Depersonalization / Dissociative Disorders Flashcards
Delirium prevalence ?
1-2%, increased with age rising to 14% over 85 years old.
Incidence in ED among older individuals is 10-30%
Delirium Etiology and risk factors ?
Increases with age ( AGE!!)
Functional impairment, falls, low level of activity, drugs and medications
** alcohol wd with delirium - delirium tremmins ( they get the shakes)**
Delirium genetics and physiology ?
Neurocognitive disorders increase risk
Febrile illness
Delirium DDx ?
Psychotic disorders,
Bipolar/Mood with psychotic features
Acute stress disorder
Malingering and factitious disorder
** delirium is a sign that the body is not taking care of the brain properly and it is irritated , delirium and pyschosis are hard to differentiate ( zyprexa Ziadisx )**
Delirium work up ?
Look for underlying conditions (CBC - infection, glucose, CMP - electrolytes disturbances , Ammonia - liver failure, TSH - hyper or hypo, HIV - delirium or dementia longer term, UA - UTI, CXR - pneumonia , Utox - drugs, CT Brain - is there a tumor or bleed ) need to rule out other things
Delirium prognosis ?
Good, with often full recovery in many individuals
reversible cause
Mortality is increased. May be as high as 40%
Increased functional decline
Requires hospitalization and increased risk of long term care placement (3X those without delirium)
- *prognosis with dementia is less good
- *
Delirium tx and medications ?
Treat underlying cause.
Fluids and nutrition
Reduce distractions and noise at night
If agitated, atypical antipsychotics (zyprexa, seroquel, risperdal)
Delirium procedures / therapy / surgery ?
Reorientation techniques with calendar, clocks and family photos
Dementia aka ?
Major and Minor Neurocognitive Disorders
Dementia prevalence ?
Varies widely by age and etiology
At 65 years old – 1-2%
At 85 years old- up to 30%
Mild NCD is variable
65 yo 2-10%
85 yo 5-25%
** clearly age related **
Dementia etiology and risk factors ?
Vary by subtype
-Age is risk for almost all
Ex. Alzheimer’s uncommon < 60yo, frontotemporal lobe is earlier
Genetics
-Parkinson’s, Huntington’s are strongly genetic; Alzheimer’s maybe also
Dementia DDx ?
Normal cognition
Delirium
MDD
Learning or developmental disorders
Dementia prognosis ?
Variable
Some may begin and remain static ( related to traumatic or infectious cause)
Some are progressive (Alzheimer’s, frontotemporal lobe, Parkinson’s, Huntington’s)
Dementia workup ?
Blood work (CBC, CMP, glucose, HbA1C, UA,
CT/MRI brain, PET scan, CXR
Neuropsychological assessment
Dementia medications ?
Cholinesterase inhibitors
Partial N-methyl-D-aspartate antagonists
Dementia procedures ?
Cholinesterase inhibitors
Partial N-methyl-D-aspartate antagonists
Alzheimer’s Dementia tx ?
Cholinesterase inhibitors
Partial N-methyl-D-aspartate antagonists
** think memory and learning
this is clinical dx
we dont have had and fats genetic testing and fam hx is good!**
Cholinesterase inhibitors
examples?
-Donzepil (Aracept), Rivastigmine (Exelon), Galantamine
Partial N-methyl-D-aspartate antagonists example ?
Memantine (Namenda)
frontotemporal Dementia tx ?
Depression- SSRI’s
So far, dopaminergic (Parkinson’s) and cholinergic (Alzheimer’s) medications do not work.
what is stored in the front of the head ?
- decision making and personality
Lewy Body Dementia tx ?
Rivastigmine (Exelon) and other cholinesterase inhibitors
Atypical antipsychotics - 2nd gen
Do not use haloperidol ( risk of neuroleptic malignant syndrome)
Levadopa/carbodopa- parkinsonian features
mainstay for parkinson’s
SSRI’s for depression
Atypical antipsychotics examples 2nd gen?
quetiapine, aripiprazole
Vascular Dementia tx ?
Prevention of future CVA’s
Rehabilitation/Adaptation-PT ( more rehabilitation) and OT (more adaptation )
stroke related
cholinesterase inhibitors (Aracept) can help
Psychotic symptoms-
antipsychotics-quetiapine, aripiprazole
Depression
SSRI’s- sertraline, citalopram
Vascular Dementia ?
stroke and now you have dementia and this is time related to a clot etc , sometimes memory and leaning with it dx, CT or MRI of brain and you see evidence
Dementia due to traumatic Brain Injury tx ?
Prevention of future TBI’s
Rehabilitation/Adaptation-PT and OT
Alzheimer’s like symptoms cholinesterase inhibitors (Aracept) can help
Parkinson’s like symptoms
Levadopa/carbadopa
Depression
SSRI’s- sertraline, citalopram
Dementia due to Parkinson’s Disease tx ?
Levadopa/carbadopa - first line but people get tolerance so they add what is below
Monoamine oxidase B inhibitor
Dopamine agonists
Depression
Dementia due to Parkinson’s Disease tx : Monoamine oxidase B inhibitor examples ?
Selegeline - specifically B
Dementia due to Parkinson’s Disease tx: Dopamine agonists
examples ?
