Dissociation Flashcards
Dissciation
- segregation of any group of mental processes from the rest of someone’s psychological activity
- Unconscious defense mechanism
- Often associated with psychological trauma
- May be transient or chronic, sudden or gradual
5 core symptoms of dissociative disorders
Amnesia
Depersonalization
Derealization
Identity Confusion
Identity Alteration
Amnesia
Recurrent gaps or defects in memory
Depersonalization
Detachment or disconnection from ones self
a stranger in my body
derealization
disconnection from one’s surroundings
everything feels unreal
Identity confusion
inner struggle about one’s sense of self/identity
I don’t know which of me is the real me
Identity Alteration
Sense of acting like a different person some of time
-may use different names
-learned skill without recollection of learning the ability
-uncontrolled mood/behavior changes
Dissociative amnesia
can’t recall personal information
autobiographical memory
reversible.
Dissociative Fuge
Sudden unexpected travel or wandering around in a dissociative state
-a subtype of dissociative amnesia
Epidemiology of dissociative amnesia
7% lifetime
2% in the last 12 months
no gender pref
age most often seen in late adolescence
-comorbid: MDD MC, bipolar, substance abuse, substance abuse, other anxiety disorders
-etiology from intolerable emotions or a traumatic experience
Dissociative Amnesia DSM
Inability to recall autobiography information usually a tramatic or stressful nature, different from normal forgetting
it can be around a event like specifically cant recall the event or generalized for identity and life history
-can be accompanied by dissociative fuge
-it is not due to an organic brain condition
Questions on dissociative amnesia
Asking about gaps in memory, have you traveled somewhere without recollection, do you have items in your posession that you don’t remember aquiring
Localized amnesia
inability to recall events related to a circumscribed period of time
continuous amnesia
failture to recall successive events as they occur
generalized amnesia
failure to recall one’s entire life
generalized amnesia
failture to recall one’s entire life
Selective Amnesia
Ability to remember some but not all of the events occuring during a circumscribed period of time
Systematized amnesia
Failure to remember a category of information, such as all memories relating to one’s family or particular person
Tx dissociative amnesia
- psychotherapy that is phase oriented so that you can overcome it
- cognitive therapy: address cognitive distortions based on trauma
- hypnosis - facilitate recall
- group therapy- for trauma related
- meds don’t treat but help support
- BZDs, barb, amphetamines to help recall during interviews
Phase-Oriented Treatment
Broken into 3 stages:
- stabilization
- traumatic memories
- fusion, integration
Depersonalization
Persistent or recurring feeling of detachment or estrangement from one’s self
- moving through the motions or on autopilot
Depersonalization/Derealization Disorder
DDD
Prevalence
- transient depersonalization/dereal in the last 12 mo is up to 20%
- correllated in pts with a hx of seizures or migraines, psychedeilc drugs, medications, head injury
- lifetime DDD is 1-3%
- equally common in men and women
- risk factors - acute or chronic trauma, drugs, psychiatric disorders
- 1/3 to 1/2 with DDD
- Comorbid - depression, anxiety, OCD, avoidant, or borderline personality
DID
multiple personality disorder
What is reality testing
depersonalization/derealization
- The person suffering from the disorder will be able to respond to questions and interact normally with his or her environment.
DDD tx
refractory to meds
psychotherapy has mixed results
-stress manaagement and relaxations may be useful
-SSRIs may be helpful but still sporadic response
DID epidemiology
- Prevalence - estimated 1% general population
- 2.5-7% in patients receiving psychiatric care in the US
- Gender - 5-9x as common in women
- Age - often diagnosed in 20s-30s
- Comorbidities - PTSD (79-100%), **depression **(83-96%), substance abuse (83-96%), personality disorders, somatoform disorders
- Etiology - **childhood trauma **in 89-97% of cases
- Typically physical or sexual abuse
- Questionable genetic link - no strong evidence to support
- Presence of two or more distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and itself
- May feel as though one is “being possessed” by an alternate self
- Amnesia must occur in order to diagnose
- Gaps in recall of everyday events, personal information, and/or traumatic events
- Syndrome causes distress and/or functional impairment
- Disturbance is not part of normal cultural or religious practices
- Ex. an “imaginary friend” is not considered indicative of a separate personality state alone
- Syndrome is not due to substance abuse or medical condition
- Ex. alcohol intoxication, complex partial seizures, etc.
