DSN-IV (The Diagnostic and Statistical Manual of 'Normal' Disorders)

Disorders Usually First Evident in Infancy, Childhood, or Adolescence

667.00 Pseudo-Simultaneous Awareness Disorder (pseudomultignosis)
(formerly Awareness Oscillation Disorder)

Diagnostic Features

The essential features of Pseudo-Simultaneous Awareness Disorder (pseudomultignosis, formerly Awareness Oscillation Disorder) are abnormal awareness oscillation (Criterion A), and resulting internal disturbances characterised by illusion of simultaneous awareness and absence of related sensory overload during the course of the disturbance (Criterion B). The disturbance involves stimuli from multiple senses, or multiple stimuli within the same sense, so does not occur solely within the context of synaesthesia or related conditions in which a single stimulus evokes multiple sensory responses (Criterion C). The disturbance is severe enough to cause marked distress or significant impairment in social or occupational functioning (Criterion D). The disturbance is not the result of a general medical condition (such as Seizure Disorders) or to the direct physiological effects of a substance (Criterion E).

Abnormal awareness oscillation is rapid switching or oscillation between two or more modes of conscious awareness. These modes of awareness can be sensory (e.g. some combination of smell, touch, taste, hearing, and sight) or social (e.g. awareness of self and awareness of others). A mild degree of awareness oscillation is normal, and it becomes abnormal at the point when the rate of oscillation is so rapid that the illusion of simultaneous awareness is created.

Illusion of simultaneous awareness is the sensation that one is truly aware of more than one mode of awareness at once, instead of oscillating rapidly between experiences. This experience may or may not be believed by the person to be a real experience. Examples include feeling that one is processing the sight of a cat and the sound of a miaow at the same time, feeling that one is processing two different people's voices and words at the same time, or feeling that one is processing self-awareness and awareness of other people at the same time. If this illusion is believed, then delusional or transient-delusional may be specified, depending on the duration and quality of the delusion.

Sensory overload is a state which can occur because of over-intense sensory input or over-rapid awareness oscillation. Sensory overload can also result in a similar experience to illusion of simultaneous awareness. However, unlike the illusion of simultaneous awareness, sensory overload has a quality of confusion and loss of awareness. Therefore, if all symptoms are experienced during sensory overload, the awareness component is lacking. However, if symptoms are sometimes experienced without direct association to sensory overload, diagnosis is still possible.

The abnormal awareness oscillation and illusion of simultaneous awareness can cause marked distress, especially in people who do not experience these symptoms constantly. In people for whom it does not cause marked distress, it can cause deficiencies in social interaction, particularly with people who do not have Pseudo-Simultaneous Awareness Disorder. The illusion of simultaneous awareness can create disorganised speech in the attempt to incorporate too many sensations or people at a time. Such speech is often only understandable to those who have Pseudo-Simultaneous Awareness Disorder, and the substance and expressive content of such speech is often questionable.

Subtypes and Specifiers

The following subtypes may be used to indicate the overall trend of the symptoms in this disorder. The diagnosis of these subtypes is subject to change over time when the disorder has been observed for a longer period of time.

Sensory Type. In this subtype, the predominant disturbance is in the sensory realm.
Social Type. In this subtype, the predominant disturbance is in the social realm.
Combined Type. In this subtype, there is a significant amount of disturbance in both the sensory and social realms.
Unspecified Type. In this subtype, the predominant disturbance is in a realm other than sensory or social.

The following specifiers may be used to indicate the duration and delusional content of the disorder.

With Delusion. This specifier applies when the symptoms of this disorder are accompanied by the belief that the illusion of simultaneous awareness is in fact real, and that the person is not truly oscillating between modes of experience, but experiencing multiple modes of experience at once. This delusion persists constantly despite the person being given logical and persuasive evidence to the contrary.
With Transient Delusion. This specifier applies when the symptoms of this disorder are accompanied by the belief that the illusion of simultaneous awareness is in fact real, and that the person is not truly oscillating between modes of experience, but experiencing multiple modes of experience at once. This delusion is transient, however, and may occur only during the course of symptoms, or may alternate with periods of proper reality-testing.
With Treatment-Responsive False Belief. This specifier applies when the symptoms of this disorder are accompanied by the belief that the illusion of simultaneous awareness is in fact real, and that the person is not truly oscillating between modes of experience, but experiencing multiple modes of experience at once. However, given logical and persuasive evidence to the contrary, the person ceases to believe this. Since a delusion will persist given logical and persuasive evidence to the contrary, this is not a true delusion.
With Self-Awareness. This specifier applies when the symptoms of this disorder may or may not have been originally accompanied by the belief that the illusion of simultaneous awareness is in fact real, and that the person is not truly oscillating between modes of experience, but experiencing multiple modes of experience or once. The person still experiences the illusion of simultaneous awareness but has somehow come to the conclusion that it is an illusion and that there is really another cause for this illusion. Although the perceived cause does not have to be abnormal awareness oscillation, it usually is.
Sporadic Duration. This specifier applies when the symptoms of this disorder occur in a sporadic fashion, such that some of the time the person is experiencing all of the symptoms and some of the time the person is experiencing few to none of the symptoms. Related delusions may be present even when the other symptoms are not.
Chronic Duration. This specifier applies when the symptoms of this disorder occur in a constant or near-constant fashion. Related delusions may or may not be present.

