Psychiatry 2 Dissociative Disorders

AY 2021-2022 Renato D. Obra, MD, FPPA, FPCAM, MM (IHSM)

1st Bimonthly 9/28/2021

B. The symptoms cause clinically significant distress or

OUTLINE impairment in social occupational or other important
I. Introduction areas of functioning.
II. Dissociative Amnesia C. The disturbance is not attributable to the physiological
III. Depersonalization Disorders effects of a substance. (e.g alcohol or other drug of
IV. Dissociative Identity Disorders abuse, a medication) or neurological or other medical
V. Other Specified Or Unspecified Dissociative Disorder condition (eg Partial Complex Seizures, Transient Global
amnesia, Sequelae or a closed injury/ Traumatic Brain
injury other neurological condition.
INTRODUCTION D. The disturbance is not better explained by dissociative
identity disorder, posttraumatic stress disorder, acute
● Dissociation
stress disorder, somatic symptoms disorder or major or
→ Unconscious defense mechanism
mild neurocognitive disorder
→ Segregation of any group of mental or behavioral processes
from the rest of the persons psychic activity
TYPES OF DISSOCIATIVE AMNESIA
● Localized amnesia
→ Inability to recall events related to circumscribed period of
DISSOCIATIVE DISORDERS
time
● Involves disruption in one or more mental functions
● Selective amnesia
→ Memory
→ Ability to remember some but not all events occuring during
→ Identity
a circumscribed period of time
→ Perception
● Generalized amnesia
→ Consciousness
→ Failure to recall one’s entire life
→ Motor behavior
● Continuous amnesia
● Sudden or gradual
→ Failure to occur successive events as they occur
● Transient or chronic
● Systematized amnesia
● Signs and symptoms are often caused by psychological trauma
→ Failure to remember a category of information, all memories
relating to ones family to a particular person
DISSOCIATIVE AMNESIA
● Main feature: Inability to recall important personal information
→ Traumatic or stressful nature
EPIDEMIOLOGY
● 2 to 6 percent of the general population
→ Too extensive to be explained by normal forgetfulness
● No known difference between men and women
● Reported in late adolescence and adulthood
● Does not result from;
→ Difficult to assess in preadolescent children
→ Direct physiological effects of a substance
→ Neurological
→ Other general medical condition ETIOLOGY
● Acute dissociative amnesia
→ Psychosocial environment that is massively conflictual
PSYCHOSEXUAL FACTORS
▪ Patient experiencing intolerable emotions of shame, guilt,
● Sexuality depends on four interrelated psychosexual factors:
despair rage and desperation.
→ sexual identity
▪ Result from conflicts over unacceptable urges or impulses
→ gender identity
− Intense sexual
→ sexual orientation
− Suicidal
→ sexual behavior.
− violent compulsions
● These factors affect personality, growth, development, and
● Traumatic experiences
functioning. Sexuality is something more than physical sex,
→ Physical abuse
coital or noncoital, and something less than all behaviors
→ Sexual abuse
directed toward attaining pleasure.
→ Betrayal trauma
→ Influence the processing and remembering of the event
DIAGNOSTIC CRITERIA FOR DISSOCIATIVE AMNESIA

A. An inability to recall important autobiographical

DIAGNOSIS AND CLINICAL FEATURES
information usually of a traumatic or stressful nature that A. CLASSICAL PRESENTATION
is inconsistent with ordinary forgetting. ● Overt, Florid, Dramatic, Clinical, Disturbance
a. Note: Dissociative amnesia most often consists ● May present with:
of localized or selective amnesia for a specific → Intercurrent somatoform or conversion symptoms
event or events → Alterations in consciousness
→ Depersonalization
→ Derealization