DID
- psychotherapy is often a mainstay of treatment
- cognitive therapy to address cognitive distortions that contribute to persistence of multiple selves
- hypnosis to alleviate self destruct impulses
- family to have social support
- expressive/occupational- to express feelings
- pharma- aimed at managing major symptoms
- SSRI, TCA, MAOI, antipsychotics
- May use BZD, betablockers, clonidine, anticonvulsants for sedation
- prazosin for PTSD type nightmares
- ECT for refractory mood disorders. it does not worsen the dissociation
Defining impulse control disorders
inability to resist the inpulse, desire, or drive that harms to self, others, or both
- mounting tension and anticipatory pleasure before doing it.
- completing action results in grat & relief
- action is followed by remorse and guilt, feeling secretive about it after
How is impulse control related to OCD?
OCD feels ashamed of it the whole time and gets no gratification out of it.
Impulse control disorders
Pyromania rare, 90% male
klept 0.6% more in females
gambling 3%, 2/3 male
trichotillomania 0.6% more in females
symptoms often worsen in times of stress
-early life events that model bad behavior
-serotonergic or limbic system abnormal
Gambling path DSM
5 or more behaviors
* Preoccupation with gambling
* Need to gamble with increasing amounts of money to get desired excitement
* Repeated unsuccessful efforts to reduce or stop gambling
* Restless or irritable when trying to reduce or stop gambling
* Gambles to improve mood or escape from problems
* After losing money, returns another day to win the money back
* Lies to others to conceal the extent of gambling
* Has committed illegal acts to finance gambling
* Jeopardizes or loses relationships, jobs, or opportunities because of gambling
* Relies on others to provide money to relieve a situation caused by gambling
Trichotillomania
- Recurrent hair pulling resulting in noticeable hair loss
- Tension or anxiety immediately before pulling out hair, or when resisting the urge
- **Pleasure, gratification, or relief **when pulling hair
Klepto
- Recurrent theft of items not needed for personal use or monetary value
- Tension or anxiety immediately before stealing, or when resisting the urge
- Pleasure, gratification, or relief when stealing
- Stealing is not due to anger or psychosis
Pyro
- Recurrent, deliberate, purposeful fire setting on multiple occasions
- Tension or anxiety immediately before setting fire, or when resisting the urge
- Pleasure, gratification, or relief when setting fires, or when witnessing or participating in their aftermath
- Fascination with, interest in, curiosity about, or attraction to fire
- Fire setting is not for monetary gain, expression of ideology, to conceal criminal activity, as an act of anger, to improve one’s living circumstances, because of psychosis, or due to impaired judgement
5 stages of impulsivity
- Urge
- Tension
- Act
- Relief
- Guilt
Treatment of impulse control disorders
All disorders –> psychotherapy
* Klepto- SSRI & lithium
* Pyromania - early intervention programs
* pathological gambling - SSRIs, opiate antagonist
* Trichotillomania - clomipramine. no SSRI. can do TCA
Defining Intermittent Explosing Disorder
- Discrete episodes of losing control of aggressive impulses
- Can result in serious assault, property destruction
- Aggressiveness is grossly out of proportion for any stressor which may have precipitated the episode
- Symptoms appear and remit spontaneously and quickly
- Between episodes…
- Patients show genuine regret or self-reproach
- No generalized impulsivity or aggressiveness
Etiology intermittent explosive disorder
- Prevalence - estimated 1-5%
- Gender - more common in males
- Age - often starts in adolescence
- Comorbidities - pyromania, other impulse control disorders, substance use, mood and anxiety disorders
- Etiology - genetic predisposition; exposure to abuse/violence as a child; narcissistic defence mechanism
- Also see decreased serotonergic activity
- Increased rates of brain inflammation, hx of T. gondii infection
Intermittent Explosive Disorder
Presence of recurrent behavioral outbursts representing a failure to control aggressive impulses, as manifested by either of the following:
* Verbal or physical aggression towards property, animals, or other individuals, occurring twice weekly on average for a period of 3 months; the aggression does not result in damage or destruction of property or physical injury
* **3+ behavioral outbursts involving damage/destruction of property or physical injury against animals or other individuals occurring within a 12-month period **
- The aggressive outbursts are not premeditated & are out of proportion
- Chronological age is at least 6 years (or equivalent developmental level)
Syndrome causes distress, functional impairment, or financial/legal consequences
Syndrome is not due to substance abuse or medical condition
Ex. alcohol intoxication, dementia, DMDD, etc.
