Identity Disorder
The essential feature of this disorder is severe subjective distress regarding
inability to integrate aspects of the self into a relatively coherent and acceptable
sense of self. There is uncertainty about a variety of issues relating to identity,
including long-term goals, career choice, friendship patterns, sexual orientation
and behavior, religious identification, moral value systems, and group loyalties.
These symptoms last at least three months and result in impairment in social or
occupational (including academic) functioning. The disturbance does not occur
exclusively during the course of another mental disorder, such as a Mood
Disorder, Schizophrenia, or Schizophreniform Disorder; the disturbance is not
sufficiently pervasive and persistent to warrant the diagnosis of Borderline
Personality Disorder.
The uncertainty regarding long-term goals may be expressed as inability to
choose or adopt a life pattern, for example, one dedicated to material success, or
service to the community, or even some combination of the two. Conflict
regarding career choice may be expressed as inability to decide on a career or as
inability to pursue an apparently chosen occupation. Conflict regarding friendship
patterns may be expressed in an inability to decide the kinds of people with whom
to be friendly and the degree of intimacy to permit. Conflict regarding values and
loyalties may include concerns about religious identification, patterns of sexual
behavior, and moral issues. The person experiences these conflicts as
irreconcilable aspects of his or her personality and, as a result, fails to perceive
himself or herself as having a coherent identity. Frequently the disturbance is
epitomized by the person's asking, 'Who am I?"
Associated features. Mild anxiety and depression are common and are
usually related to inner preoccupations rather than external events. Self-doubt
and doubt about the future are usually present, and take the form of either
difficulty in making choices or impulsive experimentation. Negative or oppositional
patterns are often chosen in an attempt to establish an independent identity
distinct from family or other close people. Such attempts may include transient
experimental phases of widely divergent behavior as the person "tries on" various
roles.
Age at onset. The most common age at onset is late adolescence, when people
generally become detached from their family value systems and attempt to
establish independent identities. As value systems change, this disorder may also
appear in young adulthood, or even in middle age, if a person begins to question
earlier life decisions.
Course. Frequently there is a phase with acute onset, which either resolves
over a period of time or becomes chronic. In other instances the onset is more
gradual. If the disorder begins in adolescence, it is usually resolved by the
mid-20s. If it becomes chronic, however, the person may be unable to make a
career commitment, or may fail to form lasting emotional attachments, with
resulting frequent shifts in jobs, relationships, and career directions.
Impairment. The degree of impairment varies. Usually there is some
interference in both occupational (including academic) and social functioning, with
deterioration in friendships and family relationships
Complications. Educational achievement and work performance below that
appropriate to the person's intellectual ability may result from this disorder
Prevalence. No information. The disorder is apparently more common now
than several decades ago, perhaps because today there are more options
regarding values, behavior, and life-styles and more conflict between adolescent
peer values and parental or societal values.
Predisposing factors, sex ratio, and familial pattern. No
information.
Differential diagnosis. Normal conflicts associated with maturing, such as
�adolescent turmoil" or "middle-age crisis," are usually not associated with severe
distress and impairment in occupational or social functioning. Nevertheless, if the
criteria are met, the diagnosis of Identity Disorder should be given regardless of
the person's developmental stage.
In Schizophrenia, Schizophreniform Disorder, and Mood Disorder, there
frequently are marked disturbances in identity, but these diagnoses preempt the
diagnosis of Identity Disorder.
In Borderline Personality Disorder, identity disturbances are only one of
several important areas of disturbance, and there is often considerable mood
disturbance. If the disturbance is sufficiently pervasive and persistent to warrant
the diagnosis of Borderline Personality Disorder, then that diagnosis preempts the
diagnosis of Identity Disorder. What appears initially to be Identity Disorder may
later turn out to have been an early manifestation of one of the disorders noted
above.
(Diagnostic Criteria for Identity Disorder)
A. Severe subjective distress regarding uncertainty about a variety of issues
relating to identity, including three or more of the following:
(1) long-term goals
(2) career choice
(3) friendship patterns
(4) sexual orientation and behavior
(5) religious identification
(6) moral value systems
(7) group loyalties
B. Impairment in social or occupational (including academic) functioning as a
result of the symptoms in A.
C. Duration of the disturbance of at least three months.
D. Occurrence not exclusively during the course of a Mood Disorder or of a
psychotic disorder, such as Schizophrenia.
