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psychiatry shlav alef > chapter 12 dissociative disorders > Flashcards

chapter 12 dissociative disorders Flashcards

1
Q

dissociation

A

involves segregation of mental or behavioral processes(such as memory, identity, pereption, consciousness, motor behavior) from psychic activity

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2
Q

dissociative amnesia vs organic amnesia

A

the latter is coded neurocognitive disorder due to a general medical condition

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3
Q

dissociative amnesia epidemiology

A

2-6%,m=f.
onset late adolescence and adulthood
difficult to assess in childhood

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4
Q

etiology of dissociative amnesisa

A

conflictual psychosocial environment, experiencing intolerable emotions- shame, despair, rage, guilt, desperation, betrayal, trauma.

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5
Q

predisposition to dissociative amnesia

A

no personality profile is specific
family history of somatoform or dissociate symptoms.
history of prior adult or childheed trauma

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6
Q

what the most important variable in development of dissociative amnesia following wartime?

A

the intensity of combat

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7
Q

intercurrent presentastions in dissociative amnesia

A

somatoform/conversion, alteration of consciousness, depersonalization, derealization, trance, spontaneous age regression, ongoing reterograde amnesia.
depression and suicidal ideation- common

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8
Q

localized amnesia

A

amnesia to specific period of time

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9
Q

selective amnesia

A

cannot recall some events in a specific period of time

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10
Q

generalized amnesia

A

cannot recall entire life

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11
Q

continuous amnesia

A

cannot recall seccessive events as they occur

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12
Q

systematized amnesia

A

cannot recall events pertaining to a specific category

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13
Q

differential diagnosis of dissociative amnesia

A 
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
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14
Q

substances causing amnesia

A

alcohol, sedative hypnotics, marijuana, narcotics, psychedelics, PCP

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15
Q

medications causing amnesia

A

anticholinergics, steroids, methyldopa, pentazocine, hpoglycemic agents, beta blockers, lithium and others,

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16
Q

specifier for dissociative amnesia

A

with or without dissociative fugue

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17
Q

patient with ongoing bizzare behavior, memory problems, irritabilitym violence- rule out

A

recurrent complex partial seizures

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18
Q

TGA vs dissociative amnesia

A

stressful life events can precede both. in TGA:

  1. sudden onset of anterograde amnesia
  2. pronounced retrograde amnesia
  3. perserved memory for personal identity
  4. amxious awareness of memory loss, perseverative questioning
  5. normal behavior
  6. lack of gross neurological symptoms
  7. rapid return to baseline with persistent short retrograde amnesia
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19
Q

risk factors and age for TGA

A

age over 50,
cerebrovascular risk factors
association with epilepsy and migraines.

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20
Q

can milngerers with amnesia be revealed in hypnosis

A

they may continue their deception during hypnosis

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21
Q

factitious dissociative amnesia

A

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.

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22
Q

course and prognosis of dissociative amnesia

A

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.

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23
Q

treatment of dissociative amnesia

A

cognitive
hypnosis
somatic therapies- no pharmacotherapy other than pharmacologically facilitated interview.
proup therapy

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24
Q

hypnosis in dissociate amnesia

A

modulate and titrate intensity of symptoms
facilitate recall
support and ego stregthening
promote working through and integration of dissociated memories

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25
Q

pharmacologically facilitated interview

A

amobarbital
thiopental
oral /IV BZ (e.g.) valium
amphetamines

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26
Q

what is the third most commonly reproted psychiatric symptom?

A

depersonalization and derealization, and depression and anxiety.

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27
Q

prevalence of depersonalization and derealization

A

one year prevalence of 19%

woman 2-4 times than men.

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28
Q

concommitant causes in depersanalization/derealization

A

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

29
Q

traumatic stress and depersonalization/derealization

A

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

30
Q

psychodynamic theory of depersonalization

A

ego disintegration, affective response to defend ego

31
Q

neurotransmitters in depersonalization

A 
reduced serotonin ( caused by marijuana, migraines, depletion of l-tryptophan). responds to SSRI.
Glutamate- primarily through NMDA receptor- central to development of this disorder
32
Q

expression of feeling in depersonalization disorder

A

have trouble expressing their feelings, seem undistressed

33
Q

organic causese of depersonalization

A

seizures, migrains, barin tumors, postconcussive syndrome, metabolic abnormalities, vertigo, meniere’s disease

34
Q

how does depersonalization secondary to organic causes differ from primary cause?

