DISSOCIATIVE
DISORDERS
By
SAIMA ZIA
PGY IV
3/31/06
Dissociative Disorders
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Dissociative amnesia
Dissociative fugue
Dissociative identity disorder
Depersonalization disorder
Dissociative disorder NOS
Dissociation
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Is a defense against trauma that
helps persons remove
themselves from trauma as it
occurs & delays the working
through of the trauma
Patients have lost sense of
having one consciousness
Defenses..
Frequently used in all dissociative disorders
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Repression:
Disturbing impulses are blocked from
consciousness
Denial: external reality is ignored
Dissociation:
Separation & independent functioning of 1
group of mental processes from others(mental contents exist in parallel
consciousness)
Dissociative Amnesia DSM IV
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1 or more episodes of inability to recall
important personal information (traumatic
or stressful, that is too extensive to be
explained by ordinary forgetfulness)
Disturbance does not occur during any
other dissociative d/o & not due to direct
effects of a substance or GMC
Symptoms cause clinically significant
distress or impaired social or occupational
,etc functioning
Signs/ symptoms : Amnesia
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Most common type
adolescents / younger adults
Female>male
Abrupt onset, abrupt termination, few reoccurrences’
Pt aware of loss
May be localized (common) or generalized or
selective
May have primary or secondary gain
Alert before and after loss
Stressors: wars/ disasters, emotional trauma,
domestic violence
R/O medical cause
Pt may confabulate or self monitor
Treatment
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Spontaneous recovery
Hypnosis
Drug assisted interview
thiopental (pentothal) / sodium
amobarbital (Amytal) or IV
benzos
Psychotherapy
Dissociative Fugue DSM IV
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Sudden unexpected travel away
from home or ones customary place
of work, with inability to recall one’s
past.
Confusion about personal identity or
assumes new identity (partial or
complete)
Not due to another dd d/o or direct
effects of substances or GMC
Causes significant distress or
impairment in imp areas of
functioning
Fugue…
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Rare, sex & age of onset
variable
Spontaneous, rapid recovery
Recurrences rare
Common after wars/disasters,
emotional stress, heavy alcohol
abuse, medical causes-epilepsy,
head trauma
Can last months-brief if due to
medical cause
Cont..
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Organic fugue states can be
caused by a variety of meds-like
phenothiazines, triozolam,
hallucinogenic drugs,
barbiturates, steroids,etc
Fugue…
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Borderline, histrionic, schizoid
Usually purposeful travel
covering long distances
Unaware of memory loss
Display normal behavior during
fugue
May be perplexed or disoriented
Treatment
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Spontaneous recovery
Hypnosis
Drug assisted interviews
Psychotherapy (expressive
supportive psychodynamic
therapy for healthy adjustment
to stressor)
Differentials
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Dissociative amnesia: no
purposeful travel or new identity
Cognitive d/o: wandering is not
purposeful or complex
Temporal lobe epilepsy: no new
identity is assumed
Malingering: secondary gain
Dissociative Identity Disorder
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The presence of 2 or more distinct
identities or personality states (each
with its own pattern of relating to the
environment and self)
At least 2 states recurrently take
control of the persons behavior
Inability to recall important personal
information that is too extensive to
be explained by ordinary
forgetfulness
Not due to substances (alcohol) or
GMC (complex partial seizures)
DID
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Most severe and chronic dissociative d/o
Original personality is generally amnestic
of & unaware of the other personalities
May be aware of certain aspects of other
personalities
Each may have their own set of memories
name & description, age, sex or race
May have different physiologic
characteristics: e.g. diff eyeglass
prescriptions
Psychometric testing: i.e. diff IQ scorings or
Psychiatric disorders: mood or personality
disorders
Signs / symptoms
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Reports of time distortions, lapses &
discontinuities
Being told of behavioral episodes by others
that are not remembered by pt
Being recognized by others or called by
another name the pt does not recognize
Notable changes in patient’s behavior
reported by a reliable observer; or pt may
call him / herself by a different name or
refer to him / herself in the 3rd person, use
of “we” during the interview
DID
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Discovery of writings, drawings etc. or
objects (identification cards, clothing)
among the patients belongings that are not
recognized by the patient or cannot be
accounted for
Headaches
Hearing voices originating from within and
not separate
Hx of witnessing a death or trauma or
severe emotional, sexual or physical abuse
as a child (incest) usually before 5yrs),poor
support
DID
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Sudden transition from one personality to
another
Unlimited number of personalities
Each distinct personality dominates the
persons behavior & thinking when it is
present
Not very rare as previously thought-5%
psych pts
Adolescent / young adults,1st degree
relatives
Female > male
Difficult to Rx, incomplete recovery
Psychodynamics
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Severe psychological & physical
abuse (mostly sexual) in childhood
leads to a profound need to distance
ones self from horror and pain.