E. The disturbance is not sufficiently pervasive and persistent to warrant the
diagnosis of Borderline Personality Disorder.
Reactive Attachment Disorder of Infancy or Early Childhood
The essential feature of this disorder is markedly disturbed social relatedness in
most contexts that begins before the age of five and is not due to Mental
Retardation or a Pervasive Developmental Disorder, such as Autistic Disorder.
The disturbance in social relatedness is presumed to be due to grossly
pathogenic care that preceded the onset of the disturbance.
The disturbance may take the form of either persistent failure to initiate or
respond in an age-expected manner to most social interactions or (in an older
child) indiscriminate sociability, e.g., excessive familiarity with relative strangers,
as shown by making requests and displaying affection. Some severe forms of this
disorder, in which there is lack of weight gain and motor development, have been
called "failure to thrive or "hospitalism."
Infants with this disorder present with poorly developed social responsiveness.
Visual tracking of eyes and faces and responding to the caregiver's voice may not
be established by two months of age; attention, interest, and gaze reciprocity may
be absent. At four to five months, the infant may fail to express pleasure by
smiling, participate in playful, simple games with the caregiver or observer, or
attempt vocal and visual reciprocity (e.g., turn his or her head toward the side
from which the voice of the caregiver or observer comes). At six to ten months,
the infant may fail to reach out when he or she is to be picked up, reach
spontaneously for the caregiver, crawl toward the caregiver, establish visual or
vocal communication with the caregiver, begin to imitate the caregiver, or display
any of the usual more subtle facial expressions of joy, coyness, curiosity,
surprise, fear, anger, or attentiveness.
The child often is apathetic; staring, weak cry, poor muscle tone, weak rooting
and grasping reactions to attempts to feed, and low spontaneous motility are
commonly observed. Excessive sleep and a rather generalized lack of interest in
the environment are frequent manifestations of the disorder.
Often such infants are noticed by a pediatrician because of failure to thrive
physically Since these infants frequently do not receive well-baby care, the
reason for the
visit to the pediatrician may be a complicating physical illness, usually infectious,
or an associated feeding problem (e.g., rumination) or injury. The head
circumference is generally normal, and failure to gain weight, if present, is
disproportionately greater than the failure (if any) to gain in length.
The diagnosis of Reactive Attachment Disorder of Infancy or Early Childhood
can be made only in the presence of clear evidence of grossly pathogenic care.
This frequently requires either a home visit, observation of the spontaneous
emotional and social interaction between the caregiver and the infant during both
feeding and non-feeding periods, or reports from other observers. Parental
reports may not be reliable, particularly when there is suspected child abuse The
pathogenic care may include persistent disregard of the child's basic emotional
needs for comfort, stimulation, and affection. For example, the caregiver may be
overly harsh, or consistently ignore the child. Some caregivers may persistently
disregard the child's physical needs, failing to feed the child adequately, or to
protect the child from physical danger or assault (including sexual abuse).
Repeated and frequent changes of the primary caregiver so that stable
attachments are not possible may also be an etiologic factor.
It is pathognomonic of this disorder that, except in cases of extreme neglect
with consequent severe physical complications (e.g., starvation, dehydration, or
other intercurrent physical complications that can cause death before therapeutic
measures can take hold), the clinical picture can be substantially improved by
adequate care (Such care need not be provided by a single person to be
effective; it can include hospitalization, for example.) Such a therapeutic response
is ultimate confirmation of the diagnosis.
Associated features. Feeding disturbances may be present, in particular,
rumination, regurgitation, and vomiting. Such disturbances may be related to
psychosocial deprivation and may, in turn, be a central factor in malnutrition.
There may be sleep disturbances, and hypersensitivity to touch and sound.
Age at onset. By definition, the age at onset is before age five. Beyond this
age, children do not develop this clinical picture in response to grossly pathogenic
care. The diagnosis can be made as early as in the first month of life.
Course, impairment, and complications. If care remains grossly
inadequate, severe malnutrition, intercurrent infection, and death can occur. As
noted above, however, the disorder is reversible with appropriate treatment and
does not recur if affectionate and developmentally appropriate care is provided,
preferably by a primary caregiver.
Predisposing factors. All factors that interfere with early emotional
attachment of the child to a primary caregiver can predispose to this disorder. In
terms of the caregiver, these include: severe depression, isolation and lack of
support systems, obsessions of infanticide that make the caregiver stay away
from the infant, impulse-control difficulties, and extreme deprivation or abuse
during the caregiver's own childhood.