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 → Trance states DEPERSONALIZATION DISORDER
→ Spontaneous age regression ● Depersonalization
→ Ongoing anterograde dissociative amnesia → Persistent or recurrent feeling of detachment or
→ Depression and suicidal ideation estrangement from one’s self
● No single personality or antecedent history → Feeling of automation
→ Family history predispose individuals to develop acute ● Derealization
amnesia during traumatic circumstances → Refers to feelings of unreality or of being detached from
one’s environment.
B. NON CLASSIC PRESENTATION → Patient may describe his or her perception of the outside
● Depression or mood swings world as lacking lucidity and emotional coloring, as though
● Substance abuse dreaming or dead
● Sleep disturbance ● sense of unreality in one's environment or sense of self
● Somatoform symptoms
● Anxiety DIAGNOSTIC CRITERIA FOR DEPERSONALIZATION
● Panic AND DEREALIZATION
● Suicidal acts
● Self mutilating impulses A. A.The presence of persistent or recurrent experiences of
● Violent outburst behavior depersonalization, derealization, or both:
● Eating problems 1. Depersonalization: Experiences of unreality,
● Interpersonal problems detachment, or being an outside observer with
respect to one's thoughts, feelings, sensations,
body, or actions (e.g., perceptual alterations,
DIFFERENTIAL DIAGNOSIS distorted sense of time, unreal or absent self,
● Ordinary forgetfulness and nonpathological amnesia emotional and physical numbing).
→ Benign and unrelated to stressful events 2. Derealization: Experiences of unreality or
● Dementia delirium and amnestic disorder due to medical detachment with respect to surroundings (e.g.,
conditions individuals or objects are experienced as
● Postraumatic amnesia unreal, dreamlike, fogey, lifeless)
→ Caused by brain injury B. During the depersonalization or derealization
● Transient Global Amnesia experiences, reality testing remains intact.
→ Sudden onset of complete anterograde amnesia and C. The symptoms cause clinically significant distress or
learning abilities impairment in social, occupational, or other important
→ Pronounced retrograde amnesia areas of functioning.
● Dissociative Identity Disorder D. The disturbance is not attributable to the physiological
● Acute Stress Disorder, Post traumatic stress disorder and effects of a substance (e.g., a drug of abuse, medication)
somatic symptom disorder or another medical condition (e.g., seizures).
● Malingering and factitious amnesia E. The disturbance is not better explained by another
mental disorder, such as schizophrenia, panic disorder,
COURSE AND PROGNOSIS major depressive disorder, acute stress disorder,
● Frequently spontaneously resolves posttraumaticstress disorder or another dissociative
→ Removed from traumatic or overwhelming circumstances disorder.
● Develop chronic forms of generalized continuous or severe
localized amnesia EPIDEMIOLOGY
● Extremely common
TREATMENT ● Third most commonly reported psychiatric symptoms, after
● Cognitive Therapy depression and anxiety.
→ Identifying the specific cognitive distortions ● Women (4x) > men
● Hypnosis ● Common in the following conditions
→ Used to contain modulate and titrate the intensity of → seizure patients and migraine sufferers
symptoms → certain types of meditation, deep hypnosis, extended mirror
→ to facilitate controlled recall of dissociated memories or crystal gazing, and sensory deprivation experiences.
→ Used to contain modulate and titrate the intensity of → after life-threatening experiences (with or without serious
symptoms bodily injury)
→ to facilitate controlled recall of dissociated memories
● Somatic Therapies ETIOLOGY
→ Sodium Amobarbital ● Psychodynamic
→ Thiopental → disintegration of the ego
→ Oral Benzodiazepines ▪ an affective response in defense of the ego.
→ Amphetamines → overwhelming painful experiences or conflictual impulses as
● Group Psychotherapy triggering events.
→ Group sessions ● Traumatic Stress
→ Supportive interventions by the group members or the group → evoked by stress and fatigue
therapist or both. → history of significant trauma
▪ accident victims (life threatening experience)

