Dissociative Disorders DSM (all) + DiD lecture + guidelines Flashcards
what disturbance characterizes the dissociative disorders
characterized by disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behaviour
what are some of the “positive” dissociative symptoms
fragmentation of identity
depersonalization
derealization
(*unbidden intrusions into awareness and behaviour with accompanying losses of continuity in subjective experience)
what is one of the “negative” dissociative symptoms
amnesia
(*inability to access information or to control mental functions that normally are readily amenable to access or control)
in what context are many of the dissociative disorders found
in aftermath of trauma
what distinguishes depersonalization/derealization from psychosis
the person has intact reality testing
what is dissociative amnesia
an inability to recall autobioraphical information that is inconsistent with normal forgetting
may or may not involve purposeful travel or bewildered wandering (fugue)
are most individuals with dissociative disorders aware of their amnesias?
most are initially UNaware of their amnesias
awareness of amnesia occurs only when personal identity is lost or when circumstances make these individuals aware that autobiographical information is missing
is dissociative fugue common in dissociative amnesia?
no but its common in dissociative identity disorder
what are the two components that characterize dissociative identity disorder
- presence of TWO or more DISTINCT personality states or an experience of POSSESSION
+ - recurrent episodes of amnesia
criterion A for dissociative identity disorder
DISRUPTION OF IDENTITY characterized by TWO or more distinct personality states, which may be described in some cultures as an experience of possession
the disruption in identity involved MARKED DISCONTINUITY in sense of SELF and sense of AGENCY, accompanied by related alterations in behaviour, consciousness, memory, perception, cognition and/or sensory-motor functioning
s/s may be observed by others or reported by the individual
criterion B for dissociative identity disorder
recurrent GAPS in the recall of everyday events, important personal information and/or traumatic events that are INCONSISTENT with ordinary forgetting
criterion C for dissociative identity disorder
clinically significant distress/impairment
criterion D for dissociative identity disorder
the disturbance is not a normal part of a broadly accepted cultural or religious practice
in kids–> symptoms not better explained by imaginary playmates or fantasy play
criterion E for dissociative identity disorder
not attirbutable to substance/med condition etc
what helps determine the overtness or covertness of the two personality states characteristic of dissociative identity disorder
varies as a function of psychological motivation, current level of stress, culture, internal conflicts and dynamics, and emotional resilience
what other psychiatric symptoms are common in some presentations of dissociative identity disorder
non epileptic seizures and other conversion disorders (especially in non-western settings)
how might those with dissociative identity disorder describe their subjective experiences (answer is copied from DSM cuz i’m lazy and just want a reminder)
“Individuals with dissociative identity disorder may report the feeling that they have suddenly become depersonalized observers of their “own” speech and actions, which they may feel powerless to stop (sense of self) Dell 2006; Spiegel et al. 2011. Such individuals may also report perceptions of voices (e.g., a child’s voice; crying; the voice of a spiritual being). In some cases, voices are experienced as multiple, perplexing, independent thought streams over which the individual experiences no control. Strong emotions, impulses, and even speech or other actions may suddenly emerge, without a sense of personal ownership or control (sense of agency). These emotions and impulses are frequently reported as ego-dystonic and puzzling. Attitudes, outlooks, and personal preferences (e.g., about food, activities, dress) may suddenly shift and then shift back. Individuals may report that their bodies feel different (e.g., like a small child, like the opposite gender, huge and muscular). Alterations in sense of self and loss of personal agency may be accompanied by a feeling that these attitudes, emotions, and behaviors—even one’s body—are “not mine” and/or are “not under my control.” Although most Criterion A symptoms are subjective, many of these sudden discontinuities in speech, affect, and behavior can be witnessed by family, friends, or the clinician.”
