Kk&s Ch.20 Dissociative Disorders

Front 1

The DSM-IV-TR dissociative disorders are

Back 1

dissociative identity disorder, depersonalization disorder, dissociative amnesia, dissociative fugue, and dissociative disorder not otherwise specified (NOS).

Front 2

essential feature of dissociative amnesia is

Back 2

an inability to recall important personal information,
usually of a traumatic or stressful nature, that is too extensive to be explained by normal forgetfulness.

Front 3

Dissociative amnesia, as defined by DSM-IV-TR, has been reported in approximately ? percent of the general population.

Back 3

6%

Front 4

WIth Dissociative amnesia, is there a difference in incidence between men and women?

Back 4

No

Front 5

Which personality ds is consistently reported in patients with dissociative amnesia?

Back 5

none

Front 6

What? has been shown to predispose individuals to develop acute amnesia during traumatic circumstances

Back 6

a prior personal or
family history of

SOMATOFORM or
dissociative symptoms

Front 7

In wartime cases, as in other forms of combat-related posttraumatic disorders, the most important variable in the development of dissociative symptoms, however, appears to be ?

Back 7

the intensity of combat.

Front 8

Causes of organic amnestic disorders include (list 6)

Back 8

Korsakoff's psychosis, cerebral vascular accident (CVA), postoperative amnesia, postinfectious amnesia, anoxic amnesia, and transient global amnesia

Front 9

Features of transient global amnesia?

Back 9

In transient global amnesia, however, there is the sudden onset of complete anterograde amnesia and learning abilities;

pronounced retrograde amnesia;

preservation of memory for personal identity;

anxious awareness of memory loss with repeated, often perseverative, questioning;

overall normal behavior;

lack of gross neurological abnormalities in most cases;

and rapid return of baseline cognitive function, with a persistent short retrograde amnesia.

Front 10

Transient global amnesia age ? risk factors?

Back 10

The patient usually is older than 50 years of age

shows risk factors for cerebrovascular disease, although epilepsy and migraine have been etiologically implicated in some cases.

Front 11

A patient who presents to psychiatric attention asking to recover repressed memories as a chief complaint most likely has a ? or ?. (Few, some, many) of these individuals actually do not describe bona fide amnesia when carefully questioned, but are often insistent that they must have been abused in childhood to explain their unhappiness or life dysfunction.

Back 11

A patient who presents to psychiatric attention asking to recover repressed memories as a chief complaint most likely has a factitious disorder or has been subject to suggestive influences. Most of these individuals actually do not describe bona fide amnesia when carefully questioned, but are often insistent that they must have been abused in childhood to explain their unhappiness or life dysfunction.

Front 12

DDX of dissociative amnesia

Back 12

Ordinary forgetfulness
D's: dementia, delirium, depression, other dissociative disorders
Amnestic Ds
Anxiety: ASD, PTSD
Substance Related
Somatization Ds
Factitious Ds
Malingering
Neurologic: Postraumatic amnesia, Transient global amnesia, Amnesia realted to seizure disorders

Front 13

Tx of dissociative amnesia?

Back 13

CT
Hypnosis
Rx: pharmacologic interviews with iv amobarbital/diazepam
Group Tx for PTSD/Pt's with childhood abuse

Front 14

The DSM-IV-TR identifies the essential feature of depersonalization as

Back 14

the persistent or recurrent feeling of detachment or estrangement from one's self

Front 15

The individual may report feeling like an automaton or as if in a dream or watching himself or herself in a movie

According to DSM-IV-TR, “there may be a sensation of being an outside observer of one's mental processes, one's body, or parts of one's body.”

Often, the patient has a sense of an absence of control over his or her actions.

Dx?

Back 15

Depersonalization Disorder

Front 16

Transient experiences of depersonalization and derealization are extremely (uncommon or common) in normal and clinical populations.

Back 16

common

Front 17

Depersonalization disorders are the ? most commonly reported psychiatric symptom after ?

Back 17

They are the third most commonly reported psychiatric symptoms, after depression and anxiety.

Front 18

Depersonalization Disorder:
One survey found a 1-year prevalence of ? percent in the general population

Back 18

19%

Front 19

GMC's/Substances associated with Depers Ds?