Associated Features and Disorders

Associated descriptive features and mental disorders. Frequently the speech of a person with pseudo-simultaneous awareness disorder is disorganised, bizarre, or manipulative. Such speech often includes attempts to draw a non-affected person into the perceptual world of the affected person, and often fails because the speech is disjointed and nonsensical. If multiple affected persons interact with each other, they may understand each other's speech, but this understanding has little practical value. There may also be a tendency to believe that everyone perceives the world this way, a feature often associated with Neurotypical Disorder.

Pseudo-Simultaneous Awareness Disorder often correlates highly with Neurotypical Disorder. The incidence of Pseudo-Simultaneous Awareness Disorder in people with Neurotypical Disorder is approximately 80% to 90%. However, there are a significant amount of people with Pseudo-Simultaneous Awareness Disorder who do not show symptoms of Neurotypical Disorder. In individuals with Neurotypical Disorder, the course of Pseudo-Simultaneous Awareness Disorder is usually chronic, of mixed type, and often involves delusion and a poor prognosis. In individuals without Neurotypical Disorder, however, the course of Pseudo-Simultaneous Awareness Disorder is usually sporadic and of sensory or social type, or chronic and of sensory type. Such individuals often exhibit the symptoms of this disorder with a high degree of self-awareness and a good prognosis.

Associated laboratory findings. No laboratory findings have been identified that are diagnostic of Pseudo-Simultaneous Awareness Disorder. However, many individuals with Pseudo-Simultaneous Awareness Disorder have been shown to be more reactive to the Social Delusion Pheromone, suggesting a correlation between Pseudo-Simultaneous Awareness Disorder and activity of the Vomeronasal Organs. This also suggests that the Social Delusion Pheromone triggers a quickening of neural impulses that causes a rapid fluctuation between modes of awareness. This could explain the high comorbidity rate with Neurotypical Disorder. Further research must be done before conclusions are drawn.

Specific Culture, Age, and Gender Features

Culturally appropriate manifestations of similar symptoms (e.g. experiences regarded as "transcendent" in the context of a religious ritual, or certain forms of meditation) are not necessarily indicative of Pseudo-Simultaneous Awareness Disorder. An effort should be made to discern whether the person displaying these symptoms participates in such rituals, and whether the symptoms display themselves independently of such rituals or roles related to such rituals.

In children with Pseudo-Simultaneous Awareness Disorder, awareness of this symptoms as abnormal might be completely absent. However, this may change as the child matures, and age should be taken into account during assessment.

Pseudo-Simultaneous Awareness Disorder is equally prevalent among males and females.

Prevalence

Although Pseudo-Simultaneous Awareness Disorder is known to be common, no exact statistics have been obtained regaring prevalence.

Course

The symptoms of Pseudo-Simultaneous Awareness Disorder usually begin in childhood or adolescence. Self-awareness is rare at this period in development. However, there are some children who are aware of their symptoms as abnormal, largely those with sporadic duration of symptoms, and who do not have an additional diagnosis of Neurotypical Disorder. As the child matures and develops, he or she is more likely to develop more awareness of his or her symptoms as abnormal, although often this does not occur.

In rare cases, individuals who previously displayed symptoms of Pseudo-Simultaneous Awareness Disorder may suddenly or gradually experience a decrease or disappearance of symptoms.

Familial Pattern

The rate of Pseudo-Simultaneous Awareness Disorder in first-degree biological relatives of individuals with Pseudo-Simultaneous Awareness Disorder and in first-degree biological relatives of individuals with Neurotypical disorder is higher than that in the general population.

Differential Diagnosis

Pseudo-Simultaneous Awareness Disorder should not be confused with Synaesthesia. Synaesthesia is a perceptual and neurological condition of unknown specific origin that involves the perception of a single stimulus within multiple sensory modalities. Pseudo-Simultaneous Awareness Disorder involves the illusion of perception and processing of multiple stimuli simultaneously. Pseudo-Simultaneous Awareness Disorder should also be distinguished from Sensory Overload. Sensory Overload most often includes an element of confusion and loss of awareness. In Pseudo-Simultaneous Awareness Disorder there is no such loss of awareness.

Symptoms resembling Pseudo-Simultaneous Awareness Disorder may be experienced in the course certain Seizure Disorders, and Pseudo-Simultaneous Awareness Disorder should only be diagnosed if such symptoms occur outside of the manifestation of aura (a period of disturbance in consciousness or perception before a seizure) or seizures.

The abnormal speech patterns in Pseudo-Simultaneous Awareness Disorder may resemble those in Schizophrenia, and may be differentiated by the fact that, although both patterns of speech appear disorganised or tangential, the speech patterns in Pseudo-Simultaneous Awareness Disorder reflect a rapid connection between multiple modes of awareness, while the speech patterns in Schizophrenia reflect a serious thought disorder.

Pseudo-Simultaneous Awareness Disorder can be distinguished from a Substance-Induced Perceptual Disorder or Substance-Induced Psychotic Disorder by the fact that a substance (e.g. a drug of abuse, a medication, or an exposure to a toxin) is judged to be etiologically related to the disturbance.

Diagnostic Criteria

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The illusion of simultaneous awareness can create disorganised speech in the attempt to incorporate too many sensations or people at a time. Such speech is often only understandable to those who have Pseudo-Simultaneous Awareness Disorder, and the substance and expressive content of such speech is often questionable.