Dissociative Disorder

Question 1

Define dissociative disorder

Answer 1

Partial or complete loss of normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements.

(mental state of DISCONNECTION of what is going on around you)

Question 2

What are the 3 types of dissociative disorder

Answer 2

Depersonalisation/derealisation (least severe)
Dissociative amnesia
Dissociative identity disorder/multiple personality disorder (most severe)

Question 3

What is depersonalisation and derealisation

Answer 3

Depersonalisation- feeling detachment from oneself
Derealisation- feeling that the world around you is NOT fully real

Question 4

What are the risk factors for dissociative disorder

Answer 4

Physical, sexual or emotional abuse during childhood
Traumatic events
Insoluble or intolerable problems
Female sex

Question 5

What is the criteria for dissociative disorders

Answer 5

Requires all three:
1. Occur in the absence of physical pathology that would explain the symptoms
2. Produced unconsciously
3. Not caused by overactivity of SNS

Question 6

What are the features of dissociative disorders

Answer 6

Often reflect a patient’s ideas about illness
Usually abnormal illness behaviour, with exaggeration of disability
Significant childhood traumas
Primary gain- immediate relief from emotional conflict
Secondary gain- social advantage gained by patient being ill and disabled (sympathy of family and friends, time off work, disability pension)
Physical disease, not uncommonly, also present e.g. pseudoseizures

Question 7

What are the features of Depersonalisation/derealisation

Answer 7

Feeling of DETACHMENT from one’s self
Weak sense of self, uncertain of their identity and who they are
May feel that they are watching themselves from the outside- i.e. “watching a movie about themselves”
Emotionally or physically numb
Deadpan speech
Trouble forming relationships
Trouble recognising familiar places, people or objects- SEVERE
Altered sense of time
Brainfog/ light-headedness
Rumination and anxiety

Question 8

What are the features of dissociative amnesia

Answer 8

Loss of memory, usually important recent events
Block out/ forget important personal information e.g. where they lived as a child or what their mother looked like
Commences suddenly
Localised: most common, trouble recalling traumatic events
Generalised: cannot remember any of their past
Systematised: forgets a category of information associated with trauma
Continuous: forgets each new event after it happens, retains nothing but the present

Question 9

What are the features of dissociated fugue

Answer 9

Lose their memory and also wander away from their usual surroundings
Disorientation and wandering/ travel- unexpected, purposeful travel (lasts hours to months)
Confused about who they are, inability to recall one’s past
May lose their identity or form a new identity
Lose deeply-ingrained skills
When found, they have no memory of their whereabouts during this wandering

Question 10

What are the features of dissociative identity disorder or multiple personality disorder

Answer 10

Have multiple personalities which interact in complex ways
May be triggered by suggestion on part of a psychotherapist
Rapid alterations between ≥ 2 ‘personalities’ in the same person- each repressed and dissociated from the other ‘personalities’
Covert or overt

Question 11

What is the difference between covert an overt dissociative disorder

Answer 11

Covert = sudden and dramatic shift in how they perceive, think or feel, takes characteristics of a different person, may hear another voice and feel they are speaking to them. Usually AWARE that their experience is unusual

Overt = ≥ 2 distinct identities/ alters who talk differently than the original person and may have different taste/views/age/gender/nationality. Usually NOT aware. May forget portions of their day

Question 12

What is Hoover’s sign

Answer 12

Hoover’s sign is a compensatory movement of the other leg, due to synergistic contraction - when the unaffected leg is flexed against resistance, the affected leg involuntarily extends
Sign of conversion disorder

Question 13

What is Gander’s syndrome

Answer 13

giving an close approximate to question, e.g., saying cows have 5 legs

Question 14

What investigations should be done for Dissociative disorder

Answer 14

Clinical Diagnosis - usually based on clinical history and examination
Dissociative experience scale- screens for features of dissociative experience
Rule out organic causes

Bedside: ECG, urine dip, urine toxicology
Bloods: FBC, CRP/ESR, LFTs, blood cultures, toxicology, prolactin

Question 15

What is the management for dissociative disorder

Answer 15

1. Risk assess
2. Education
   - Explain to patient and family
   - Explore and address life stresses
   - Encourage return to normal activities and avoid reinforcing disability symptoms
3. Assessment (psychotherapeutic)
4. Interventions
   + rehabilitation programme and graded and mutated return to normal function (consider other modalities e.g. SALT, physio)

Question 16

What interventions are available for dissociative disorder

Answer 16

First line: Eclectic psychotherapy e.g. CBT, mindfulness, interpersonal, general
± hypnotherapy
± biofeedback training
Second line: Further psychotherapy e.g. psychodynamic, family, group, EMDR

Bio
1st Line: Lorazepam
2nd Line: Diazepam

Question 17

What is the prognosis for dissociative disorder

Answer 17

Most cases of recent onset recover quickly with treatment
Cases that last > 1 year are likely to persist
25% of those who exhibit short-term resolution of symptoms after reassurance will relapse or develop new conversion symptoms over time

Question 18

Describe trance and possession

Answer 18

Temporary loss of personal identity but full sense of awareness of the world around them