Back 19

It is common in seizure patients and migraine sufferers; they can also occur with use of psychedelic drugs, especially marijuana, lysergic acid diethylamide (LSD), and mescaline; and less frequently as a side effect of some medications, such as anticholinergic agents.

They are also common after mild to moderate head injury, wherein little or no loss of consciousness occurs, but they are significantly less likely if unconsciousness lasts for more than 30 minutes.

Front 20

Other situations that GMC's/Substances associated with Depersonalization?

Back 20

They are also common after life-threatening experiences, with or without serious bodily injury.

They have been described after certain types of meditation, deep hypnosis, extended mirror or crystal gazing, and sensory deprivation experiences.

Front 21

Depersonalization is found two to four times more in (sex) than in (sex)

Back 21

>in women than in men

Front 22

Traditional psychodynamic formulations have emphasized the disintegration of the ? or have viewed depersonalization as an affective response in defense of the ?.

Back 22

ego

Front 23

Several studies of accident victims find as much as ? percent of those with a life-threatening experience report at least transient depersonalization during the event or immediately thereafter.

Back 23

60% (most)

Front 24

What neuorotransmitter associated with depersonalization disorder and why?

Back 24

The association of depersonalization with
migraines and
marijuana, its generally
favorable response to selective serotonin reuptake inhibitor (SSRI) drugs, and the

increase in depersonalization symptoms seen with the depletion of L-tryptophan, a serotonin precursor, point to serotoninergic involvement.

Front 25

Depersonalization is the primary dissociative symptom elicited by the drug-challenge studies described in the section on neurobiological theories of dissociation. These studies strongly implicate the ? subtype of the ? receptor as central to the genesis of depersonalization symptoms

Back 25

NMDA receptor of the glutamate receptor

Front 26

Depersonalization DDX

Back 26

Depersonalization can result from a medical condition or neurological condition,
Substances: intoxication or withdrawal from illicit drugs; as a side effect of medications;
Anxiety: panic attacks, phobias, PTSD, or acute stress disorder,
Psychosis: schizophrenia, or another dissociative disorder.

Front 27

Depersonalization Disorder onset?

Back 27

Mean age of onset is thought to be in late adolescence or early adulthood in most cases.

Front 28

Tx of depersonalization disorder

Back 28

Rx: SSRi's but ... Two recent, double-blind, placebo-controlled studies, however, found no efficacy for fluvoxetine (Luvox) and lamotrigine, respectively, for depersonalization disorder

Psychotherapy and stress management ... but many do not have robust response

Front 29

? is described as sudden, unexpected travel away from home or one's customary place of daily activities, with inability to recall some or all of one's past

This is accompanied by confusion about personal identity or even the assumption of a new identity

Back 29

dissociative fugue (Table 20-5)

Front 30

underlying cause of most fugue episode

Back 30

Traumatic circumstances (i.e., combat, rape, recurrent childhood sexual abuse, massive social dislocations, natural disasters), leading to an altered state of consciousness dominated by a wish to flee, are the underlying cause of most fugue episodes.

Front 31

Dissociative fugue and gender bias?

Back 31

No

Front 32

Tx of Dissociative Fugue

Back 32

Eclectic Psychodynamic Psychotherapy
Hypnotherapy
Rx facilitated interviews
Family Tx

Front 33

Tx to avoid? and recommendation instead?

Back 33

Complete suppression of new identity ... seek integration/fusion of identities

Traumatic experiences, memories, cognitions, identifications, emotions, strivings, or self-perceptions, or a combination of these, have become so conflicting and, yet, so peremptory that the person can resolve them only by embodying them in an alter identity. The therapeutic goal in such cases is neither suppression of the new identity nor fascinated explication of all its attributes. As in dissociative identity disorder, the clinician should appreciate the importance of the psychodynamic information contained within the alter personality state and the intensity of the psychological forces that necessitated its creation. In these cases, the most desirable therapeutic outcome is fusion of the identities, with the person working through and integrating the memories of the experiences that precipitated the fugue.

Front 34

previously called multiple personality disorder, “is characterized by the presence of two or more distinct identities or personality states that recurrently take control of the individual's behavior accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.”

Dx?

Back 34

Dissociative Identity Disorder

Front 35

DID
> in women or men?

Back 35

women .. 5 or 9 to 1

Front 36

Dissociative identity disorder is strongly linked to severe experiences of

Back 36

early childhood trauma, usually maltreatment.

