DISSOCIATIVE DISSOCIATIVE DISORDERSDISORDERS

By By SAIMA ZIASAIMA ZIA

PGY IVPGY IV3/31/063/31/06

Dissociative DisordersDissociative Disorders

Dissociative amnesiaDissociative amnesia Dissociative fugueDissociative fugue Dissociative identity disorderDissociative identity disorder Depersonalization disorderDepersonalization disorder Dissociative disorder NOSDissociative disorder NOS

DissociationDissociation

Is a defense against trauma that Is a defense against trauma that helps persons remove helps persons remove themselves from trauma as it themselves from trauma as it occurs & delays the working occurs & delays the working through of the traumathrough of the trauma

Patients have lost sense of Patients have lost sense of having one consciousnesshaving one consciousness

Defenses..Defenses..

Frequently used in all dissociative disorders Frequently used in all dissociative disorders

Repression:Repression: Disturbing impulses are blocked from Disturbing impulses are blocked from

consciousnessconsciousness DenialDenial: external reality is ignored: external reality is ignored DissociationDissociation:: Separation & independent functioning of 1 Separation & independent functioning of 1

group of mental processes from others-group of mental processes from others-(mental contents exist in parallel (mental contents exist in parallel consciousness)consciousness)

Dissociative Amnesia DSM IVDissociative Amnesia DSM IV

1 or more episodes of inability to recall 1 or more episodes of inability to recall

important personal information (traumatic important personal information (traumatic or stressful, that is too extensive to be or stressful, that is too extensive to be explained by ordinary forgetfulness)explained by ordinary forgetfulness)

Disturbance does not occur during any Disturbance does not occur during any other dissociative d/o & not due to direct other dissociative d/o & not due to direct effects of a substance or GMCeffects of a substance or GMC

Symptoms cause clinically significant Symptoms cause clinically significant distress or impaired social or distress or impaired social or occupational ,etc functioningoccupational ,etc functioning

Signs/ symptoms : AmnesiaSigns/ symptoms : Amnesia

Most common typeMost common type adolescents / younger adults adolescents / younger adults Female>maleFemale>male Abrupt onset, abrupt termination, few re-Abrupt onset, abrupt termination, few re-

occurrences’occurrences’ Pt aware of lossPt aware of loss May be localized (common) or generalized or May be localized (common) or generalized or

selectiveselective May have primary or secondary gainMay have primary or secondary gain Alert before and after lossAlert before and after loss Stressors: wars/ disasters, emotional trauma, Stressors: wars/ disasters, emotional trauma,

domestic violencedomestic violence R/O medical cause R/O medical cause Pt may confabulate or self monitorPt may confabulate or self monitor

TreatmentTreatment

Spontaneous recoverySpontaneous recovery HypnosisHypnosis Drug assisted interviewDrug assisted interview

thiopental (pentothal) / sodium thiopental (pentothal) / sodium amobarbital (Amytal) or IV amobarbital (Amytal) or IV benzosbenzos

PsychotherapyPsychotherapy

Dissociative Fugue DSM IVDissociative Fugue DSM IV

SuddenSudden unexpected travel away unexpected travel away from home or ones customary place from home or ones customary place of work, with inability to recall one’s of work, with inability to recall one’s past.past.

Confusion about personal identity or Confusion about personal identity or assumes new identity (partial or assumes new identity (partial or complete)complete)

Not due to another dd d/o or direct Not due to another dd d/o or direct effects of substances or GMCeffects of substances or GMC

Causes significant distress or Causes significant distress or impairment in imp areas of impairment in imp areas of functioningfunctioning

Fugue…Fugue…

Rare, sex & age of onset variableRare, sex & age of onset variable Spontaneous, rapid recoverySpontaneous, rapid recovery Recurrences rareRecurrences rare Common after wars/disasters, Common after wars/disasters,

emotional stress, heavy alcohol emotional stress, heavy alcohol abuse, medical causes-epilepsy, abuse, medical causes-epilepsy, head traumahead trauma

Can last months-brief if due to Can last months-brief if due to medical causemedical cause

Cont..Cont..