Borderline or personality disorder is different from IED
aggression will linger between outbursts for BPD
IED different from conduct disorder how?
conduct is persistent, repetitive aggression rather than episodic outbursts
IED Tx
Combination psychotherapy and pharma
-hard to do thearpy but group and family therapy is helpful. a therapist alone struggles to set limits
- pharmacothearpy
-SSRIs, trazodone, buspirone
-Lithium, carbamazepine, valproate, phenytoin, gabapentin
adjunct - antipsychotics, betablockers, calcium channel blockers
Defining Oppositional
Defiant Disorder (ODD)
- Enduring pattern of negativistic, hostile, disobedient behavior
- Frequently argue with adults and authority figures
- Often angry, resentful, easily annoyed
- Inability to take responsibility for mistakes
- Places blame on others for their own transgressions or omissions
- Commonly have problems with peer relationships and in school
- Symptoms may initially only manifest in one setting, and later show in others
- Typically do not display much physical aggression or violent behavior
- May display verbal aggression
- Reactive (ex. in response to rules) rather than proactive (ex. bullying)
- Overt (ex. shouting) rather than covert (ex. spreading rumors)
Three major subtypes of ODD
Angry irritable- often lose tempers & feel angry all the time
Argumentative/defiant- habitually argue with authority figures
vindicative - vengeful and spiteful
Oppositional Defiant Disorder Epidemiology
- 2-12% prevalence decrease when looking at pts 12 and older
- Note - some degree of oppositional behavior is normal in childhood and adolescence
- more common in males before puberty. after puberty its equal
- age begins as a young as three, average age at onset is 6. identified by age 14
- ## comorbidities - pyromania, other impulse control disorders
ODD DSM
Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by 4+ symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling:
Angry/Irritable Mood
Often loses temper
Often touchy or easily annoyed
Often angry and resentful
Vindictiveness
Has been spiteful or vindictive at least twice within the past 6 months
Argumentative/Defiant Behavior
Often argues with authority figures or, for children and adolescents, with adults
Often actively defies or refuses to comply with rules or requests from authority figures
Often deliberately annoys others
Often blames others for his or her mistakes or misbehavior
Training family members
- Family therapy - train parents to reinforce desired behavior and diminish attention/not reinforce oppositional or negative behavior
- Individual therapy - role play positive behavior, help work on self esteem to improve ability to deal with conflict and disappointment
- Pharmacotherapy- only as indicated for comorbid conditions
Opposite Defiant Disorder
Over time…
- 25%: few/absent symptoms of ODD by late adolescents and early adulthood
- 50%: still display partial or full symptoms ODD
- 25%: progress to Conduct Disorder - especially patient with predominantly angry/irritable or vinditive types due to higher levels of aggression
- May also develop mood and anxiety
ODD criteria
Note - persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic
Pt < 5 y/o - Behavior should occur on most days for a period of at least 6 months
Pt 5+ y/o - Behavior should occur at least once per week for at least 6 months, unless otherwise noted
Severity
Mild - Symptoms are confined to only one setting
Moderate - Some symptoms are present in at least two settings
Severe - Some symptoms are present in three or more settings
Prognosis for ODD
25% - few/absent symptoms of ODD by late adolescence and early adulthood
50%- still display partial or full symptoms of ODD
25% - progress to Conduct Disorder
Conduct disorder
aggression and violation of the rights of others
theft
physical aggression and harm to others
starts in kids or adolescents
Conduct Disorder
- Pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as determined by 3+ of the following 15 criteria in the past 12 months (at least 1 in the past 6 months):
- Aggression to People and Animals
- Often bullies, threatens, or intimidates others
- Often initiates physical fights
- Has used a weapon that can cause serious physical harm to others
- Has been physically cruel to people
- Has been physically cruel to animals
- Has stolen while confronting a victim
- Has forced someone into sexual activity
- Destruction of Property
- Has deliberately set a fire with intent to cause serious damage
- Has deliberately destroyed others’ property (other than by fire setting)
Criteria Conduct Disorder
Onset
Childhood-onset type - At least one symptom present prior to age 10
Adolescent-onset type - No symptoms present prior to age 10
Unspecified onset - Unable to clarify age at
onset of symptoms
Severity-
- Mild - Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others
Ex. lying, truancy, staying out after dark without permission, other rule breaking
- Moderate - The number of conduct problems and the effect on others are intermediate between those specified in “mild” and those in “severe”
Ex. stealing without confronting a victim, vandalism - Severe - Many conduct problems in excess of those required to make the dx, or conduct problems cause **considerable harm to others **
Ex. forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering
Conduct disorder treatment
early psychotherapy
-kindergarten
-reinforcement
pharmacotherapy
-atypical to reduce aggresive behavior
-SSRI- can help inpulsive, irritability, and mood lability
anticonvulsants - may help with aggression