Front 37

The rates of reported severe childhood trauma for child and adult patients with dissociative identity disorder range from ? percent of cases.

Back 37

85 to 97

Front 38

? and ? abuse are the most frequently reported sources of childhood trauma

Back 38

Physical and sexual

Front 39

A number of common dimensions underlie traumatic sequelae.
They are

Back 39

Affect dysregulation
Impaired Impulse Control
High Anxiety
Identity diffusion
Also associated with
Eating Ds
Somatization Ds
Low pain threshold

Front 40

Approximately 70 percent of patients with dissociative identity disorder have been shown to meet diagnostic criteria for ? by DSM-IV-TR criteria

Back 40

PTSD

Front 41

Of patients with dissociative identity disorder, 40 to 60 percent also meet diagnostic criteria for ?, and many others meet diagnostic criteria for

Back 41

somatization disorder, and many others meet diagnostic criteria for undifferentiated somatoform disorder, somatoform pain disorder, or conversion disorder, or a combination of these.

Front 42

(few, some, most) patients with dissociative identity disorder meet criteria for a mood disorder, usually one of the depression spectrum disorders.

Back 42

Most

Front 43

Is DID associated with OCD?

Back 43

Yes
OCD symptoms commonly have a posttraumatic quality: checking repeatedly to be sure that no one can enter the house or the bedroom, compulsive washing to relieve a feeling of being dirty because of abuse, and repetitive counting or singing in the mind to distract from anxiety over being abused, for example.

Front 44

Tx of DID?

Back 44

Psychotherapy
Hypnosis

Front 45

Recent research suggests that ?, may be helpful for PTSD nightmares.

Back 45

α1-adrenergic antagonist, prazosin (Minipress)

Front 46

Case reports suggest that aggression may respond to ? in some individuals if EEG abnormalities are present

Back 46

carbamazepine

Front 47

Open-label studies suggest that ? may be helpful for amelioration of recurrent self-injurious behaviors in a subset of traumatized patients.

Back 47

naltrexone (ReVia)

Front 48

Rx? for overwhelming anxiety and intrusive PTSD symptoms in patients with dissociative identity disorder.

Back 48

s, such as risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), and olanzapine (Zyprexa), may be more effective and better tolerated than typical neuroleptics

Front 49

For some patients, ECT is helpful in ameliorating refractory mood disorders ECT (does or does not)worsen dissociative memory problems.

Back 49

does not

Front 50

Which type of therapy has shown NOT to be helpful for DID?

Back 50

Patients with dissociative identity disorder usually have a negative outcome to self-help groups or 12-step groups for incest survivors. A variety of problematic issues occur in these settings, including intensification of PTSD symptoms because of discussion of trauma material without clinical safeguards, exploitation of the patient with dissociative identity disorder by predatory group members, contamination of that patient's recall by group discussions of trauma, and a feeling of alienation even from these other reputed sufferers of trauma and dissociation.

Front 51

? disorder is manifest by a temporary, marked alteration in the state of consciousness or by loss of the customary sense of personal identity without the replacement by an alternate sense of identity

Back 51

Dissociative trance

Front 52

Under hypnosis or during psychotherapy, a patient may recover a memory of a painful experience or conflict—particularly of sexual or physical abuse—that is etiologically significant. When the repressed material is brought back to consciousness, the person not only may recall the experience but may relive it, accompanied by the appropriate affective response (a process called ?)

Back 52

abreaction

Front 53

If the event recalled never really happened but the person believes it to be true and reacts accordingly, it is known as ?.

Back 53

false memory syndrome

Front 54

? is a poorly understood condition characterized by the giving of approximate answers (paralogia) together with a clouding of consciousness, and frequently accompanied by hallucinations and other dissociative, somatoform, or conversion symptoms.

Back 54

Ganser syndrome

Front 55

Ganser > in men or women?

Back 55

Men 2: 1 women

Front 56

Neurological examination may reveal what Ganser called ?, for example, a nonneurological analgesia or shifting hyperalgesia.

Back 56

hysterical stigmata

Front 57

Tx of Gansers Syndrome (and what not to do)

Back 57

Confrontation or interpretations of the patient's approximate answers are not productive, but exploration of possible stressors may be helpful.