what are the 3 primary ways in which the dissociative amnesia seen in dissociative identity disorder may manifest
- gaps in REMOTE memory of personal life events i.e periods of childhood, adolescence, getting married, giving birth
- lapses in DEPENDABLE memory i.e what happened today, well learned skills such as how to do their job, read, drive
- discovery of evidence of their every actions and tasks that they do not recollect doing i.e finding unexplained objects in their shopping bags, perplexing writings or drawings that they must have created, discovering injuries, “coming to” in the midst of going something
list brain regions that have been implicated in the pathophysiology of dissociative identity disorder
orbitofrontal cortex
hippocampus
parahippocampal gyrus
amygdala
what is the 12 month prevalence of dissociative identity disorder in the USA
1.5% (about equal males and females)
dissociative identity disorder is associated with what type of life events
overwhelming experiences
traumatic events
and/or abuse occurring in childhood
when does dissociative identity disorder usually manifest
can manifest at any time from early childhood to late life
psychological decompensation and overt changes in identity in people with dissociative identity disorder may be triggered by what events
- removal from the traumatizing situation
- individual’s children reaching same age at which individual was initially traumatized
- later traumatic experiences
- the death of or onset of a fatal illness in their abuser
list environmental risk factors for dissociative identity disorder
interpersonal physical and sexual abuse
other forms of traumatizing experiences
list factors associated with poorer prognosis in dissociative identity disorder
ongoing abuse
later life re-traumatization
comorbidity with mental disorders
severe medical illness
delay in appropriate treatment
what % of people with dissociative identity disorder report hx of interpersonal physical/sexual abuse
90%
how do you distinguish possession-form dissociative identity disorder from culturally accepted “possession states”
possession-form dissociative identity disorder = involuntary, distressing, uncontrollable and often recurrent or persistent
involves conflict between person and their family/social/work environment
manifested at times and in places that violate the norms of the culture or religion
how do presentations differ between female and males with dissociative identity disorder
females–> more common acute dissociative states
males–> more common criminal or violent behaviour
how common is suicide in dissociative identity disorder
very common–> over 70% of those with dissociative identity disorder have attempted suicide
*multiple attempts are common and other self injurious behaviour is frequent
what makes assessing for suicide risk in dissociative identity disorder challenging
may be amnesia for past suicidal behaviour
presenting identity may not feel suicidal and is unaware that other dissociated identities do
does treatment for dissociative identity disorder improve functioning
yes, often markedly
however some remain highly impaired
ddx dissociative identity disorder
other specified dissociative disorder
MDD
bipolar disorders
PTSD
psychotic disorders
sub/med induced disorders
personality disorders
conversion disorder
seizure disorder
factitious disorder and malingering
depressive symptoms/disorder in those with dissociative identity disorder often has one particular feature–what is it?
depressed mood and cognitions often FLUCTUATE because they are experienced in some identity states but not others
what is the common misdiagnosis in people with dissociative identity disorder
bipolar disorders, especially bipolar II
what dissociative symptoms are found in dissociative identity disorder but NOT in PTSD
amnesias for EVERYDAY events (not just traumatic events like in PTSD)
dissociative flashbacks that may be followed by amnesia for the content of the flashback
disruptive INTRUSIONS (unrelated to traumatic material) by dissociated identity states into individuals sense of self and agency
infrequent, full blown changes among different identity states
what is a very commonly comorbid disorder with dissociative identity disorder
PTSD
other than PTSD, list other conditions that are frequently comorbid with dissociative identity disorder
depressive
trauma and stressor related
personality
conversion
somatic symptom disorder
eating disorders
SUDs
OCD
sleep disorders
criterion A for dissociative amnesia
an inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting
*most often consists of LOCALIZED for SELECTIVE amnesia for a specific event or events or generalized amnesia for identity and life history
criteria B-D for dissociative amnesia
clinically significant distress
not attributable to substance/neuro/med condition
not better explained by DiD, PTSD, acute stress disorder, somatic symptom disorder, NCD
name the specifier available for dissociative amnesia
with dissociative fugue
what is dissociative fugue
apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical info
how does dissociative amnesia differ from permanent amnesias due to neurobiological damage or toxicity that prevent memory storage/retreival
in dissociative amnesia, memory loss is almost always reversible because the memory has been successfully stored
what is localized amnesia
failure to recall events during a circumscribed period of time
may be broader than amnesia for a single traumatic event (i.e may span years of abuse)
*most common form of dissociative amnesia
what is selective amnesia
may recall some but not all of the events during a circumscribed period of time
