Download DISSOCIATIVE DISORDER

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

Types:
1. Dissociative Amnesia
2. Dissociative Fugue
3. Dissociative Identity DO
4. 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

Forms:
1. Localized amnesia: most common; loss
of memory for a short time (a few hours
to a few days)
2. Generalized amnesia: loss of memory for
a whole lifetime of experience
3. Selective amnesia: failure to recall some
but not all the events that occurred
during a short time
Differential Diagnosis

1.
2.
3.
4.
5.
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. The predominant disturbance is
sudden, unexpected travel away from
home or one’s customary place of
work, with inability to recall one’s
past.
B. 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
1. Dissociative amnesia
2. Dementia/delirium
3. Complex partial seizure
4. Malingering
5. Medications
6. 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

1.
2.
3.
4.
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:
A. The presence of 2 or more distinct
identities or personality states.
B. At least 2 of these identities or personality
states recurrently take control of the
person’s behavior.
C. Inability to recall important personal
information that is too extensive to be
explained by ordinary forgetfulness.
D. 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
1. Dissociative amnesia
2. Schizophrenia
3. Bipolar mood disorder
4. Borderline PD
5. Malingering
6. Complex partial seizure
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:
1. Chaotic life
2. 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
1. Psychological: emotional trauma,
anxiety, depression, sunbstances
2. Neurological: epilepsy, brain tumor,
sensory deprivation
3. 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
1. Depressive disorder
2. Schizophrenia
3. Brain tumor
4. Seizure
Course and Prognosis
 Often appear suddenly
 Onset = 15-30 years
 Tends to be chronic
Treatment
 Treat the underlying cause
Dissociative DO NOS
1. Dissociative Trance DO: single or
episodic alterations in consciousness
that are limited to particular
locations or cultures
1. 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)