Babies that are �difficult" or very lethargic may frustrate the caregiver
excessively and discourage appropriate caregiver behavior. Other factors that
predispose to the disorder are lack of affectionate body-to-body contact during
the first weeks of life, such as a prolonged period in an incubator or other early
separations from a caring adult.
Prevalence, sex ratio, and familial pattern. No information.
Differential diagnosis. The diagnosis of Reactive Attachment Disorder of
Infancy or Early Childhood is not made if the disturbance in social relatedness is
attributed to either Mental Retardation or a Pervasive Developmental
Disorder, such as Autistic Disorder.
Children with a variety of severe neuralgic abnormalities, such as
deafness, blindness, profound multisensory defects, major central nervous
system disease, or severe chronic physical illness, may have very specific
needs and few means of satisfying them, and thus may suffer minor secondary
attachment disturbances However, markedly disturbed social relatedness is
generally not present.
ln psychosocial dwarfism there may also be apathy, parental neglect, and
disappearance of symptoms with hospitalization. However, in psychosocial
dwarfism there rarely is a history of grossly pathogenic care.
(Diagnostic Criteria for Reactive Attachment Disorder of Infancy or Early
Childhood)
A. Markedly disturbed social relatedness in most contexts, beginning
before the age of five, as evidenced by either (1) or (2);
(1)persistent failure to initiate or respond to most social interactions
(e.g., in infants, absence of visual tracking and reciprocal play, lack of
vocal imitation or playfulness, apathy, little or no spontaneity; at later
ages, lack of or little curiosity and social interest)
(2)indiscriminate sociability, e.g., excessive familiarity with relative
strangers by making requests and displaying affection
B. The disturbance in A is not a symptom of either Mental Retardation or a
Pervasive Developmental Disorder, such as Autistic Disorder.
C. Grossly pathogenic care, as evidenced by at least one of the following:
(1) persistent disregard of the child's basic emotional needs for comfort,
stimulation, and affection. Examples: overly harsh punishment by
caregiver; consistent neglect by caregiver.
(2) persistent disregard of the child's basic physical needs, including
nutrition, adequate housing, and protection from physical danger and
assault (including sexual abuse)
(3) repeated change of primary caregiver so that stable attachments are not
possible, e.g., frequent changes in foster parents
D. There is a presumption that the care described in C is responsible for the
disturbed behavior in A; this presumption is warranted if the disturbance in A
began following the pathogenic care in C.
Page 16
Adoption World Main Site
The essential feature of this disorder is severe subjective distress regarding inability to integrate aspects of the self into a relatively coherent and acceptable sense of self. There is uncertainty about a variety of issues relating to identity, including long-term goals, career choice, friendship patterns, sexual orientation and behavior, religious identification, moral value systems, and group loyalties. These symptoms last at least three months and result in impairment in social or occupational (including academic) functioning. The disturbance does not occur exclusively during the course of another mental disorder, such as a Mood Disorder, Schizophrenia, or Schizophreniform Disorder; the disturbance is not sufficiently pervasive and persistent to warrant the diagnosis of Borderline Personality Disorder.
The uncertainty regarding long-term goals may be expressed as inability to choose or adopt a life pattern, for example, one dedicated to material success, or service to the community, or even some combination of the two. Conflict regarding career choice may be expressed as inability to decide on a career or as inability to pursue an apparently chosen occupation. Conflict regarding friendship patterns may be expressed in an inability to decide the kinds of people with whom to be friendly and the degree of intimacy to permit. Conflict regarding values and loyalties may include concerns about religious identification, patterns of sexual behavior, and moral issues. The person experiences these conflicts as irreconcilable aspects of his or her personality and, as a result, fails to perceive himself or herself as having a coherent identity. Frequently the disturbance is epitomized by the person's asking, 'Who am I?"
Associated features. Mild anxiety and depression are common and are usually related to inner preoccupations rather than external events. Self-doubt and doubt about the future are usually present, and take the form of either difficulty in making choices or impulsive experimentation. Negative or oppositional patterns are often chosen in an attempt to establish an independent identity distinct from family or other close people. Such attempts may include transient experimental phases of widely divergent behavior as the person "tries on" various roles.
Age at onset. The most common age at onset is late adolescence, when people generally become detached from their family value systems and attempt to establish independent identities. As value systems change, this disorder may also appear in young adulthood, or even in middle age, if a person begins to question earlier life decisions.