what is generalized amnesia
complete loss of memory for ones life history
*rare
may forget personal identity, lose knowledge of the work (i.e semantic knowledge) and can no longer access well learned skills (i.e procedural knowledge)
how does generalized amnesia usually present
acute onset
perplexity, disorientation and purposelessness of wandering usually bring them to attention of police or ER services
generalized amnesia may be more common amongst which populations
combat veterans
sexual assault victims
individuals experiencing extreme emotional stress or conflict
are people with dissociative amnesia usually aware of their memory problems
no they are frequently UNaware of the problem
what is systematized amnesia
losing memory for a specific CATEGORY of into–> i.e all memories related to ones family, a particular person etc)
what is continuous amnesia
individual forgets each new event as it occurs
what is the estimated 12 month prevalence of dissociative amnesia in the USA
1.8% (in a small US community)
are men or women more frequently affected by dissociative amnesia
women
how does the presentation of dissociative amnesia change over the lifespan
dissociative capacities may decline with age
as amnesia remits, there may be considerable stress, suicidal behaviour, symptoms of PTSD
the memory loss of those with dissociative amnesia may be particularly refractory in which patients
those with dissociative fugue
what is one way to modify the course of dissociative amnesia
removal from the traumatic circumstances underlying the dissociative amnesia (i.e from combat) may bring about rapid return of memory
in what types of cultures might the precipitants of dissociative amnesia often not involve frank trauma
cultures with highly restrictive social traditions
amnesia may in these cases be preceeded by severe psychological stresses or conflicts i.e marital conflict, other family disturabnces, attachment problems, conflicts due to restriction or oppression
suicidal behaviour may be a particular risk in those dissociative amnesia at what stage of illness
if/when amnesia remits suddently and person is overwhelmed by intolerable memories
ddx dissociative amnesia
dissociative identity disorder
PTSD
neurocognitive disorders
substance related disorders
posttraumatic amnesia due to brain injury
seizure disorders
catatonic stupor
factitious disorder and malingering
normal and age related changes in memory
in someone with PTSD who cannot recall all or part of a specific traumatic event, when is an additional dx of dissociative amnesia also warranted
when the amnesia extends beyond the immediate time of the trauma
how do you distinguish dissociative amnesia from neurocognitive disorders
in dissociative amnesia, intellectual and cognitive abilities are preserved unlike in NCDs
feigned (factitious) amnesia is more common in what circumstances/populations
- acute, florid dissociative amnesia
- financial, sexual or legal problems
- a wish to escape stressful circumstances
may individuals with dissociative amnesia also have symptoms that meet criteria for what other disorder(s)
somatic symptom disorders and conversion disorder
PDs–> especially dependent, avoidant and borderline
criterion A for depersonalization/derealization disorder
presence of persistent or recurrent experiences of depersonalization, derealization or both
criterion B for depersonalization/derealization disorder
during the deperson/derealiz. experiences, reality testing remains INTACT
criteria C-E for depersonalization/derealization disorder
clinically sig. distress
not attributable to sub/med condition
not better explained by another disorder
how might someone with depersonalization describe the experience
detached from entire being or from parts of self (i.e emotions, thoughts)
“The individual may feel detached from his or her entire being (e.g., “I am no one,” “I have no self”). He or she may also feel subjectively detached from aspects of the self, including feelings (e.g., hypoemotionality:303“I know I have feelings but I don’t feel them”), thoughts (e.g., “My thoughts don’t feel like my own,” “head filled with cotton”), whole body or body parts, or sensations (e.g., touch, proprioception, hunger, thirst, libido). There may also be a diminished sense of agency (e.g., feeling robotic, like an automaton; lacking control of one’s speech or movements). The depersonalization experience can sometimes be one of a split self, with one part observing and one participating, known as an “out-of-body experience” in its most extreme form. The unitary symptom of “depersonalization” consists of several symptom factors Sierra et al. 2005; Simeon et al. 2008: anomalous body experiences (i.e., unreality of the self and perceptual alterations); emotional or physical numbing; and temporal distortions with anomalous subjective recall.”=
how might someone with derealization describe the experience
“Episodes of derealization are characterized by a feeling of unreality or detachment from, or unfamiliarity with, the world, be it individuals, inanimate objects, or all surroundings (Criterion A2). The individual may feel as if he or she were in a fog, dream, or bubble, or as if there were a veil or a glass wall between the individual and world around. Surroundings may be experienced as artificial, colorless, or lifeless. Derealization is commonly accompanied by subjective visual distortions, such as blurriness, heightened acuity, widened or narrowed visual field, two-dimensionality or flatness, exaggerated three-dimensionality, or altered distance or size of objects (i.e., macropsia or micropsia). Auditory distortions can also occur, whereby voices or sounds are muted or heightened.”
