The Diagnostic and Statistical Manual of Mental Disorders, currently in its fifth edition (DSM-5), is the “bible” of psychiatric diagnosis. Decisions about treatment, communication among mental health professionals, and whole traditions of psychiatric research depend on use of the DSM system. Insurance companies will not pay for treatment unless the client has a DSM diagnosis. While it’s true that developing diagnostic categories can be an inexact science, and that some disorders have come and gone, years of empirical research and clinical observation go into each subsequent revision of this document. In short, if the diagnosis of Dissociative Amnesia was in DSM-IV and kept for DSM-5, it’s likely there for good reasons.
There are often politicized battles among different groups of psychiatrists and psychologists invested in certain diagnostic approaches, and certain diagnoses are contested by some clinicians and researchers. But two characteristics of DSM itself, which stem from the nature of the revision process, are particularly relevant here:
- Since the 1970s the DSM approach to diagnosis has been highly descriptive; that is, diagnostic categories and their revisions are grounded in empirical evidence and observable phenomena, not theoretical constructs involving assumptions about causal mechanisms (though in the case of trauma-induced disorders, to some extent this cannot be avoided).
- Because committees and decisions tend to be dominated by older, “establishment” psychiatrists, the DSM is a quite conservative document.
Both of these characteristics of DSM have clear implications for the diagnosis of Dissociative Amnesia:
- “Dissociative Amnesia” is a descriptive diagnosis that adheres closely to empirical data and clinically observed symptomology (there is no theory-laden diagnosis of “Repressive Amnesia,” and it was never even considered).
- “Dissociative Amnesia” did not enter the DSM diagnostic system because a small group of radical therapists hijacked the DSM-revision process. (For example, the DSM-IV Working Group on Dissociative Disorders included, among others, David Spiegel, a Stanford psychiatrist and researcher whose work has been funded by the National Institutes of Health and the MacArthur Foundation; see the pre-DSM-IV paper he wrote with Etzel Cardena, in which they review empirical research on trauma and dissociation and offer recommendations for DSM-IV dissociative diagnoses [Spiegel & Cardena, 1991, “Disintegrated Experience: The Dissociative Disorders Revisited,” Journal of Abnormal Psychology, 100, 366-378]).
Please note: Many clinicians have worked with clients who were doing well until returning memories sent them into treatment. As indicated below, to have the disorder of Dissociative Amnesia a person must experience distress or impairment because he or she cannot remember past (traumatic) events. Thus people can experience dissociative amnesia for memories of childhood sexual abuse without having this disorder.
The below excerpts from DSM-IV (from which DSM-5 does not substantially differ with respect to dissociative disorders) clarify the nature of dissociation and show just how accepted this psychological construct is in the field of psychiatry. For starters, the same scientific progress which has led to increasing reliance on the construct of dissociation also brought about the change of the disorder’s name – from “Psychogenic Amnesia” to “Dissociative Amnesia” in DSM-IV.
“The essential feature of the Dissociative Disorders is a disruption of the usually integrated functions of consciousness, memory, identity, or perception of the environment. The disturbance may be sudden or gradual, transient or chronic. The following disorders are included in this section:“Dissociative Amnesia is characterized by an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness” (p.477).
“300.12 Dissociative Amnesia(formerly Psychogenic Amnesia)
“The essential feature of Dissociative Amnesia is an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by normal forgetfulness (Criterion A). This disorder involves a reversible memory impairment in which memories of personal experience cannot be retrieved in a verbal form (or, if temporarily retrieved, cannot be wholly retained in consciousness). The disturbance does not occur exclusively during the course of Dissociative Identity Disorder [formerly Multiple Personality Disorder], Dissociative Fugue, Posttraumatic Stress Disorder, Acute Stress Disorder, or Somatization Disorder and is not due to the direct physiological effects of a substance or a neurological or other general medical condition (Criterion B). The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C).
“Dissociative Amnesia most commonly presents as a retrospectively reported gap or series of gaps in recall for aspects of the individual’s life history. These gaps are usually related to traumatic or extremely stressful events. Some individuals may have amnesia for episodes of self-mutilation, violent outbursts, or suicide attempts. Less commonly, Dissociative Amnesia presents as a florid episode with sudden onset. This acute form is more likely to occur during wartime or in response to a natural disaster” (p.478).
“In recent years in the United States, there has been an increase in reported cases of Dissociative Amnesia that involves previously forgotten early childhood traumas. This increase has been subject to very different interpretations. Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. In contrast, others believe that the syndrome has been overdiagnosed in individuals who are highly suggestible” (p.479).
The above paragraph was written in 1993, prior to the publication of most of the more than 100 research studies of amnesia and delayed recall.
American Psychiatric Association. (1994). Diagnostic and statistic manual of mental disorders (4th ed.). Washington, DC: Author.