DISSOCIATIVE DISORDER

   Loss of unitary sense of self as a single human being with a single basic personality Arises as a defense mechanism Contradictory representations of the self, which conflict with each other, are kept in separate compartments

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Types: Dissociative Amnesia 2.

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Dissociative Fugue Dissociative Identity DO Depersonalization DO

Dissociative Amnesia

   Characterized by inability to remember information, usually related to stressful or traumatic event Cannot be explained by ordinary forgetfulness, the ingestion of substances, or a general medical condition Dissociative phenomena is limited to amnesia

Epidemiology

  Women, young adults Usually associated with stressful and traumatic events; domestic settings

Etiology

  Learning is state dependent: memory of a traumatic event is laid down during an event, and the emotional state may be so extraordinary that it is hard for the affected person to remember information learned during that state Psychoanalytic approach: defense mechanism, a way to deal with an emotional conflict or an external stressor

Diagnosis

  Forgotten information is usually of a traumatic or stressful nature Not due to a general medical condition or ingestion of a substance

Clinical Features

    History: precipitating emotional trauma charged with painful emotions and psychological conflict Onset: often abrupt Depression and anxiety: common predisposing factors and seen in MSE Amnesia may provide a primary or secondary gain

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Forms: Localized amnesia: most common; loss of memory for a short time (a few hours to a few days) Generalized amnesia: loss of memory for a whole lifetime of experience Selective amnesia: failure to recall some but not all the events that occurred during a short time

Differential Diagnosis

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Medical history, PE, lab work-up, psych history, MSE Dementia/delirium Postconcussion amnesia Epilepsy Transient global amnesia Other mental disorder

Course and Prognosis

 Symptoms usually terminate abruptly and recovery is generally complete

Treament

   Drug-assisted interviews to help patients recover their forgotten memories Hypnosis: means to relax to recall what has been forgotten Psychotherapy: to help patients incorporate the memories into their conscious state

Dissociative Fugue

  Characterized by sudden and unexpected travel away from home or work, associated with an inability to recall the past and with confusion about a person’s personal identity or with adoption of a new identity Old and new identities do not alternate

Etiology

    Withdraw from emotionally painful experiences Predisposed Dos: mood DO, PDs Psychosocial factors: marital, financial, occupational, war-related stressors Others: depression, suicide attempts, organic Dos, hx of substance abuse, head trauma

Diagnosis and Clinical Features

     Confused about his or her identity or assume a new identity Sudden onset Wander in a purposeful way Have complete amnesia for their past lives and associations Generally unaware that they have forgotten anything

Diagnostic Criteria:

A.

B.

The predominant disturbance is sudden, unexpected travel away from home or one’s customary place of work, with inability to recall one’s past.

Confusion about personal identity or assumption of a new identity (partial or complete).

C. The disturbance does not occur exclusively during the course of dissociative identity disorder and is not due to the direct physiological effects of a substance or a general medical condition.

D. The symptoms cause clinical significant distress or impairment in social, occupational, or other important areas of functioning.

Differential Diagnosis

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Dissociative amnesia Dementia/delirium Complex partial seizure Malingering Medications Alcoholic blackout

Course and Prognosis

   Brief, hours to days Generally, recovery is spontaneous and rapid Recurrences are possible

Treatment

  Psychiatric interview, drug-assisted interview, hypnosis TOC: expressive-supportive psychodynamic psychotherapy

Dissociative Identity DO

   Multiple personality disorder The most severe and chronic Characterized by the presence of two or more distinct personalities within a single person

Epidemiology

      Female:Male = 5-9:1 Maybe underreported in men Most common in late adolescence and young adults Mean age at diagnosis = 30 years Frequently coexists with other mental Dos Suicide attempts are common

Etiology

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Four types of causative factors: A traumatic life event A vulnerability for the disorder to develop Environmental factors Absence of external support

Diagnosis and Clinical Features

     Amnestic component At least 2 distinct personality states Not due to a general medical condition or substances Host personality - depressed or anxious Subordinate personality - childlike

Diagnostic Criteria:

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The presence of 2 or more distinct identities or personality states.

At least 2 of these identities or personality states recurrently take control of the person’s behavior.

Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

The disturbance is not due to the direct physiological effects of a substance or a general medical condition.

Signs of Multiplicity:

    Reports of time distortions, lapses and discontinuities.

Being told of behavioral episodes by others that are not remembered by the patient.

Being recognized by others or called by another name by people whom the patient does not recognized.

Notable changes in the patient’s behavior reported by a reliable observer.

   Other personalities are elicited under hypnosis or during amobarbital interviews.

Use of the word “we” in the course of the interview.

Discovery of writings, drawings or other productions or objects among the patient’s personal belongings that are not recognized or cannot be accounted for.

   Headaches Hearing voices originating from within and not identified as separate.

History of severe emotional or physical trauma as a child.

Differential Diagnosis

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Dissociative amnesia Schizophrenia Bipolar mood disorder Borderline PD Malingering Complex partial seizure

Course and Prognosis

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In children: trance-like symptoms, depressive sxs, amnestic periods, hallucinatory voices, disavowel of behaviors, changes in abilities, suicidal or self-injurious behaviors 2 symptom patterns in female adolescents: Chaotic life Withdrawal and childlike behaviors

    The earlier onset, the worse prognosis Level of impairment: moderate to severe Recovery is generally incomplete Individual personalities may have their own separate mental disorders

Treatment

  Insight-oriented psychotherapy Hypnotherapy and drug-assisted interviewing

Depersonalization DO

  Characterized by recurrent or persistent feelings of detachment from the body or mind.

Episodes are ego-dystonic

Epidemiology

    Transient depersonalization: 70% of population F (2X) > M Rarely found in persons over 40 yo Mean age of onset = 16 years

Etiology

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Psychological: emotional trauma, anxiety, depression, sunbstances Neurological: epilepsy, brain tumor, sensory deprivation Systemic diseases: endocrine disorders of the thyroid and pancreas

Diagnosis and Clinical Features

       Persistent episodes of depersonalization Intact reality testing Significant distress and impairment Central characteristic: quality of unreality and estrangement Usually with anxiety Doubling phenomena Reduplicative paramnesia or double orientation

Differential Diagnosis

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Depressive disorder Schizophrenia Brain tumor Seizure

Course and Prognosis

   Often appear suddenly Onset = 15-30 years Tends to be chronic

Treatment

 Treat the underlying cause

Dissociative DO NOS

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Dissociative Trance DO: single or episodic alterations in consciousness that are limited to particular locations or cultures E.g. highway hypnosis, automatic writing, crystal gazing, mediium

2. Ganser’s syndrome: voluntary production of severe psychiatric symptoms may occur in schizophrenia, depressive DO, toxic states, paresis, ROH-use DO, factitious DO - major predisposing factor: existence of severe PD

3. Brainwashing: states of dissociation that occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion (e.g. brainwashing, thought reform, or indoctrination while captive)