A

primarily sensory, without elaborated descriptions of personalizaed meanigs.

35
Q

mental disorders that can manifest with depersonalization

A

ASD/PTSD/ other dissociative disorders/ panic/phobia/schizophrenia

36
Q

pharmacotherapy for depersonalization/derealization

A

generally treatment refractory(if chronic)
prozac found effective in some studies
fluvoxamie and lamictal not effective
try coombination of different therapies

37
Q

non pharmacological modalities for depersonalization/derealization

A 
different types of psychotherapies
stress management
reductin of sensory stimulation
relaxation trainng
exercise
38
Q

dissociative fugue in ICD vs DSM5/4

A

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

39
Q

FUGUE causes

A

usually resulting from major traumas such as natural disasters/ war. described more in men in military settings.Usually no antedecent psychological trauma.
usually adults

40
Q

FUGUE and nightmares

A

in some cases with severe PTSD nightmares are terminated by a waking fugue where the patient runs outside,

41
Q

fugue vs dissociative amnesia

A

in FUGUE state the patient purposefully travels away while preoccupied by a single wish- to run away.
amnestics wander out of confusion. .

42
Q

course and prognosis of fugue

A

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.

43
Q

treatment of fugue

A

psychodynamic therapy accompanied with hypnotherapy.

no supression of alter identity, but integration of identities

44
Q

bleular and DID

A

symptoms are reflective of schizophrenia

45
Q

epidemiology of DID

A

not enough data. female to male ratio 5:1-9:1

46
Q

etiology of DID

A

85-97% - severe childhood trauma, particularly sexual abuse

no known genetic contribution

47
Q

associated symptoms in DID

A 
PTSD
somatic
affective
OCD
SOAP
48
Q

OCD symptoms in DID

A

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)

49
Q

affective symptoms in DID

A

depression/anhedoia/dysphoria
mood swings- caused by PTSD, not a true cyclic mood dis.
suicidal thoughts/self mutilation
helplessness and hopelessness

50
Q

warning symptoms of DID in childhood

A

imaginary companionship, elaborated day dreams, auditary pseudohallucintaions or passive influence by imaginary companion.

51
Q

factitious/malingering in DID

A

DID are usually distressed by their symptoms, ashames and coflicted.
maligerers will show little dysphoria, and may take advantage of symptoms for antisocia behavior.

52
Q

poor prognostic factors in DID

A 
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
53
Q

psychotherapy in DID

A

multimidal
cognitive therapy- may cause dysphoria
hypnosis

54
Q

pharmacotherapy in DID

A

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

55
Q

DID and ECT

A

if with melancholic depression- predicts positive results to ECT/

56
Q

group therapy in DID

A

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

57
Q

self help groups and DID

A

usually have a negative outcome

58
Q

family therapy and DID

A

important for long term stabilization, and adress problematic family issues that are common in these families

59
Q

expressive and occupational therapies in DID

A

very helpful

60
Q

EMDR in DID

A

case reports suggest that some , especialy in acutely increased PTSD and dissociation- respond to EMDR.
clinician must be trained for treatment of this population

61
Q

other specified dissociative disorder

A

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

62
Q

dissociative trance disorder

A

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.

63
Q

brain washing

A

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.

64
Q

recovered memory syndrome

A

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.

65
Q

Ganser

A

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.

66
Q

ganser- epidemiology

A

M:F= 2:1

3/4 of Ganser’s cases were convicts,

67
Q

etiology of ganser

A

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

68
Q

treatment of ganser

A

supportive environment, usually rapid return to normal functioning.
low dose of antipsychoticd
hypnosis
do not confront or use interpretation

psychiatry shlav alef (22 decks)

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