dissociative disorders

1: DISSOCIATIVE DISORDERS By SAIMA ZIA PGY IV 3/31/06

3: Dissociation 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

4: Defenses.. Frequently used in all dissociative disorders 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)

5: Dissociative Amnesia DSM IV 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

6: Signs/ symptoms : Amnesia Most common type adolescents / younger adults Female>male Abrupt onset, abrupt termination, few re-occurrences� 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

7: Treatment Spontaneous recovery Hypnosis Drug assisted interview thiopental (pentothal) / sodium amobarbital (Amytal) or IV benzos Psychotherapy

8: Dissociative Fugue DSM IV 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

9: Fugue� 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

10: Cont.. Organic fugue states can be caused by a variety of meds-like phenothiazines, triozolam, hallucinogenic drugs, barbiturates, steroids,etc

11: Fugue� Borderline, histrionic, schizoid Usually purposeful travel covering long distances Unaware of memory loss Display normal behavior during fugue May be perplexed or disoriented

12: Treatment Spontaneous recovery Hypnosis Drug assisted interviews Psychotherapy (expressive supportive psychodynamic therapy for healthy adjustment to stressor)

13: Differentials 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

14: Dissociative Identity Disorder 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)

15: DID 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

16: Signs / symptoms 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

17: DID 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

18: DID 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

19: Psychodynamics 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

20: DID 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

21: 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

22: Treatment 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

23: Defined Depersonalization; is feeling that the body or personal self is strange Derealization; perception of objects in the external world are strange and unreal

24: Depersonalization 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)

25: Signs / Symptoms Onset usually sudden, chronic course Ego dystonic Rare over 40, females > males Severe stress, anxiety & depression predispose to depersonalization episodes

26: Depersonalization 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.

27: Phenomenon: 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

28: Treatment Rx anxiety With anxiolytic�s, supportive and insight oriented therapy As anxiety is reduced, episodes of depersonalization decrease

29: differentials 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.

30: Dissociaive d/o nos 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 questions-eg. 2+2=5 or talking past the point usually with other symptoms like amnesia, perceptual disturbances .

31: Dissociative d/o nos 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

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