Lecture 14: Dissociative Disorders Flashcards
Define dissociation.
Segregation of any group of mental processes from the rest of someone’s physiological activity.
What are the 5 core symptoms of dissociative disorders?
- Amnesia
- Depersonalization
- Derealization
- Identity Confusion
- Identity Alteration
Define depersonalization.
Sense of detachment or disconnection from one’s self.
No longer personal.
Often described as stranger in one’s own body.
Feeling like you’re a robot or on autopilot.
Define derealization.
Sense of disconnection from familiar people or one’s surroundings.
No longer reality.
Often described as friends and work seeming unreal or unfamiliar.
Define identity confusion.
Inner struggle about one’s sense of self/identity
I don’t know who I am anymore
I don’t know which me is the real me
Define identity alteration.
Sense of acting like a different person some of the time.
Like split personalities
May use different names in different situations.
May have a learned skill without recollection of learning that ability.
What falls under dissociative disorders?
Dissociative amnesia
Depersonalization/Derealization disorder
Dissociative Identity Disorder
Define dissociative amnesia.
Potentially reversible memory impairment that primarily affects AUTObiographical memory (name, address, phone #).
Cannot recall personal info.
Define dissociative fugue.
Sudden unexpected travel or wandering in a dissociated state, with subsequent dissociative for the episode.
Subtype of dissociative amnesia
Usually occurs due to looking for the gaps in their memory.
When do we usually see dissociative amnesia?
Late adolescence/early adulthood
What is the diagnostic criteria for Dissociative Amnesia?
- Inability to recall important AUTObiographical information, usually of a traumatic or stressful nature, INCONSISTENT with ordinary forgetfulness.
- Significant distress/impairment in functioning
- Not caused by something else (Ex: Alzheimer’s)
- To add on dissociative fugue, must include purposeful travel or bewildered wandering associated with amnesia.
DX: Dissociative Amnesia w/ Dissociative fugue or just DA.
What are the 5 types of dissociative amnesia?
- Localized amnesia
- Continuous amnesia
- Generalized amnesia
- Selective amnesia
- Systematized amnesia
Systematized example: failure to rememer a category of info, such as all memories related to one’s family.
What is the treatment of choice in dissociative amnesia?
- Phase oriented psychotherapy (Standard of care)
- Cognitive therapy
- Hypnosis
- Group therapy
What is the role of meds in dissociative amnesia?
No use in standard treatment.
Benzos/amphetamines/barbs can be used to facilitate interviews.
What are the 3 phases in phase-oriented therapy?
- Stabilization and safety
- Work on traumatic memories
- Fusion, integration, resolution, and recovery
Fusion is combining 2+ psychological entities at a point in time, w/ subjective loss of all separateness.
How common is depersonalization/derealization disorder (DDD)?
Transient is more common, but it is generally rare in general.
1-3% lifetime prevalence.
What is the main risk factor and comorbidities for DDD?
Risk factor: Chronic trauma/stressor exposure
Depression and anxiety
What is the diagnostic criteria for DDD?
- Presence of persistent or recurrent experiences of depersonalization, derealization, or both
- Reality testing remains intact
- Causes distress
- Not due to a condition/mental disorder
What is reality testing?
If you ask a patient about reality, they answer appropriately still even while under derealization.
How is DDD treated?
Refractory to treatment often.
Psychotherapy often gives mixed results.
SSRIs may be helpful.
Define Dissociative Identity Disorder (DID).
Two or more distinct selves with distinct memories, thoughts, opinions, and goals.
What is the common demographic for DID?
Women
20s-30s
PTSD (MCC)
Childhood trauma (MCC risk factor)
What is the diagnostic criteria for DID?
- Presence of 2+ distinct identities or personality states.
- Amnesia must occur
- Distress/functional impairment
- Disturbance CANNOT be due to cultural/religious practices
- Syndrome is not due to other conditions
What are some signs that people may have DID?
- Referring to self in first (we) or third person (they)
- Depersonalized references
- Referring to parts of themselves by their roles (the wife, the angry one)
What are the treatment options for DID?
Psychotherapy is a mainstay.
Pharmacotherapy is used to manage major symptoms.
ECT for refractory mood disorders. DOES NOT worsen dissociation.
Define impulse control disorder.
Umbrella term for conditions related to difficulty controlling a temptation or impulse.
Often characterized by the inability to resist the impulse, desire, or drive to perform an act that is OBVIOUSLY HARMFUL.
Name some examples of impulse control disorders.
- Pyromania
- Kleptomania
- Pathologic gambling
- Trichotillomania
- Intermittent Explosive Disorder
What impulse control disorders are more common in males? Females?
Males: pathological gambling and pyromania
Females: Kleptomania and trichotillomania
What are the common symptoms criteria for pathologic gambling?
Persistent, recurrent maladaptive gambling behaviors
5+ gambling-related symptoms.
What are the common symptoms of trichotillomania?
- Recurrent hair pulling with noticeable hair loss.
- Tension/anxiety before pulling it out or resisting urge.
- Pleasure, gratification, or relief when pulling out the hair.
What are the common symptoms of Kleptomania?
- Recurrent theft of items not needed
- Tension/anxiety before stealing
- Pleasure, gratification, or relief when stealing
- Stealing NOT due to anger or psychosis.
What are the common symptoms of pyromania?
- Recurrent, purposeful fire setting on MULTIPLE occasions.
- Tension/ anxiety before or resisting the urge.