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

Fugue…Fugue…

Borderline, histrionic, schizoid Borderline, histrionic, schizoid Usually purposeful travel Usually purposeful travel

covering long distancescovering long distances Unaware of memory lossUnaware of memory loss Display normal behavior during Display normal behavior during

fuguefugue May be perplexed or disorientedMay be perplexed or disoriented

TreatmentTreatment

Spontaneous recoverySpontaneous recovery HypnosisHypnosis Drug assisted interviews Drug assisted interviews Psychotherapy (expressive Psychotherapy (expressive

supportive psychodynamic supportive psychodynamic therapy for healthy adjustment therapy for healthy adjustment to stressor)to stressor)

DifferentialsDifferentials

Dissociative amnesia: no Dissociative amnesia: no purposeful travel or new identitypurposeful travel or new identity

Cognitive d/o: wandering is not Cognitive d/o: wandering is not purposeful or complexpurposeful or complex

Temporal lobe epilepsy: no new Temporal lobe epilepsy: no new identity is assumedidentity is assumed

Malingering: secondary gain Malingering: secondary gain

Dissociative Identity DisorderDissociative Identity Disorder

The presence of 2 or more distinct The presence of 2 or more distinct identities or personality states (each identities or personality states (each with its own pattern of relating to the with its own pattern of relating to the environment and self)environment and self)

At least 2 states recurrently take At least 2 states recurrently take control of the persons behaviorcontrol of the persons behavior

Inability to recall important personal Inability to recall important personal information that is too extensive to information that is too extensive to be explained by ordinary be explained by ordinary forgetfulnessforgetfulness

Not due to substances (alcohol) or Not due to substances (alcohol) or GMC (complex partial seizures)GMC (complex partial seizures)

DIDDID

Most severe and chronic dissociative d/oMost severe and chronic dissociative d/o Original personality is generally amnestic of Original personality is generally amnestic of

& unaware of the other personalities & unaware of the other personalities May be aware of certain aspects of other May be aware of certain aspects of other

personalitiespersonalities Each may have their own set of memories Each may have their own set of memories

name & description, age, sex or racename & description, age, sex or race May have different physiologic May have different physiologic

characteristics: e.g. diff eyeglass characteristics: e.g. diff eyeglass prescriptionsprescriptions

Psychometric testing: i.e. diff IQ scorings orPsychometric testing: i.e. diff IQ scorings or Psychiatric disorders: mood or personality Psychiatric disorders: mood or personality

disordersdisorders

Signs / symptomsSigns / symptoms

Reports of time distortions, lapses & Reports of time distortions, lapses & discontinuitiesdiscontinuities

Being told of behavioral episodes by others Being told of behavioral episodes by others that are not remembered by pt that are not remembered by pt

Being recognized by others or called by Being recognized by others or called by another name the pt does not recognizeanother name the pt does not recognize

Notable changes in patient’s behavior Notable changes in patient’s behavior reported by a reliable observer; or pt may reported by a reliable observer; or pt may call him / herself by a different name or call him / herself by a different name or refer to him / herself in the 3refer to him / herself in the 3rdrd person, use person, use of “we” during the interviewof “we” during the interview

DIDDID

Discovery of writings, drawings etc. or Discovery of writings, drawings etc. or objects (identification cards, clothing) objects (identification cards, clothing) among the patients belongings that are not among the patients belongings that are not recognized by the patient or cannot be recognized by the patient or cannot be accounted foraccounted for

HeadachesHeadaches Hearing voices originating from within and Hearing voices originating from within and

not separatenot separate Hx of witnessing a death or trauma or Hx of witnessing a death or trauma or

severe emotional, sexual or physical abuse severe emotional, sexual or physical abuse as a child (incest) usually before 5yrs),poor as a child (incest) usually before 5yrs),poor supportsupport

DIDDID

Sudden transition from one personality to Sudden transition from one personality to anotheranother