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 − transient depersonalization during the event or ● Cause clinically significant distress or impairment in social,
immediately thereafter. occupational, or other important areas of functioning.
● Neurobiological Theories
● associated with migraines and marijuana ETIOLOGY
● serotoninergic involvement ● Traumatic circumstances
→ response to SSRIs uptake, → combat
→ depletion of L-tryptophan (depersonalization) → rape
● Primary dissociative symptom elicited by the drug-challenge → recurrent childhood sexual abuse
studies → massive social dislocations
→ 1 N-methyl-D-aspartate(NMDA) subtype of the glutamate → natural disasters
receptor ● leads to an altered state of consciousness dominated by a wish
▪ central in the pathogenesis of depersonalization to flee
symptoms ● Psychological trauma is not present at the onset of the fugue
episode.
DIAGNOSIS AND CLINICAL FEATURES
● Distinct components comprise the experience of EPIDEMIOLOGY
depersonalization ● More common during natural disasters, wartime, or times of
→ sense of bodily changes ● major social dislocation and violence
→ duality of self as observer and actor ● Most cases describe men, primarily in the military.
→ being cut off from others ● Adults
→ being cut off from one's own emotions. ●
● Patients have great difficulty expressing what they are feeling
→ express their subjective suffering with banal phrases, such
DIAGNOSIS AND CLINICAL FEATURES
● Duration - minutes to months
as "I feel dead." "Nothing seems real," or "I'm standing
● Some report multiple fugues
outside of myself,
● Waking fugue
→ nightmares being terminated by a patient running to another
COURSE AND PROGNOSIS par of the house or runs outside.
● Commonly remits spontaneously ● Post fugue symptoms
● May have an episodic, relapsing and remitting, or chronic → perplexity, confusion, trance-like behaviors,
course. depersonalization, derealization, and conversion symptoms
● Chronic depersonalization → amnesia
→ severe impairment in occupational, social, and personal → generalized dissociative amnesia.
functioning. ● Symptoms associated with lesser dissociation state
● Mean age of onset → mood disorder symptoms, intense suicidal ideation, and
→ late adolescence or early adulthood. PTSD or anxiety disorder symptoms.
● Children or adolescent fugue
TREATMENT → limited than adults in their ability to travel
● SSRI antidepressants → may be brief and involve only short distances.
→ fluoxetine (Prozac)
● Antidepressants COURSE AND PROGNOSIS
● Mood stabilizers ● Relatively brief, lasting from hours to days.
● Typical and atypical neuroleptics ● Refractory dissociative amnesia (rare),
● Anticonvulsants ● Recurrent fugues presenting with an episode of dissociative
● Psychotherapy fugue.
→ psychodynamic
→ cognitive
→ cognitive-behavioral
TREATMENT
● Psychotherapy
→ hypnotherapeutic
→ eclectic, psychodynamically oriented
→ supportive.
→ focuses on helping the patient recover memory for identity
● Stress management strategies, distraction techniques,
and recent experience.
reduction of sensory stimulation, relaxation training, and
● Hypnotherapy (adjunctive)
physical exercise
● Pharmacologically facilitated interviews (adjunctive)
● Medical treatment
DISSOCIATIVE FUGUE → injuries sustained during the fugue
● Subtype (specifier) of dissociative amnesia. ● Family treatment and social service interventions
● Can be seen in patients with both dissociative amnesia and → If family, sexual, occupational, or legal problems that were
dissociative identity disorder. part of the original matrix that generated the fugue episode
● Sudden, unexpected travel away from home or one's customary
place of daily activities, with inability to recall some or all of DISSOCIATIVE IDENTITY DISORDER
one's past.
→ accompanied by confusion about personal identity or even
● Multiple personality disorder
the assumption of a new identity.
● It is characterized by the presence of two or more distinct
● Not due to the direct physiological effects of a substance or a
identities or personality states.
general medical condition.
→ alters, self-states, alter identities, or parts

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 → differ from one another in that each presents as having its COURSE AND PROGNOSIS
own pattern of perceiving, relating to, and thinking about the ● Patients with undiagnosed or untreated dissociative identity
environment and self disorder die by suicide or as a result of their risk-taking
→ its own personality. behaviors.
● Paradigmatic dissociative psychopathology ● Poor prognosis
→ amnesia, fugue, depersonalization, derealization. → in patients with comorbid organic, mental disorders,
psychotic disorders and severe medical illnesses.
ETIOLOGY → refractory substance abuse and eating disorders
● Strongly linked to severe experiences of early childhood trauma, → significant antisocial personality features
usually maltreatment. → current criminal activity
→ 85 to 97 percent of cases. → ongoing perpetration of abuse
→ Physical and sexual abuse → current victimization, with refusal to leave abusive
● Genetic factors relationships.
→ preliminary studies have not found evidence of a significant → Repeated adult traumas with recurrent episodes of acute
genetic contribution stress disorder