- Pleasure after setting fire.
- Fascinated with fire
- Fire setting not for monetary gain or reward.
- Must cause significant distress
- Not accounted for by any other condition.
What are the 5 stages of impulsivity?
- Urge
- Tension
- Act
- Relief
- Guilt
Which impulse control disorder does not have pharmacotherapy indicated?
Pyromania
Which impulse control disorder specifically does not use SSRIs? What does it use instead?
Trichotillomania uses TCAs over SSRIs.
Which impulse control disorder can be treated with opiate antagonists?
Pathologic gambling
Define intermittent explosive disorder (IED).
- Discrete episodes of losing control of aggressive impulses.
- Aggression is out of proportion.
- Symptoms appear quickly and remit quickly.
- Between episodes, pts show genuine regret.
- Not generalized aggressiveness.
What is the common demographic for IED?
Adolescent male
What are the etiologies for development of IED?
- Genetic
- Exposure to abuse/violence
- Brain inflammation
- Decreased serotonergic activity
- Hx of T. Gondii infection
What is the diagnostic criteria for IED?
- Recurrent behavioral outbursts with either verbal/physical aggression 2x a week for 3 months.
- OR
- 3+ behavioral outbursts with destruction of property/animals in past 12 months.
- Aggression is grossly out of proportion.
- No premeditation or committed to an objective
- 6+ years old or equivalent developmental level
- Causes distress
- Not due to other condition.
What is the main difference between conduct disorder and IED?
Conduct disorder is persistent and repetitive.
How is IED treated?
- Psychotherapy may be helpful, but it is difficult.
- SSRIs, Anticonvulsants/mood stabilizers
- Adjunct therapy: antipsychotics, BBs, CCBs
Define oppositional defiant disorder.
- Enduring pattern of negativistic, hostile, disobedient behavior.
- Inability to take responsibility for their mistakes
- Commonly have problems with peer relationships and in school
- Typically display MINIMAL PHYSICAL AGGRESSION or VIOLENCE.
What are the 3 major subtypes of ODD?
- Angry/irritable: often lose temper, easily annoyed.
- Argumentative: Habitually argues with authority, intentional rule breaker.
- Vindictive: vengeful and spiteful behavior + clashing with authority.
What is the common demographic for ODD?
Males before puberty, equal after.
Average age of onset is 6, with Dx at 14.
What is the diagnostic criteria for ODD?
- 6+ months with 4+ symptoms that are shown with others, NOT including a sibling.
How does symptom frequency for ODD criteria vary depending on age?
- For ages <5, behavior should occur on most days for a period for 6+ months.
- For ages >5, beheavior should occur at least once per week for 6+ months.
How is severity rated for ODD?
- Mild: symptoms confined to 1 setting.
- Moderate: symptoms present in 2 settings.
- Severe: symptoms present in 3 settings.
What can ODD progress to?
Conduct Disorder
25% of ODD becomes conduct disorder.
How is ODD treated?
Psychotherapy is first-line therapy.
Pharmacotherapy is only indicated for comorbid conditions.
What two types of psychotherapy are especially helpful in ODD?
Family therapy
Individual therapy
What is conduct disorder?
Enduring set of behaviors that evolve over time, characterized by aggression and violation of the rights of others.
Physical destruction, theft, violation of age-appropriate rules.
What psychosocial factors are associated with conduct disorder?
- Childhood maltreatment
- Harsh or punitive parenting
- Family discord
- Lack of appropriate parental supervision
- Lack of social competence
- Low socioeconomic level
What is the common demographic for conduct disorder?
More common in adolescent males, but prevalence goes down 12+.
What is the diagnostic criteria for conduct disorder?
- Behavior causes functional impairment
- Not explained by other disorders
- 3+ of the following 15 criteria for 12+ months (1 must’ve occurred in 6 months)
- Bullying
- Animal cruelty
- Destruction of property
- Fighting
- Out late at night
- Running away from home
- Actively forcing sex
- Being cruel
- Using a weapon
- Setting Fires
- Into someone’s home, building or car
- Not going to school
- Everyday lying/conning
- Stealing while confronting a victim
- Stealing without confronting a victim
Mnemonic: BAD FOR BUSINESS
What are the 4 general categories for conduct disorder criteria?
- Trespassing and theft
- Rule Breaking
- Aggression
- Property Destruction
Mnemonic: TRAP
What are the 3 onset types for conduct disorder?
- Childhood onset: 1 symptom prior to age 10.
- Adolescent onset: no symptoms prior to age 10.
- Unspecified onset: unable to clarify age
What are the 3 severity ratings for conduct disorder?
- Mild: relatively minor harm (usually hard to Dx someone as well).
- Moderate: intermediate harm
- Severe: Considerable harm to others
What is the criteria to add on “with limited prosocial emotions” to conduct disorder?
- 2+ of the following traits over 1+ year in MULTIPLE relationships and settings.
- Lack of remorse/guilt (lack of concern with consequences)
- Callous, lack of empathy (unconcerned with others’ feelings.)
- Unconcerned about performance (blames others usually)
- Shallow or deficient affect (does not express feelings)
What is the triad associated with conduct disorder?
ADHD often has comorbid ODD.
ODD can often progress to CD.
How do we treat conduct disorder?
Psychotherapy, focusing on rewarding good behavior and early therapy.
Pharmacotherapy options
* Atypical antipsychs (resperidone)
* SSRIs
* Anticonvulsants
* Treating ADHD if present.