Unlimited number of personalitiesUnlimited number of personalities Each distinct personality dominates the Each distinct personality dominates the

persons behavior & thinking when it is persons behavior & thinking when it is presentpresent

Not very rare as previously thought-5% Not very rare as previously thought-5% psych ptspsych pts

Adolescent / young adults,1Adolescent / young adults,1stst degree degree relativesrelatives

Female > maleFemale > male Difficult to Rx, incomplete recoveryDifficult to Rx, incomplete recovery

PsychodynamicsPsychodynamics

Severe psychological & physical Severe psychological & physical abuse (mostly sexual) in childhood abuse (mostly sexual) in childhood leads to a profound need to leads to a profound need to distancedistance ones self from horror and pain. ones self from horror and pain.

This leads to an unconscious This leads to an unconscious splitting off of different aspects of the splitting off of different aspects of the originaloriginal personality, with each personality, with each personality expressing a necessary personality expressing a necessary emotion or state (rage, sexuality, emotion or state (rage, sexuality, competence, playfulness) that the competence, playfulness) that the original personality dare not expressoriginal personality dare not express

DID DID

During abuse, the child attempts to During abuse, the child attempts to protect him / herself from trauma by protect him / herself from trauma by dissociating from the terrifying acts, dissociating from the terrifying acts, becoming in essence another person becoming in essence another person who could not be subject to abuse or who could not be subject to abuse or who is not experiencing abusewho is not experiencing abuse

In children the symptoms are not In children the symptoms are not attributable to imaginary playmates attributable to imaginary playmates or other fantasy playor other fantasy play

The dissociative selves become a The dissociative selves become a long term, ingrained method of self long term, ingrained method of self protection from emotional threatsprotection from emotional threats

DID-Steps in therapyDID-Steps in therapy

Establish strong therapeutic alliance and a safe Establish strong therapeutic alliance and a safe atmosphereatmosphere

Have consistency ,clear communication, Have consistency ,clear communication, Set boundaries with most readily reached personalities Set boundaries with most readily reached personalities

and agreements not to abandon therapyand agreements not to abandon therapyHx gathering from the diff alters and understanding Hx gathering from the diff alters and understanding

their reasons for creation and persistence-their their reasons for creation and persistence-their problems, concerns and how they function,problems, concerns and how they function,

Responding to all alters in the same wayResponding to all alters in the same wayPacing therapy to avoid re-traumatizing pt as buried Pacing therapy to avoid re-traumatizing pt as buried

trauma resurfacestrauma resurfacesFacilitate integrating the personalities into one by Facilitate integrating the personalities into one by

pressing for collaboration and cooperation among pressing for collaboration and cooperation among the altersthe alters

Teaching new coping skillsTeaching new coping skills

TreatmentTreatment

Treat co-morbid disordersTreat co-morbid disorders Intense insight-oriented Intense insight-oriented

psychotherapy-attempt to integrate psychotherapy-attempt to integrate split personalities into one wholesplit personalities into one whole

Help pt understand that original Help pt understand that original reasons for dissociation reasons for dissociation (overwhelming rage, fear & (overwhelming rage, fear & confusion secondary to abuse) no confusion secondary to abuse) no longer exist longer exist

& affect states can be expressed by & affect states can be expressed by one whole person without the self one whole person without the self being destroyedbeing destroyed

DefinedDefined

DepersonalizationDepersonalization;;

is feeling that the body or is feeling that the body or personal self is strangepersonal self is strange

DerealizationDerealization;;

perception of objects in the perception of objects in the external world are strange and external world are strange and unrealunreal

DepersonalizationDepersonalization

A. Persistent or recurrent experiences of A. Persistent or recurrent experiences of feeling detached from & as if one is an feeling detached from & as if one is an outside observer of, one’s mental outside observer of, one’s mental processes or body (e.g. like feeling like one processes or body (e.g. like feeling like one is in a dream)is in a dream)