Course. Frequently there is a phase with acute onset, which either resolves over a period of time or becomes chronic. In other instances the onset is more gradual. If the disorder begins in adolescence, it is usually resolved by the mid-20s. If it becomes chronic, however, the person may be unable to make a career commitment, or may fail to form lasting emotional attachments, with resulting frequent shifts in jobs, relationships, and career directions.
Impairment. The degree of impairment varies. Usually there is some interference in both occupational (including academic) and social functioning, with deterioration in friendships and family relationships
Complications. Educational achievement and work performance below that appropriate to the person's intellectual ability may result from this disorder
Prevalence. No information. The disorder is apparently more common now than several decades ago, perhaps because today there are more options regarding values, behavior, and life-styles and more conflict between adolescent peer values and parental or societal values.
Predisposing factors, sex ratio, and familial pattern. No information.
Differential diagnosis. Normal conflicts associated with maturing, such as �adolescent turmoil" or "middle-age crisis," are usually not associated with severe distress and impairment in occupational or social functioning. Nevertheless, if the criteria are met, the diagnosis of Identity Disorder should be given regardless of the person's developmental stage.
In Schizophrenia, Schizophreniform Disorder, and Mood Disorder, there frequently are marked disturbances in identity, but these diagnoses preempt the diagnosis of Identity Disorder.
In Borderline Personality Disorder, identity disturbances are only one of several important areas of disturbance, and there is often considerable mood disturbance. If the disturbance is sufficiently pervasive and persistent to warrant the diagnosis of Borderline Personality Disorder, then that diagnosis preempts the diagnosis of Identity Disorder. What appears initially to be Identity Disorder may later turn out to have been an early manifestation of one of the disorders noted above.
(Diagnostic Criteria for Identity Disorder)
A. Severe subjective distress regarding uncertainty about a variety of issues relating to identity, including three or more of the following:
(1) long-term goals
(2) career choice
(3) friendship patterns
(4) sexual orientation and behavior
(5) religious identification
(6) moral value systems
(7) group loyalties
B. Impairment in social or occupational (including academic) functioning as a result of the symptoms in A.
C. Duration of the disturbance of at least three months.
D. Occurrence not exclusively during the course of a Mood Disorder or of a psychotic disorder, such as Schizophrenia.
E. The disturbance is not sufficiently pervasive and persistent to warrant the diagnosis of Borderline Personality Disorder.
Reactive Attachment Disorder of Infancy or Early Childhood
The essential feature of this disorder is markedly disturbed social relatedness in most contexts that begins before the age of five and is not due to Mental Retardation or a Pervasive Developmental Disorder, such as Autistic Disorder. The disturbance in social relatedness is presumed to be due to grossly pathogenic care that preceded the onset of the disturbance.
The disturbance may take the form of either persistent failure to initiate or respond in an age-expected manner to most social interactions or (in an older child) indiscriminate sociability, e.g., excessive familiarity with relative strangers, as shown by making requests and displaying affection. Some severe forms of this disorder, in which there is lack of weight gain and motor development, have been called "failure to thrive or "hospitalism."
Infants with this disorder present with poorly developed social responsiveness. Visual tracking of eyes and faces and responding to the caregiver's voice may not be established by two months of age; attention, interest, and gaze reciprocity may be absent. At four to five months, the infant may fail to express pleasure by smiling, participate in playful, simple games with the caregiver or observer, or attempt vocal and visual reciprocity (e.g., turn his or her head toward the side from which the voice of the caregiver or observer comes). At six to ten months, the infant may fail to reach out when he or she is to be picked up, reach spontaneously for the caregiver, crawl toward the caregiver, establish visual or vocal communication with the caregiver, begin to imitate the caregiver, or display any of the usual more subtle facial expressions of joy, coyness, curiosity, surprise, fear, anger, or attentiveness.
The child often is apathetic; staring, weak cry, poor muscle tone, weak rooting and grasping reactions to attempts to feed, and low spontaneous motility are commonly observed. Excessive sleep and a rather generalized lack of interest in the environment are frequent manifestations of the disorder.
Often such infants are noticed by a pediatrician because of failure to thrive physically Since these infants frequently do not receive well-baby care, the reason for the visit to the pediatrician may be a complicating physical illness, usually infectious, or an associated feeding problem (e.g., rumination) or injury. The head circumference is generally normal, and failure to gain weight, if present, is disproportionately greater than the failure (if any) to gain in length.