Ropinirole (Requip),
Pramipexole (Miraplex)
Depression tx ?
SSRI’s- sertraline, citalopram
Dementia due to Huntington’s Disease tx ?
Cholinesterase inhibitors
Partial N-methyl-D-aspartate antagonists
Atypical antipsychotics
Antidepressants
Cholinesterase inhibitors
examples ?
Rivastigmine (Exelon),
Partial N-methyl-D-aspartate antagonists
memantine ( Namenda)
Depersonalization / Derealization Disorder prevalence ?
~2% of U.S.
Depersonalization / Derealization Disorder Etiology and Risk factors ?
Trauma, significant stressor (death of a loved one, very severe financial, social or other stressors)
Severe sleep deprivation
Other disorders such as anxiety or depression
**traum trauma trauma !!!
this is not short term grieving and this is long term**
Depersonalization / Derealization Disorder genetics ?
Unclear
Depersonalization / Derealization Disorder DDx ?
Schizophrenia
Panic Disorder
Acute and Post Traumatic Stress Disorders
Borderline / Avoidant Personality Disorders
Depersonalization / Derealization Disorder prognosis ?
variable
Depersonalization / Derealization Disorder medications ?
SSRI’s (maybe) but very limited studies
Lamotrigine (mood stabilizing anticonvulsant)
Depersonalization / Derealization Disorder procedures / therapy / surgery ?
CBT and psychotherapy
Derealization symptoms ?
Symptoms of derealization include:
Feelings of being alienated from or unfamiliar with your surroundings, perhaps like you’re living in a movie
Feeling emotionally disconnected from people you care about, as if you were separated by a glass wall
Surroundings that appear distorted, blurry, colorless, two-dimensional or artificial, or a heightened awareness and clarity of your surroundings
Distortions in perception of time, such as recent events feeling like distant past
Distortions of distance and the size and shape of objects
Episodes of depersonalization-derealization disorder may last hours, days, weeks or even months at a time.
In some people, these episodes turn into ongoing feelings of depersonalization or derealization that may periodically get better or worse.
In this disorder, feelings of depersonalization and derealization aren’t directly caused by drugs, alcohol, a mental health disorder or a medical condition.
Depersonalization symptoms ?
Symptoms of depersonalization include:
Feelings that you’re an outside observer of your thoughts, feelings, your body or parts of your body, perhaps as if you were floating in air above yourself
Feeling like a robot or that you’re not in control of your speech or movements
The sense that your body, legs or arms appear distorted, enlarged or shrunken, or that your head is wrapped in cotton
Emotional or physical numbness of your senses or responses to the world around you
A sense that your memories lack emotion, and that they may or may not be your own memories
Dissociative Amnesia prevalence ?
Female > Male (~2 to 6%)
Dissociative Amnesia Etiology and risk factors ?
Usually trauma after r/o of organic causes
Dissociative Amnesia genetics ?
Possibly – there is a slightly higher incidence of individuals with family members having amnesia issues.
Currently unclear details of the association
Dissociative Amnesia DDx ?
Dementia / Head Trauma / Substance Intoxication. Early symptoms of neurological disorders (eg multiple sclerosis).
Dissociative Amnesia prognosis ?
Generally good, improves with removal from traumatic event
Dissociative Amnesia work up ?
Mini mental, look for biological causes (CT/MRI, cbc, cmp, UA, Utox, etc.)
Dissociative Amnesia medications ?
Rarely successful.
depression or anxiety might benefit from treatment with a medication such as an antidepressant or anti-anxiety medicine.
hypnosis is common tx for this
**Versed causes retrograde amnesia ( can remember) **
Dissociative Amnesia procedures / therapy / surgery ?
Slow gradual psychotherapy
Hypnosis
Often resolve spontaneously
Dissociative Fugue prevalence ?
~0.2% more common in war time/areas
**very rare **
Dissociative Fugue Etiology and risk factors ?
Related to dissociative amnesia or Extreme stress
Dissociative Fugue genetics ?
Many theories - genetic influences, accounting for about 50% of the variance in twin studies. Smaller hippocampal and amygdala volumes (possible)
Dissociative Fugue DDx ?
Dementia
Head Trauma
Substance Intoxication
Malingering
Dissociative Fugue prognosis ?
Mostly self-limited
Dissociative Fugue medications ?
There is no medication to treat the dissociative disorders themselves. However, a person with a dissociative disorder who also suffers from depression or anxiety / antidepressants or anxiolytics
Dissociative Fugue procedures / therapy / surgery ?
Supportive environment and sometimes hypnosis
Psychotherapy to deal with issues associated with recovered memories
Dissociative Identity Disorder prevalence ?
~.01 to 1%
Dissociative Identity Disorder Etiology and risk factors ?
Family Hx
Trauma is a large risk factor
Dissociative Identity Disorder genetics ?
Unclear
Dissociative Identity Disorder DDx ?
Dementia
Head Trauma.
Substance Intoxication.
Malingering
Dissociative Identity Disorder prognosis ?
No large scale studies but many psychiatrists report excellent results with therapy
Dissociative Identity Disorder medications ?
There are no approved medications
Dissociative Identity Disorder procedures / therapy / surgery ?
Supportive environment and sometimes hypnosis
Psychotherapy