B. During the episode, reality testing B. During the episode, reality testing remains intactremains intact

C. Causes significant distress or C. Causes significant distress or impairment in social, occupational impairment in social, occupational functioning functioning

D. Not due to another mental D. Not due to another mental d/o, ,dissociative d/o, substances or GMC d/o, ,dissociative d/o, substances or GMC (temp lobe epilepsy)(temp lobe epilepsy)

Signs / SymptomsSigns / Symptoms

Onset usually sudden, chronic Onset usually sudden, chronic coursecourse

Ego dystonicEgo dystonic Rare over 40, females > malesRare over 40, females > males Severe stress, anxiety & Severe stress, anxiety &

depression predispose to depression predispose to depersonalization episodesdepersonalization episodes

DepersonalizationDepersonalization

Distortion in sense of time and Distortion in sense of time and spacespace

Parts of the body (limbs) may Parts of the body (limbs) may seem unreal, detached or seem unreal, detached or strangestrange

Causes could be substance Causes could be substance abuse, (benzos, THC, alcohol) abuse, (benzos, THC, alcohol) epilepsy, endocrine d/os, epilepsy, endocrine d/os, emotional trauma.emotional trauma.

Phenomenon:Phenomenon:

Doubling-Pts feel consciousness is Doubling-Pts feel consciousness is outside the body, a few feet outside the body, a few feet overheadoverhead

Hemi-depersonalization; half the Hemi-depersonalization; half the body is unreal or does not exist, body is unreal or does not exist, (parietal lobe)(parietal lobe)

Double orientation; Pts believe they Double orientation; Pts believe they are in 2 places at the same timeare in 2 places at the same time

Pts are very aware of their disturbed Pts are very aware of their disturbed sense of consciousnesssense of consciousness

TreatmentTreatment

Rx anxietyRx anxiety With anxiolytic’s, supportive and With anxiolytic’s, supportive and

insight oriented therapyinsight oriented therapy As anxiety is reduced, episodes As anxiety is reduced, episodes

of depersonalization decreaseof depersonalization decrease

differentialsdifferentials

Neurological-epilepsy, migraine, Neurological-epilepsy, migraine, brain tumors,brain tumors,

Toxic / metabolic-hypothyroidism, Toxic / metabolic-hypothyroidism, hyperventilation, hypoglycemiahyperventilation, hypoglycemia

Psych-schizo, conversion d/o, Psych-schizo, conversion d/o, anxiety d/o, OCD etcanxiety d/o, OCD etc

Normal- Exhaustion, boredom, Normal- Exhaustion, boredom, emotional shockemotional shock

Hemi-depersonalization-(usually R Hemi-depersonalization-(usually R parietal) focal brain lesion.parietal) focal brain lesion.

Dissociaive d/o nosDissociaive d/o nos

Dissociative symptoms are Dissociative symptoms are predominant, but the clinical picture predominant, but the clinical picture does not meet full criteria for a does not meet full criteria for a dissociative d/odissociative d/o

1. Ganser’s syndrome; Prisoners 1. Ganser’s syndrome; Prisoners with personality d/os giving with personality d/os giving approximate answers to questions-approximate answers to questions-eg. 2+2=5 or talking past the point eg. 2+2=5 or talking past the point usually with other symptoms like usually with other symptoms like amnesia, perceptual disturbances .amnesia, perceptual disturbances .

Dissociative d/o nosDissociative d/o nos

Derealization unaccompanied by Derealization unaccompanied by depersonalizationdepersonalization

Dissociative states (brainwashing, Dissociative states (brainwashing, thought reform," mind control” due to thought reform," mind control” due to intense coercive persuasion while intense coercive persuasion while captive with terrorists or in cults) captive with terrorists or in cults)

Dissociative trance d/o-in certain Dissociative trance d/o-in certain cultures amok (rage reaction), cultures amok (rage reaction), possessions, mediums in dissociative possessions, mediums in dissociative states where spirits take over , states where spirits take over , automatic writingautomatic writing

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