DIAGNOSIS AND CLINICAL FEATURES TREATMENT

● Presence of two or more distinct personality states ● Psychotherapy
● Posttraumatic stress disorder symptoms ● Cognitive Therapy
→ Intrusive symptoms ● Hypnosis
→ Hyperarousal → can often alleviate self-destructive impulses or reduce
→ Avoidance and numbing symptoms symptoms, such as flashbacks, dissociative hallucinations,
● Somatic symptoms and passive-influence experiences.
→ Conversion and pseudoneurological symptoms ● Psychopharmacological Interventions
→ Seizure-like episodes → Antidepressant medications - reduction of depression and
→ Pain symptoms stabilization of mood
→ Headache, abdominal, musculoskeletal, pelvic pain → SSRI, tricyclic, and monamine oxidase (MAO)
→ Psychophysiological symptoms or disorders antidepressants, ß- blockers, clonidine (Catapres),
→ Asthma and breathing problems anticonvulsants, and Benzodiazepines - reducing intrusive
→ Perimenstrual disorders symptoms, hyperarousal, and anxiety
→ Irritable bowel syndrome → Prazosin (Minipress)- may be helpful for PTSD nightmares.
→ Gastroesophageal reflux disease → carbamazepine (Tegretol) - against aggression
→ Somatic memory → naltrexone (ReVia) - amelioration of recurrent self-injurious
● Affective symptoms behaviors
→ Depressed mood, dysphoria, or anhedonia → Neuroleptics- for overwhelming anxiety and intrusive PTSD
→ Brief mood swings or mood lability symptoms
→ Suicidal thoughts and attempts of self-mutilation → Clozapine - chronically ill patient
→ Helpless and hopeless feelings ● Electroconvulsive Therapy
● Obsessive-compulsive symptoms → helpful in ameliorating refractory mood disorders
→ Ruminations about trauma → does not worsen dissociative memory problems.
→ Obsessive counting, singing
→ Arranging OTHER SPECIFIED OR UNSPECIFIED
→ Washing DISSOCIATIVE DISORDER
→ Checking
● Brainwashing
→ identity disturbance due to prolonged and intense coercive
DIAGNOSIS AND CLINICAL FEATURES persuasionRecovered Memory Syndrome
● Mental Status ● Dissociative Trance Disorder
→ To rule out schizophrenia, borderline personality disorder, or → temporary, marked alteration in the state of consciousness
of outright malingering. → loss of the customary sense of personal identity without the
● Memory and Amnesia Symptoms replacement by an alternate, sense of identity
→ significant gaps in autobiographical memory, especially for ● Recovered Memory Syndrome
childhood events. → a repressed material is brought back to consciousness, the
● Dissociative Alterations in Identity person not only may recall the experience but may relive it,
→ first clinical manifestation is odd first-person plural or third- accompanied by the appropriate affective response
person singular or plural self-references. (abreaction).
→ Patients may suddenly change the way in which they refer to ● Ganser Syndrome
others, for example, "the son" instead of "my son." → characterized by the giving of approximate answers
● Other Associated Symptoms (paralogia) together with a clouding of consciousness
→ rapid mood swings → frequently accompanied by hallucinations and other
▪ not a true cyclic mood disorder. dissociative, somatoform, or conversion symptoms.
→ PTSD symptoms of anxiety, disturbed sleep, and dysphoria → The symptom of passing over (vorbeigehen) the correct
and mood disorder symptoms. answer for a related, but incorrect one, is the hallmark of
→ Obsessive--compulsive personality traits and intercurrent Ganser syndrome.
obsessive-_compulsive disorder (OCD) symptoms

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