what is a commonly associated symptom with depersonalization/derealization disorder
subjectively altered sense of time (i.e too fast or too slow)
subjective difficulty in recalling past memories and owning them as personal and emotional
with regard to physiologic reactivity to emotional stimuli, how do those with depersonalization/derealization disorder differ from normal controls
those with depersonalization/derealization disorder have been found to have physiological HYPOreactivity to emotional stimuli
list the neural substrates of interest in depersonalization/derealization disorder
hypothalamic-pituitary-adrenocortical axis
inferior parietal lobule
prefrontal cortical-limbic circuits
do people in the general population experience depersonalization/derealization
yes–> transient symptoms lasting hours to days are common in the general population
approx. half of all adults have experienced at least one episode of depersonalization/derealization
*full disorder is MUCH less common–seems to be lifetime prevalence of about 2% for full disorder
are males or female more affected by depersonalization/derealization disorder
equal
what is the mean age at onset of depersonalization/derealization disorder
16 years old
*less than 20% of people experience onset after age 20 and only 5% after age 25
*onset in 4th decade of life or later is highly unusual
what is the natural course of depersonalization/derealization disorder
can be sudden or gradual onset
duration of episodes can vary widely (brief = hours or days to prolonged = months or years)
course is often PERSISTENT
1/3–> discrete episodes of depersonalization/derealization
1/3–> continuous symptoms from the start of symptom onset
1/3–> initially episodic course that eventually becomes continuous
list some factors that can trigger exacerbations of depersonalization/derealization disorder
stress
worsening mood or anxiety symptoms
novel or overstimulating settings
physical factors like lack of sleep
list 3 temperamental characteristics common to those with depersonalization/derealization disorder
harm-avoidant temperament
immature defenses
both disconnection and overconnection schemata
list some of the immature defenses common in those with depersonalization/derealization disorder
idealization/devaluation
projection
acting out resulting in denial of reality and poor adaptation
describe cognitive “disconnection schemata” (predispose to depersonalization/derealization disorder)
reflect DEFECTIVENESS and emotional inhibition
subsume themes of abuse, neglect and depreivation
describe cognitive “overconnection schemata” (predispose to depersonalization/derealization disorder)
involved IMPAIRED AUTONOMY with themes of dependency, vulnerability and incompetence
list environmental risk factors for depersonalization/derealization disorder
clear association with depersonalization/derealization disorder and childhood interpersonal traumas (not as pervalent as in other dissociative disorders)
–> esp. emotional abuse and emotional neglect
physical abuse
witnessing domestic violence
growing up with seriously impaired, mentally ill parent
unexpected death or suicide of family member or close friend
(sexual abuse = much less common antecedent but can be encountered)
list the most common PROXIMAL precipitants of depersonalization/derealization disorder
severe stress
depression
anxiety (esp. panic attacks)
illicit drug use
list substances that can specifically induce depersonalization/derealization disorder
THC
hallucinogens
ketamine
MDMA
salvia
*marijuana use may precipitate new onset panic attacks and depersonalization/derealization disorder simultaneously
how do people with depersonalization/derealization disorder often appear affectively
may be affectively flattened or robotic–> at odds with extreme emotional pain reported by those with the disorder
*hypoemotionality may lead to significant interpersonal dysfunction
ddx depersonalization/derealization disorder
illness anxiety disorder
MDD
OCD
other dissociative disorders
anxiety disorders
psychotic disorders
sub/med induced disorders
due to another medical condition
in what % of cases of depersonalization/derealization disorder can the onset be tied to ingestion of a substance (with symptoms persisting beyond intox/withdrawal)
about 15%
if someone were to present with symptoms of depersonalization/derealization disorder after age 40, what tests should you do to rule out an underlying medical condition
consider:
lab studies
viral titres
EEG
vestibular testing
visual testing
sleep studies
brain imaging
may need ambulatory EEG if think there is a seizure disorder
which type of epilepsy is most commonly implicated in cases where patients present with depersonalization/derealization symptoms
temporal lobe epilepsy