The diagnosis of Reactive Attachment Disorder of Infancy or Early Childhood can be made only in the presence of clear evidence of grossly pathogenic care. This frequently requires either a home visit, observation of the spontaneous emotional and social interaction between the caregiver and the infant during both feeding and non-feeding periods, or reports from other observers. Parental reports may not be reliable, particularly when there is suspected child abuse The pathogenic care may include persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection. For example, the caregiver may be overly harsh, or consistently ignore the child. Some caregivers may persistently disregard the child's physical needs, failing to feed the child adequately, or to protect the child from physical danger or assault (including sexual abuse). Repeated and frequent changes of the primary caregiver so that stable attachments are not possible may also be an etiologic factor.
It is pathognomonic of this disorder that, except in cases of extreme neglect with consequent severe physical complications (e.g., starvation, dehydration, or other intercurrent physical complications that can cause death before therapeutic measures can take hold), the clinical picture can be substantially improved by adequate care (Such care need not be provided by a single person to be effective; it can include hospitalization, for example.) Such a therapeutic response is ultimate confirmation of the diagnosis.
Associated features. Feeding disturbances may be present, in particular, rumination, regurgitation, and vomiting. Such disturbances may be related to psychosocial deprivation and may, in turn, be a central factor in malnutrition. There may be sleep disturbances, and hypersensitivity to touch and sound.
Age at onset. By definition, the age at onset is before age five. Beyond this age, children do not develop this clinical picture in response to grossly pathogenic care. The diagnosis can be made as early as in the first month of life.
Course, impairment, and complications. If care remains grossly inadequate, severe malnutrition, intercurrent infection, and death can occur. As noted above, however, the disorder is reversible with appropriate treatment and does not recur if affectionate and developmentally appropriate care is provided, preferably by a primary caregiver.
Predisposing factors. All factors that interfere with early emotional attachment of the child to a primary caregiver can predispose to this disorder. In terms of the caregiver, these include: severe depression, isolation and lack of support systems, obsessions of infanticide that make the caregiver stay away from the infant, impulse-control difficulties, and extreme deprivation or abuse during the caregiver's own childhood.
Babies that are �difficult" or very lethargic may frustrate the caregiver excessively and discourage appropriate caregiver behavior. Other factors that predispose to the disorder are lack of affectionate body-to-body contact during the first weeks of life, such as a prolonged period in an incubator or other early separations from a caring adult.
Prevalence, sex ratio, and familial pattern. No information.
Differential diagnosis. The diagnosis of Reactive Attachment Disorder of Infancy or Early Childhood is not made if the disturbance in social relatedness is attributed to either Mental Retardation or a Pervasive Developmental Disorder, such as Autistic Disorder.
Children with a variety of severe neuralgic abnormalities, such as deafness, blindness, profound multisensory defects, major central nervous system disease, or severe chronic physical illness, may have very specific needs and few means of satisfying them, and thus may suffer minor secondary attachment disturbances However, markedly disturbed social relatedness is generally not present.
ln psychosocial dwarfism there may also be apathy, parental neglect, and disappearance of symptoms with hospitalization. However, in psychosocial dwarfism there rarely is a history of grossly pathogenic care.
(Diagnostic Criteria for Reactive Attachment Disorder of Infancy or Early Childhood)
A. Markedly disturbed social relatedness in most contexts, beginning before the age of five, as evidenced by either (1) or (2);
(1)persistent failure to initiate or respond to most social interactions (e.g., in infants, absence of visual tracking and reciprocal play, lack of vocal imitation or playfulness, apathy, little or no spontaneity; at later ages, lack of or little curiosity and social interest)
(2)indiscriminate sociability, e.g., excessive familiarity with relative strangers by making requests and displaying affection
B. The disturbance in A is not a symptom of either Mental Retardation or a Pervasive Developmental Disorder, such as Autistic Disorder.
C. Grossly pathogenic care, as evidenced by at least one of the following:
(1) persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection. Examples: overly harsh punishment by caregiver; consistent neglect by caregiver.
(2) persistent disregard of the child's basic physical needs, including nutrition, adequate housing, and protection from physical danger and assault (including sexual abuse)
(3) repeated change of primary caregiver so that stable attachments are not possible, e.g., frequent changes in foster parents
D. There is a presumption that the care described in C is responsible for the disturbed behavior in A; this presumption is warranted if the disturbance in A began following the pathogenic care in C.