Dissociative Disorders

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Dissociative Disorder

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disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment

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What is dissociation a defense against?

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trauma that involves the segregation of mental or behavioral processes from the rest of the person’s psychic activity

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in dissociative amnesia, what can patient not recall

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an important personal memory, usually one that is stressful or traumatic (It is not a cognitive issue)

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In dissociative amnesia, what do forgotten memories usually relate to

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relate to day-to-day information that is routine part of conscious awareness (who a person is)
• Patient does have capacity to learn and remember new information

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in dis. amn, is General cognitive functioning and language capacity usually intact

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yes

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gen. amn. onset

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abrupt

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HX dissociative amnesia

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precipitating emotional trauma charged with painful emotions and psychological conflict

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in dis. amn, are patients aware they lost memory

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yes

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Differences between localized, general, and selective amnesia

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– Localized - memory loss for events over short period of time
– Generalized amnesia - loss of memory for a whole lifetime of experiences
– Selective or systematized amnesia - inability to recall some but not all events over a short time

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MC dissociative disorder?

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dissociative amnesia
young, female

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What do you need to R/O with dissociative amnesia

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dementia, delirium, epilepsy, transient global amnesia

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Describe transient global amnesia

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•Associated with anterograde amnesia during the episode
• Patients more upset and concerned about the symptoms
•Patients able to retain personal identity
•Memory loss is generalized
Past remote events recalled better than recent events
•Patients usually have cardiovascular disorders

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HOw do SX of dissociative amnesia terminate

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abruptly

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in diss. amn, why should memories be restored ASAP

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repressed memory may form a nucleus in the unconscious mind where future amnestic episodes may develop

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TX dissociative amnesia

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psychotherapy, pharmacotherapy: • Drug-assisted interviews with short-acting barbiturates, such as Pentothal (thiopental) and Amytal (sodium amobarbital) IV; benzos may be used to help patients recover their forgotten memories

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What is dissociative fugae

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Impulsive, sudden travel away from customary home or work and failure to remember important aspects of previous identity (name, family, occupation). A new identity often is assumed.

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How do you DX fugae? type of memory loss? are they away?

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– Sudden memory loss
– Associated with purposeful, unconfused travel, often for extended periods of time
– Patients lose part or complete memory of past life
– Often unaware of the memory loss

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What happens when they return to their former self?

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they recall the time antedating the fugue
• BUT are amnestic for the period of the fugue itself

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When does fugae often occur?

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• During times of war
• During natural disasters
• As a result of personal crises with intense internal conflict

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fugae psychosocial factors

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• Marital
• Financial
• Occupational
• Wartime stressors

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Predisposing factors fugae

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• Personality disorders: borderline, histrionic, schizoid
• Alcohol abuse
• Mood disorders
• Organic disorders (Esp epilepsy)
• Head trauma

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fugae prognosis? how long does it last? does it persist? recurrences?

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– Brief - hours-days or longer
– Most recover
– Refractory dissociated amnesia may persist
– Recovery spontaneous and rapid
– Recurrences possible

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TX Fugae

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– Psychiatric interviews
– Drug-assisted interviews
– Hypnosis to reveal psychological stressors that precipitated the episode
– Psychotherapy

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What is Dissociative Identity Disorder (Multiple Personality Disorder)

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• A chronic dissociative disorder usually involving a traumatic event, often childhood physical or sexual abuse
• Patients have two or more distinct personalities or identities within themselves, each of which, when present, may dominate the person’s attitudes, behavior, and self-view as though no other personality existed

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DX criteria for dissociative identity disorder

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– Must have two distinct personality states
– Original personality is generally amnestic for and unaware of other personality/personalities

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how many personalities are usually evident at time of DX

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2-3, others come out during TX

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During a personality state, are patients amnestic about other states and events that took place when other personality was dominant

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yes

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epidemiology multiple personality disorder

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adolescence and young adulthood, although symptoms may be present for 5-10 years before diagnosis, 1st degree biologic relatives, 2/3 suicide

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multiple personality disorder prognosis

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– Prognosis is worse the earlier the onset of the disorder
– Most chronic and severe of the dissociative disorders
– Recovery is generally incomplete

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MC comorbid personality disorder with multiple personality disorder

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other dissociative disorders being the most common

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goal of psychotherapy in multiple personality disorder

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reconciliation of disparate, split-off affects by helping patient understand original reasons for the dissociation no longer exists and one whole personality can express all the feeling without the self being destroyed.

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meds for multiple personality disorder

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• Drug-assisted interviewing to obtain hx and identify unrecognized identities
• Antidepressant and anti-anxiety medications useful adjuvants
• Anticonvulsant meds (eg: Tegretol) helpful in some patients

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What is depersonalization disorder

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–Persistent, recurrent episodes of feeling detached from one’s self or body
–Pt reports seems like watching herself in a movie, feeling mechanical, or as if in a dream (dreaming)

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How do patients feel about depersonalization episodes

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–Episodes are ego-dystonic (unwelcomed and uncomfortable)
–Patients recognize the unreality of the symptoms (“I feel like I’m walking around in a dream.”)

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is reality testing intact w/depersonalization disorder

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yes

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Patient’s inner mental processes and external events remain unchanged, yet they no longer what

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appear to have any relation or significance to the person

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Central characteristic of dissociation disorder

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sense of unreality and estrangement

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Other common occurences with depersonalization disorder

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– Distortions of sense of time and space
– Feeling that extremities are too large or too small
– Derealization (sense of strangeness- lack of realness- about external world) common

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T/F Occasional isolated depersonalization episodes are common and occur in 70% of a given population

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T

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Who is depersonalization disorder rarely found in age wise

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>40

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predisposing factors to depersonalization disorder

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• Anxiety
• Depression
• Severe stress
– Could be caused by psychological, neurologic, or systemic disease
– Associated with array of substances- alcohol, barbiturates, benzos, scopolamine, B-adrenergic antagonists, pot, PCP, hallucinogens

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causes of depersonalization disorder

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Migraines, Epilepsy, Hypoparathyroidism, Hypothyroidism, – Various psychiatric diagnoses , – Normal individuals who are bored, shocked, sensory deprived, exhausted

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TX depersonalization disorder

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– Disorder long lasting in more than 50% of cases
– Benzos/SSRI’s may do something. Some recent evidence- Lamictal
– Cognitive behavioral- re-learn feelings and attitudes