chapter 12 dissociative disorders Flashcards
dissociation
involves segregation of mental or behavioral processes(such as memory, identity, pereption, consciousness, motor behavior) from psychic activity
dissociative amnesia vs organic amnesia
the latter is coded neurocognitive disorder due to a general medical condition
dissociative amnesia epidemiology
2-6%,m=f.
onset late adolescence and adulthood
difficult to assess in childhood
etiology of dissociative amnesisa
conflictual psychosocial environment, experiencing intolerable emotions- shame, despair, rage, guilt, desperation, betrayal, trauma.
predisposition to dissociative amnesia
no personality profile is specific
family history of somatoform or dissociate symptoms.
history of prior adult or childheed trauma
what the most important variable in development of dissociative amnesia following wartime?
the intensity of combat
intercurrent presentastions in dissociative amnesia
somatoform/conversion, alteration of consciousness, depersonalization, derealization, trance, spontaneous age regression, ongoing reterograde amnesia.
depression and suicidal ideation- common
localized amnesia
amnesia to specific period of time
selective amnesia
cannot recall some events in a specific period of time
generalized amnesia
cannot recall entire life
continuous amnesia
cannot recall seccessive events as they occur
systematized amnesia
cannot recall events pertaining to a specific category
differential diagnosis of dissociative amnesia
ordinary forgetfullness organic-including delirium, TBI, ECT etc. seizure substance related PTSD/ASD TGA DID/ other dissociative dis. Somatic symptom dis. amnesia to psychotic or affective episode after remission factitious/malingering
substances causing amnesia
alcohol, sedative hypnotics, marijuana, narcotics, psychedelics, PCP
medications causing amnesia
anticholinergics, steroids, methyldopa, pentazocine, hpoglycemic agents, beta blockers, lithium and others,
specifier for dissociative amnesia
with or without dissociative fugue
patient with ongoing bizzare behavior, memory problems, irritabilitym violence- rule out
recurrent complex partial seizures
TGA vs dissociative amnesia
stressful life events can precede both. in TGA:
- sudden onset of anterograde amnesia
- pronounced retrograde amnesia
- perserved memory for personal identity
- amxious awareness of memory loss, perseverative questioning
- normal behavior
- lack of gross neurological symptoms
- rapid return to baseline with persistent short retrograde amnesia
risk factors and age for TGA
age over 50,
cerebrovascular risk factors
association with epilepsy and migraines.
can milngerers with amnesia be revealed in hypnosis
they may continue their deception during hypnosis
factitious dissociative amnesia
will psychiatric attention with a chief complaint of recovering repressed memories. when carefully questioned- will focus on childhood abuse to explain unhappiness and life dysfunction.
course and prognosis of dissociative amnesia
acute cases usually resolve spontaneously when removed from overwhelming environment.
-treat to recover memories as early as possible as memories can be deeply repressed and less accessible later, leading to a difficult to treat chronic condition.
treatment of dissociative amnesia
cognitive
hypnosis
somatic therapies- no pharmacotherapy other than pharmacologically facilitated interview.
proup therapy
hypnosis in dissociate amnesia
modulate and titrate intensity of symptoms
facilitate recall
support and ego stregthening
promote working through and integration of dissociated memories
pharmacologically facilitated interview
amobarbital
thiopental
oral /IV BZ (e.g.) valium
amphetamines
what is the third most commonly reproted psychiatric symptom?
depersonalization and derealization, and depression and anxiety.
prevalence of depersonalization and derealization
one year prevalence of 19%
woman 2-4 times than men.
concommitant causes in depersanalization/derealization
migraine
epilepsy
psychedelics- especially marijuana, LSD, mecaline.
(stimulants, such as cocaine)
anticholinergics(less frequent)
after meditation, hypnosis, extended crystal/mirror gazing
sensory deprivation
after mild-moderate head injury (but not with significant loss of consciousnees, i,e, more than 30 min).
after life threatening experiences
traumatic stress and depersonalization/derealization
1/3- 1/2 report history of trauma
60% of accident victims (transient)
in military training- evoked by stress and fatiue and inversly related to performance
psychodynamic theory of depersonalization
ego disintegration, affective response to defend ego
neurotransmitters in depersonalization
reduced serotonin ( caused by marijuana, migraines, depletion of l-tryptophan). responds to SSRI. Glutamate- primarily through NMDA receptor- central to development of this disorder
expression of feeling in depersonalization disorder
have trouble expressing their feelings, seem undistressed
organic causese of depersonalization
seizures, migrains, barin tumors, postconcussive syndrome, metabolic abnormalities, vertigo, meniere’s disease
how does depersonalization secondary to organic causes differ from primary cause?
primarily sensory, without elaborated descriptions of personalizaed meanigs.
mental disorders that can manifest with depersonalization
ASD/PTSD/ other dissociative disorders/ panic/phobia/schizophrenia
pharmacotherapy for depersonalization/derealization
generally treatment refractory(if chronic)
prozac found effective in some studies
fluvoxamie and lamictal not effective
try coombination of different therapies
non pharmacological modalities for depersonalization/derealization
different types of psychotherapies stress management reductin of sensory stimulation relaxation trainng exercise
dissociative fugue in ICD vs DSM5/4
removed from DSM 4 as a separate diagnosis(but remained in ICD-10), and is only a specifier in dissociative amnesia.
