The Dissociative
Disorders
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process
A Presentation for the Students of Ohio University
Heritage College of Osteopathic Medicine
Kendall L. Stewart, MD, MBA, DFAPA
December 2, 2011
1I
intend to outline a practical process that will assist you in diagnosing and treating these dramatic patients.
let me know how successful I was on your evaluation form and on Facebook.
2Please
Why does this matter?
• These dramatic disorders are
fairly common, and they are
challenges for those who care
for them.
• The essential features include a
disruption in the integrated
functions of
–
–
–
–
Consciousness,
Memory,
Identity, or
Perception.
• These disturbances may be
sudden, gradual, transient or
chronic.
1This
• After mastering the information
in this presentation, you will be
able to
– Specify the diagnostic criteria
for each of the disorders in this
category,
– Describe how the typical
patient with Dissociative
Identity Disorder (DID)—or
Multiple Personality Disorder
(MPD)—presents,
– Outline a preliminary
treatment plan for DID
patients1,2, and
– Discuss some of the formidable
treatment challenges in these
cases.
diagnosis remains controversial.
was trained in Augusta with “The Three Faces of Eve,” and Athens, Ohio is a hotbed of “Multiples.”
3You can see the real Chris Sizemore on YouTube.
2I
What diagnoses are included in the
Dissociative Disorders category?
•
•
•
•
•
Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Depersonalization Disorder
Dissociative Disorder NOS
What are the diagnostic criteria for
Dissociative Amnesia?
• Cannot recall important personal information—usually of
a traumatic or stressful nature—and too extensive to be
explained by ordinary forgetfulness
• Not due to
–
–
–
–
–
–
–
Dissociative Identity Disorder
Dissociative Fugue
Somatization Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Substance use
Neurological or General Medical Condition
• Causes significant impairment in social or occupational
functioning1,2,3
1Dissociation
is a common phenomenon.
hypnosis and “freeway hypnosis.”
3Dissociation commonly occurs in religious rituals.
2Consider
What are the diagnostic criteria for
Dissociative Fugue?
• Sudden, unexpected travel away from home or
work and the inability to recall one’s past1
• Confusion about personal identity or partial or
complete assumption of a new identity
• Not due to something else
• Causes significant distress or impairment in
social or occupational functioning
1Let
me tell you about a retired physician who “ran away” to Huntington.
What are the diagnostic criteria for
Dissociative Identity Disorder?
• The presence of two or more distinct identities or
personalities (each with its own relatively
enduring pattern of perceiving, relating to, and
thinking about the environment and self)
• At least two of these identities recurrently take
control of the person’s behavior1
• Inability to recall important information that
cannot be explained by ordinary forgetfulness
• Not due to something else
• (Significant impairment is assumed)
1One
of my patient’s personalities called me precisely at 3 AM several nights in a row.
What are the diagnostic criteria for
Depersonalization Disorder?1
• Persistent or recurring perceptions of
feeling detached from one’s mental
processes or body (feeling like one is in a
dream)
• Reality testing remains intact
• Not due to something else
• Causes significant distress or impairment
in social or occupational functioning
1I
have never made this diagnosis; I always see it as a symptom of anxiety.
How can you keep these patients
straight?
No
Memory loss?
Yes
Altered sense
of self or reality?
Travel to
another place?
Depersonalization
Disorder
No
Yes
Evidence of
more than
one identity?
Dissociative
Fugue
No
Yes
Dissociative
Amnesia
Dissociative
Identity Disorder
What is the biological basis of the
Dissociative Disorders?1
• Neuroanatomical,
neurophysiological and
neurochemical processes are
being clarified.
• The hippocampus plays a central
role.
• Neurotransmitters play key roles
in short-term and long-term
memory.
• Learning is often state dependent.
• Memory of a traumatic event is
encoded during that event and
may be difficult or impossible to
recall outside that context.
1
Kaplan & Sadock, 2003
What treatments are indicated and
what challenges may appear?
•
•
•
•
•
Dissociative Amnesia
• Cognitive therapy may be helpful in patients with a history of trauma
• Hypnosis may play a helpful role in modulating arousal.
• Medication is not helpful.
• Group therapy may offer support, education and insight.
Dissociative Fugue
• These patients are best treated with supportive therapy.
• Impulse control issues usually emerge as the repressed conflicts emerge.
Dissociative Identity Disorder
• Intensive psychotherapy is the treatment of choice.
• Therapeutic curiosity can make this condition much worse.
• Medication may be helpful for symptom relief.
Depersonalization Disorder
• These patients are often refractory to psychotherapy and medication.
Dissociative Disorder NOS
Where can you learn more?
•
•
•
•
•
•
•
•
•
•
American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April
2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
•
•
•
•
•
•
•
Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice here.
Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by
the Substance Abuse and Mental Health Services Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
StewartK@somc.org
KendallLStewartMD@yahoo.com
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Sarah Ann Flaherty, DO
OUCOM 2003
Kevin Kammler, DO
OUCOM 1993
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