patietal and frontal epilepsy is also possible
list commonly comorbid conditions with depersonalization/derealization disorder
unipolar depressive
anxiety disorders
comorbidity with PTSD was LOW
what are the 3 most commonly comorbid personality disorders with depersonalization/derealization disorder
avoidant
borderline
OCPD
list 4 examples of presentations that can be specified using the “other specified” designation for dissociative disorders
- chronic and recurrent syndromes of mixed dissociative symptoms
- identity disturbance due to prolonged and intensive coercive persuasion
- acute dissociative reactions to stressful events
- dissociative trance
define “chronic and recurrent syndromes of mixed dissociative symptoms”
includes identity disturbance associated with less-than-marked discontinuities in sense of self and agency
or alterations of identity or episodes of possession in an individual who reports no dissociative amnesia
define “identity disturbance due to prolonged and intensive coercive persuasion”
individuals who have been subjected to intense coercive persuasion (i.e brainwashing, thought reform, indoctrination while captive, torture, long term political imprisonment, recruitment by sects/cults or by terror organizations) may present with prolonged changes in, or conscious questioning of, their identity
when might you use the diagnosis “acute dissociative reactions to stressful events”
for acute, TRANSIENT conditions that typically last LESS THAN one month (sometimes only a few hours or days)
characterized by CONSTRICTION of consciousness, depersonalization, derealization, perceptual disturbances (i.e time slowing), microamnesias, transient stupor, and/or alterations in sensory-motor functioning (i.e analgesia, paralysis)
what is “dissociative trance”
condition characterized by narrowing or complete loss of awareness of immediate surroundings that manifests as profound UNRESPONSIVENESS or INSENSITIVITY to environmental stimuli
unresponsiveness may be accompanied by minor or stereotyped behaviours (i.e finger tapping) of which the individual in unaware and/or that they cannot control as well as transient paralysis or loss of consicousness
NOT a normal part of a broadly accepted cultural or religious practice
is dissociative identity disorder a valid cross-cultural diagnosis
appears to be, according to guidelines for treating DiD in adults from 2011
what model of therapy is the state of the art approach for treatment of complex PTSD
phase based or sequential model
at what age does dissociative capacity “peak”
around age 9-10 and rapidly declines during adolescence (i.e absorption in every day activities, daydreaming, fantasy, dreaming)
is there a biological predisposition to dissociation
yes–> pathological dissociation appears to be inherited
hypnotizability also is a biological predisposition, with higher predisposition to hynotizability seen in dissociation disorders
what is the developmental window after which it is difficult/unlikely for trauma to cause dissociative identity disorder
infancy to age 6 –> after age 6, difficult to cause DiD
trauma is usually repetitive and severe
associated with disturbed parental/child affective communications contributing to disorganized-dissociative attachment
what parenting style is associated with DiD in the child
rigid
authoritarian
role inversion
what are the four factors in Klufts “4 factor theory” of DiD
1–> capacity to dissociate (relates to hypotizability and other factors)
2–> overwhelmed by traumatic events or circumstances, including losses
3–> personality and sense of “self” forms around traumas, using various defences especially dissociation
4–> failure of significant others to protect and nurture the child
hyper-arousal and re-experiencing in the face of trauma is hypothesized to be related to what neurobiological dysfunction
failure of CORTICOLIMBIC inhibition
i.e UNDER-modulation by medial prefrontal cortex to limbic structures especially the amygdala
dissociation in the face of trauma is hypothesized to be related to what neurobiological dysfunction
OVER-modulation of limbic structures (including amygdala) by the medial prefrontal and anterior cingulate cortices (i.e too much inhibition of these areas)
–> see reduced hippocampal and amygdala volume on imaging in PTSD + DD but not with DD alone
who came up with the “autohypnosis theory” of conversion disorder
Dr. Pierre Janet in 19th century
–> innate hypnotic capacities to induce self-hypnosis as a defence against trauma/unbearable emotions
–> conversion symptoms involve dissociation of sensory and motor processes
what scales/questionnaires can be used to assess for dissociative disorders
Dissociative Experiences Scale
Traumatic Experiences Questionnaire