This leads to an unconscious
splitting off of different aspects of the
original personality, with each
personality expressing a necessary
emotion or state (rage, sexuality,
competence, playfulness) that the
original personality dare not express
DID
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During abuse, the child attempts to
protect him / herself from trauma by
dissociating from the terrifying acts,
becoming in essence another person
who could not be subject to abuse or
who is not experiencing abuse
In children the symptoms are not
attributable to imaginary playmates
or other fantasy play
The dissociative selves become a
long term, ingrained method of self
protection from emotional threats
DID-Steps in therapy
Establish strong therapeutic alliance and a safe
atmosphere
Have consistency ,clear communication,
Set boundaries with most readily reached personalities
and agreements not to abandon therapy
Hx gathering from the diff alters and understanding
their reasons for creation and persistence-their
problems, concerns and how they function,
Responding to all alters in the same way
Pacing therapy to avoid re-traumatizing pt as buried
trauma resurfaces
Facilitate integrating the personalities into one by
pressing for collaboration and cooperation among
the alters
Teaching new coping skills
Treatment
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Treat co-morbid disorders
Intense insight-oriented
psychotherapy-attempt to integrate
split personalities into one whole
Help pt understand that original
reasons for dissociation
(overwhelming rage, fear &
confusion secondary to abuse) no
longer exist
& affect states can be expressed by
one whole person without the self
being destroyed
Defined
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Depersonalization;
is feeling that the body or
personal self is strange
Derealization;
perception of objects in the
external world are strange and
unreal
Depersonalization
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A. Persistent or recurrent experiences of
feeling detached from & as if one is an
outside observer of, one’s mental
processes or body (e.g. like feeling like one
is in a dream)
B. During the episode, reality testing
remains intact
C. Causes significant distress or
impairment in social, occupational
functioning
D. Not due to another mental d/o,
,dissociative d/o, substances or GMC
(temp lobe epilepsy)
Signs / Symptoms
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Onset usually sudden, chronic
course
Ego dystonic
Rare over 40, females > males
Severe stress, anxiety &
depression predispose to
depersonalization episodes
Depersonalization
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Distortion in sense of time and
space
Parts of the body (limbs) may
seem unreal, detached or
strange
Causes could be substance
abuse, (benzos, THC, alcohol)
epilepsy, endocrine d/os,
emotional trauma.
Phenomenon:
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Doubling-Pts feel consciousness is
outside the body, a few feet
overhead
Hemi-depersonalization; half the
body is unreal or does not exist,
(parietal lobe)
Double orientation; Pts believe they
are in 2 places at the same time
Pts are very aware of their disturbed
sense of consciousness
Treatment
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Rx anxiety
With anxiolytic’s, supportive and
insight oriented therapy
As anxiety is reduced, episodes
of depersonalization decrease
differentials
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Neurological-epilepsy, migraine,
brain tumors,
Toxic / metabolic-hypothyroidism,
hyperventilation, hypoglycemia
Psych-schizo, conversion d/o,
anxiety d/o, OCD etc
Normal- Exhaustion, boredom,
emotional shock
Hemi-depersonalization-(usually R
parietal) focal brain lesion.
Dissociaive d/o nos
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Dissociative symptoms are
predominant, but the clinical picture
does not meet full criteria for a
dissociative d/o
1. Ganser’s syndrome; Prisoners
with personality d/os giving
approximate answers to questionseg. 2+2=5 or talking past the point
usually with other symptoms like
amnesia, perceptual disturbances .
Dissociative d/o nos
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Derealization unaccompanied by
depersonalization
Dissociative states (brainwashing,
thought reform," mind control” due
to intense coercive persuasion while
captive with terrorists or in cults)
Dissociative trance d/o-in certain
cultures amok (rage reaction),
possessions, mediums in
dissociative states where spirits take
over , automatic writing
END