive symptoms], in Proceedings of the 9th N ational
Congress of Psychiatry and N eurology. Ankara, M eteksan,
1973, pp 155–164 (Turkish)
20. Ö ztürk O M : [H ysterical neurosis], in [Textbook of M ental
H ealth and Diseases]. Edited by Ö ztürk O M . Ankara, M eteksan,
1981, pp 209–219 (Turkish)
21. Şar İ : [A Retrospective Evaluation of Inpatients Diagnosed as
24.
A m J Psychiatry 155:6, June 1998
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
H aving “ H ysteria” in H acettepe University Psychiatry Clinic Between 1970–1980] (doctoral dissertation). Ankara, Turkey,
H acettepe University M edical Faculty, Department of Psychiatry, 1983 (Turkish)
Spiegel D: Dissociation and trauma, in American Psychiatric
Press Review of Psychiatry, vol 10. Edited by Tasman A, Goldfinger SM . Washington, DC, American Psychiatric Press, 1991,
pp 261–275
Tutkun H , Yargιç Lİ , Şar V: Dissociative identity disorder presenting as hysterical psychosis. Dissociation 1996; 9:244–252
Şar V, Yargιç Lİ , Tutkun H : [Sociodemographic and clinical features of 25 patients with dissociative identity disorder: results of
long-term evaluation and treatment]. Düsünen Adam 1995; 8:
38–46 (Turkish)
Şar V, Yargιç Lİ , Tutkun H : Current status of dissociative identity disorder in Turkey, in Proceedings of the Fifth Annual M eeting of the International Society for the Study of Dissociation.
Edited by van der H art O , Boon S, Draijer N . Amsterdam, International Society for the Study of Dissociation, 1995, p 76
Şar V, Tutkun H , Alyanak B, Bakim B, Baral I: Frequency of
dissociative identity disorder among psychiatric outpatients in a
Turkish university clinic, in Program Book, 13th Fall Conference
of the International Society for the Study of Dissociation. Glenview, Ill, International Society for the Study of Dissociation,
1996, p 141
Akyüz G, DoG^an O , Şar V, Yargιç Lİ , Tutkun H : Frequency of
dissociative identity disorder in the general population: an epidemiologic study on a representative sample from a city in Central Turkey. Ibid, p 143
Z oroG^lu S, Tuzun U, Şar V, Erocal-Kora M , Ö ztürk M , Alyanak
B: Childhood abuse, self-injury and dissociative experiences
among high-school students. Ibid, p 285
Yargιç Lİ , Tutkun H , Şar V: Childhood abuse and dissociative
experiences in adulthood, in Proceedings of the Fifth Annual
Meeting of the International Society for the Study of Dissociation. Edited by van der H art O , Boon S, Draijer N . Amsterdam,
International Society for the Study of Dissociation, 1995, p 84
Carlson EB, Putnam FW, Ross CA, Torem M , Coons P, Dill DL,
Loewenstein RJ, Braun BG: Validity of the Dissociative Experiences Scale in screening for multiple personality disorder: a multicenter study. Am J Psychiatry 1993; 150:1030–1036
Yargιç Lİ , Tutkun H , Şar V: The reliability and validity of the
Turkish version of the Dissociative Experiences Scale. Dissociation 1995; 8:10–13
Yargιç Lİ , Şar V, Tutkun H : [Differential diagnosis of multiple
personality disorder using a self-rating scale (DES) and a structured clinical interview schedule (DDIS)], in [Proceedings of the
31st N ational Congress of Psychiatry]. Istanbul, Turkish N europsychiatric Society, 1995, p 70 (Turkish)
Ross CA, Anderson G, Fleisher WP, N orton GR: The frequency
of multiple personality disorder among psychiatric inpatients.
Am J Psychiatry 1991; 148:1717–1720
Saxe GN , van der Kolk BA, Berkowitz R, Chinman G, H all K,
Lieberg G, Schwartz J: Dissociative disorders in psychiatric inpatients. Am J Psychiatry 1993; 150:1037–1042
Latz TT, Kramer SI, H ughes DL: M ultiple personality disorder
among female inpatients in a state hospital. Am J Psychiatry
1995; 152:1343–1348
M odestin J, Ebner G, Junghan M , Erni T: Dissociative experiences and dissociative disorders in acute psychiatric inpatients.
Compr Psychiatry 1996; 37:355–361
van der Kolk BA, Perry JC, H erman JL: Childhood origins of
self-destructive behavior. Am J Psychiatry 1991; 148:1665–1671
Chu JA, Dill LD: Dissociative symptoms in relation to childhood
physical and sexual abuse. Am J Psychiatry 1990; 147:887–892
Ross CA, Joshi S, Currie R: Dissociative experiences in the general population. Am J Psychiatry 1990; 147:1547–1552
Jacobson A, H erald C: The relevance of childhood sexual abuse
to adult psychiatric inpatient care. H osp Community Psychiatry
1990; 41:154–158
Brown GR, Anderson B: Psychiatric morbidity in adult inpatients
with childhood histories of sexual and physical abuse. Am J Psychiatry 1991; 148:55–61
805