Dissociative Disorders Interview Schedule
Multidimensional Inventory of Dissociation
borderline personality disorder is diagnosable in what % of DiD sufferers
30-70%
DiD IS diagnosed in what % of those with BPD
10-27%
what is the most common comorbid disorder with dissociative disorders
depressive
what types of psychological treatments might be indicated for DiD
psychodynamic psychotherapy –> deal with alters
CBT
hypnosis
what types of medications might be indicated to treat DiD
SSRIs and lorazepam
are there any RCTs for psychotherapies in DiD
no–> expert concensus
why should you avoid working directly with the “alters” in DiD too much (vs via the host)
working around the host too much of the time colludes with the fragmented system
i.e “ask the angry one why that happened”
how is treatment for DiD approached
phase-oriented, like c-PTSD
describe the developmental model for the etiology of DiD
hypothesizes that alternate identities result from the inability of many traumatized children to develop a unified sense of self that is maintained across various behavioural states, especially if the trauma first occurs before age 5
Freud–> fragmentation and encapsulation of traumatic experiences may serve to protect relationships with important (though inadequate or abusive) caregivers and allow for more normal maturation in other developmental areas (i.e intelelctual, interpestonal, artistic endeavors)
“these developmental models posit that DiD does not arise from a previously mature, unified mind or “core personality” that becomes fractured but rather results from a failure of normal developmental integration caused by overwhelming experiences and disturbed caregiver-child interactions during critical early developmental periods”
what should patients be asked about when screening for DID
episodes of amnesia
fugure
depersonalization
derealization
identity confusion
identity alteration
what type of psychotherapy may be particularly helpful for resolving somatoform symptoms seen in DID
sensorimotor psychotherapy
how should the therapist understand the DID patient
as a whole adult person (not as a collection of separate people sharing the same body) with the identities sharing responsibility for daily life
generally must hole the whole person (i.e system of alternate identities) responsible for the behaviour of any or all of the constituent identities even in the presence of amnesia or the sense of lack of control or agency over behaviour
what is the goal of treatment of DID
“integrated functioning”
treament should move the patient toward better integrated functioning whenever possible
helping the identities be aware of one another as legitimate parts of the self and to negotiate as resolve their conflicts is at the very core of the therapeutic process
want sufficiently integrated and coordinated functioning among alternate identities to promote optimal functioning –> either through “resolution” (cooperation among alters) or “final fusion” (no remaining separation between identities remaining)
what are the 3 phases of DID treatment
- safety–> establishing safety, stabilization and symptom reduction
- confronting, working through and integrating traumatic memories
- identity integration and rehabilitation
what is often an essential component of the first/safety phase of DID treatment
skills training
–enhacing emotional awareness + regulation
–decreasing affect phobia
–building distress tolerance
–learning to optimize effectiveness in relationships
i.e Seeking Safety program
what is the primary treatment modality for DID
outpatient psychotherapy
usually requires years of treatment
minimum frequency usually once a week
what is the most commonly recommended psychotherapeutic treatment orientation for DID
individual psychodynamically oriented psychotherapy
–
*hypnosis may be adjunctive
*may incorporate some ideas from CBT
is group therapy generally recommended for DID
generally not great for DID, especially as primary treatment modality–have trouble tolerating affects of others especially if discussing trauma
is pharmacology a primary treatment modality for DID
no–however most people with DID are on meds for some aspect of presentation
what symptoms are most commonly targeted by meds in DID
hyperarousal and intrusive symptoms of PTSD and comorbid conditions like mood d/os and OCD symptoms
think of meds as “shock absorbers” rather than as curative interventions
what older medication might be particularly helpful for those with DID
clomipramine (TCA)
in what context might naltrexone be used for the treatment of DID
may have some efficacy in decreasing the pressure for self mutilation or other self destructive and self stimulatory behaviours (especially if patient reports a “high” from self harm)