can occur also in DID
FUGUE causes
usually resulting from major traumas such as natural disasters/ war. described more in men in military settings.Usually no antedecent psychological trauma.
usually adults
FUGUE and nightmares
in some cases with severe PTSD nightmares are terminated by a waking fugue where the patient runs outside,
fugue vs dissociative amnesia
in FUGUE state the patient purposefully travels away while preoccupied by a single wish- to run away.
amnestics wander out of confusion. .
course and prognosis of fugue
most are brief, lasting from hours to days. most recover, after recovery - confusion, dissociative states, conversion. some develop refractory dissociative amnesia, and some develop an alter identity (DID) .. when less dissociated may display mood symptoms, intense suicidal ideation,ptsd, anxiety.
treatment of fugue
psychodynamic therapy accompanied with hypnotherapy.
no supression of alter identity, but integration of identities
bleular and DID
symptoms are reflective of schizophrenia
epidemiology of DID
not enough data. female to male ratio 5:1-9:1
etiology of DID
85-97% - severe childhood trauma, particularly sexual abuse
no known genetic contribution
associated symptoms in DID
PTSD somatic affective OCD SOAP
OCD symptoms in DID
ruminations about trauma
obsessive counting and singing(distraction from anxiety)
arranging
washing(feeling dirty because of abuse)
checking(that no one can enter the house)
affective symptoms in DID
depression/anhedoia/dysphoria
mood swings- caused by PTSD, not a true cyclic mood dis.
suicidal thoughts/self mutilation
helplessness and hopelessness
warning symptoms of DID in childhood
imaginary companionship, elaborated day dreams, auditary pseudohallucintaions or passive influence by imaginary companion.
factitious/malingering in DID
DID are usually distressed by their symptoms, ashames and coflicted.
maligerers will show little dysphoria, and may take advantage of symptoms for antisocia behavior.
poor prognostic factors in DID
organic mental disorder psychotic disorder(not pseudocyesis) ssevere medical illness refractory substance abuse eating disorders antisocial personality criminal activity ongoing perpetration of abuse victimization with refusal to leave relationship
psychotherapy in DID
multimidal
cognitive therapy- may cause dysphoria
hypnosis
pharmacotherapy in DID
traumatic symptoms, especiall intrusive and hyperarausal are medication responsive.
antidepressants, beta blockers, clonidine, anticonvulsants( especially tegraol- found useful for aggressive behavior when accomodated with abnormal EEG), BZ.
prazosin for nightmare.
naltreson fo self injurious behavior.
neuroleptics (atypical) for intrusive symp. and anxiety, and in extreme cases- leponex
DID and ECT
if with melancholic depression- predicts positive results to ECT/
group therapy in DID
with other disorders- probematic, as alter identities can disrupt group.
better with other DID- but carefully structured, firm rules, focus only on here and ow
self help groups and DID
usually have a negative outcome
family therapy and DID
important for long term stabilization, and adress problematic family issues that are common in these families
expressive and occupational therapies in DID
very helpful
EMDR in DID
case reports suggest that some , especialy in acutely increased PTSD and dissociation- respond to EMDR.
clinician must be trained for treatment of this population
other specified dissociative disorder
chronic and recurrent syndromes of mixed dissociative smptoms
identity disturbance due to prolonged and intense coercive persuasion
acute dissociative reaction to stressful events
dissociative trance
dissociative trance disorder
temporary alteration of state of consciousness or loss of identity without an alter identity. unresponsive. may have stereotypical movements-in culture bound possession trance disorder. full amnesia to the event.
not related to normal cultural or religious practice.
brain washing
first stage- identity crisis
next- extreme idealization with captors- identification with the aggressor, externalization of superego, regressive adaptation (traumatic infantilism), paralysis of will, a state of frozen fright.
recovered memory syndrome
patients may recover under hypnosis memories of abuse,these may be false memories.
Thomas E Gutheil - memory isn’t strong enought for a court case. even if memory is real- suing is not therapeutic, but patient should overcome the sense of victimhood, and move on.
Ganser
approximate answers (paralogia) together with clouding of cosciousness, disorientation, loss of personal information, impaired reality testting,
frequently accompanied by hallucinations(up to half of cases) and
must be accompanied by dissociative symmptoms such as amnesia, trance like behaviors somatoform and conversion symptoms.
“hysterical stigmata” such as noneurological analgesia/hyperalgesia
after recovery- amnesia to the experience.
ganser- epidemiology
M:F= 2:1
3/4 of Ganser’s cases were convicts,
etiology of ganser
preciitating stressers- personal conflicts, financial problems
organic brain syndrome,head trauma, seizures, medical or psychiatric illness
some report childhood maltreatment in past
*patient with DID may exiit Ganser-like symptoms
treatment of ganser
supportive environment, usually rapid return to normal functioning.
low dose of antipsychoticd
hypnosis
do not confront or use interpretation
