DISSOCIATIVE DISORDER

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DISSOCIATIVE DISORDER
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• 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
• Dissociative Fugue
• Dissociative Identity DO
• Depersonalization DO

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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

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Epidemiology

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

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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

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Diagnosis

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

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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

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Differential Diagnosis

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

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Course and Prognosis

• Symptoms usually terminate abruptly and recovery
  is generally complete

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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

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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 persons personal identity or with
  adoption of a new identity
• Old and new identities do not alternate

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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

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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

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Diagnostic Criteria

1. The predominant disturbance is sudden, unexpected
   travel away from home or ones customary place of
   work, with inability to recall ones past.
2. Confusion about personal identity or assumption
   of a new identity (partial or complete).

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• 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.

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Differential Diagnosis

1. Dissociative amnesia
2. Dementia/delirium
3. Complex partial seizure
4. Malingering
5. Medications
6. Alcoholic blackout

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Course and Prognosis

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

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Treatment

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

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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

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Epidemiology

• FemaleMale 5-91
• 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

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Etiology

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

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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

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Diagnostic Criteria

1. The presence of 2 or more distinct identities or
   personality states.
2. At least 2 of these identities or personality
   states recurrently take control of the persons
   behavior.
3. Inability to recall important personal
   information that is too extensive to be explained
   by ordinary forgetfulness.
4. The disturbance is not due to the direct
   physiological effects of a substance or a general
   medical condition.

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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 patients behavior
  reported by a reliable observer.

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• 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 patients
  personal belongings that are not recognized or
  cannot be accounted for.

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• Headaches
• Hearing voices originating from within and not
  identified as separate.
• History of severe emotional or physical trauma as
  a child.

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Differential Diagnosis

1. Dissociative amnesia
2. Schizophrenia
3. Bipolar mood disorder
4. Borderline PD
5. Malingering
6. Complex partial seizure

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Course and Prognosis

• 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

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• 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

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Treatment

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

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Depersonalization DO

• Characterized by recurrent or persistent feelings
  of detachment from the body or mind.
• Episodes are ego-dystonic

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Epidemiology

• Transient depersonalization 70 of population
• F (2X) gt M
• Rarely found in persons over 40 yo
• Mean age of onset 16 years

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Etiology

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

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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

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Differential Diagnosis

• Depressive disorder
• Schizophrenia
• Brain tumor
• Seizure

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Course and Prognosis

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

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Treatment

• Treat the underlying cause

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Dissociative DO NOS

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

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• 2. Gansers 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

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• 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)