Trastornos Disociativos Flashcards
11.1.
A wife brings her husband to the emergency room (ER)
presenting with unusual behavior. She noted that he doesn’t
remember her or his name, his job, and is acting like a child.
Which diagnosis is most likely?
A. Acute stress disorder
B. Dissociative amnesia
C. Dissociative fugue
D. Malingering
E. Transient global amnesia
11.1. B. Dissociative amnesia
This case presents a classic description of dissociative amenia,
including a patient with a history of an acute trauma and physical
symptoms including alterations in consciousness, a trance state, age
regression, anterograde dissociative amnesia, etc. Dissociative fugue
involves a sudden, unexpected travel away from the usual place
where the person resides, along with the amnesia and identity
confusion. While there is no absolute way to differentiate dissociative
amnesia from a factitious disorder or malingering, often there is a
history of the individual trying to escape legal, financial, or personal
difficulties. Often, these patients will confess spontaneously when
confronted. While dissociative amnesia can be a part of an acute
stress disorder, the other acute stress features are not also present in
this case. Transient global amnesia involves a sudden onset of
complete anterograde amnesia, along with retrograde amnesia, while
there is preservation of personal identity and an anxious awareness
of the memory loss.
11.2.
Which symptom is more indicative of a seizure disorder rather
than a dissociative amnesia?
A. Alterations in consciousness
B. Ongoing depersonalization
C. Persistence of memory impairment
D. Sudden wandering and traveling away from a main
residence
E. Quick resolution of bizarre behaviors
11.2. E. Quick resolution of bizarre behaviors
While seizures should be part of the differential diagnosis for
dissociate amnesia and in some cases, the diagnosis can only be
clarified by EEG monitoring, for the most part, the clinical
presentation of seizures differs from dissociate amnesia. With
seizure, there are clear-cut ictal events and the patient can show
wandering, semipurposeful, or bizarre behavior and memory
problems but rarely do after postictal event. Changes in
consciousness and depersonalization can be seen with dissociative
amnesia and a sudden change in residence can be seen with
dissociative fugue
11.3.
Which of the following DSM-5 criteria for
depersonalization/derealization disorder is only present for
derealization symptoms and not for depersonalization?
A. Detachment from surroundings
B. Feelings of observing
C. Perceptual distortions
D. Sense of unreality
E. Time distortion
11.3. A. Detachment from surroundings
While feelings that things aren’t real can be a part of
depersonalization or derealization symptoms, the only other DSM-5
criteria to describe derealization includes feeling detached from one’s
surroundings. Depersonalization symptoms including feeling
detached from oneself and feeling as if observing oneself, along with
time and perceptual distortions.
11.4.
Which personality traits are most commonly seen with
dissociative identity disorder?
A. Avoidant
B. Borderline
C. Obsessive compulsive
D. Narcissistic
E. Schizotypal
11.4. C. Obsessive compulsive
Obsessive compulsive disorder (OCD) symptoms along with
obsessive compulsive personality traits are most commonly seen in
dissociative identity disorder. Compulsive checking, handwashing,
and counting often occur in those with dissociative phenomena,
abuse, and post-traumatic stress disorder (PTSD) symptoms.
11.5.
A patient is evaluated in the emergency room after being
brought in off the street and was found to be in a trance-like
state. The patient is unable to identify their age or address.
Upon cognitive testing, the patient replies that 2 + 2 is 5 and
hands the doctor a key when asked to hand a pencil. When
asked to point to the color green, the patient points to
something gray. The patient reports feeling confused due to
hearing voices and seeing strange things. These symptoms
best fit which of the following diagnoses?
A. Depersonalization disorder
B. Derealization disorder
C. Dissociative identity disorder
D. Ganser syndrome
E. Transient global amnesia
11.5. D. Ganser syndrome
Ganser syndrome is characterized by giving approximate answers
and often the correct answer is passed over for a related, but
incorrect one. It also includes clouding of consciousness or
conversion symptoms, along with dissociative symptoms, such as
amnesia, along with trance-like behaviors, and in half of the cases,
visual and auditory hallucinations are also reported. In dissociative
identity disorder, acute forms of amnesia along with a fugue episode
can be present. These patients report multiple forms of complex
amnesia including recurrent blackouts, and have fluctuations in
skills, habits, and knowledge. Depersonalization disorder is the
persistent feeling of detachment or estranged from one’s self.
Derealization involves feelings of unreality or being detached from
one’s environment. Transient global amnesia includes a sudden
onset of complete anterograde amnesia, along with pronounced
retrograde amnesia but preservation of memory for personal identity
is intact.
11.6.
While often a treatment-refractory group, those with
depersonalization and derealization disorders appear to
partially benefit from which of the following medication
treatments?
A. Atypical antipsychotics
B. Mood stabilizers
C. Serotonin reupdate inhibitors
D. Tricyclic antidepressants
E. Typical antipsychotics
11.6. C. Serotonin reuptake inhibitors
Those with depersonalization and derealization disorders might
partially respond to medication including serotonin reupdate
inhibitors, benzodiazepines, and stimulants. Also, there is some
evidence for opioid antagonists and cognitive enhancers in helping
with depersonalization and derealization disorders. There is
absolutely no empirical evidence to support the use of either typical
or atypical antipsychotics and these medications may increase
feelings of emotional deadness
11.7.
Which is the first step in psychotherapy in treating a patient
with dissociative identity disorder?
A. Establishing safety and symptom stabilization
B. Fusion and integration of all states
C. Improved communication and collaboration with self-states
D. Hypnotherapeutic interventions
E. Processing of traumatic memories and life experiences
11.7. A. Establishing safety and symptom stabilization
Psychotherapy using a phasic model to treat the complex
posttraumatic disorder is mainstay treatment for dissociative
identity disorder. Phase 1 consists of stabilization of the dissociative
symptoms and comorbid symptoms and establishing safety. Phase 2
involves working on the traumatic memories and making sure the
patient is stabilized and aware of the risk of acute worsening of PTSD
symptoms. Phase 3 involves fusion, reintegration, and recovery.
While hypnotherapy can alleviate some symptoms such as flashbacks
and dissociative hallucinations, some controversies exist and it
should not be the first step in psychotherapy.
11.8.
Limitations of dialectical behavioral therapy (DBT) for
treatment of dissociative identity disorder include a lack of
focus in which of the following areas?
A. Affect regulation
B. Depersonalization/derealization and flashbacks
C. Distress tolerance
D. Safety and wellness
E. Therapy-interfering behaviors
11.8. B. Depersonalization/derealization and flashbacks
DBT was developed for the treatment of borderline personality
disorder. Given many patients with borderline personality disorder
report trauma histories, it has been thought that DBT might help
those with dissociative identity disorder as well. DBT focuses on
safety, therapy-interfering behaviors, affect regulation strategies,
distress tolerance, and radical acceptance, all of which can be helpful
in the treatment of dissociative identity disorder. However, one
limitation is that it does not directly focus on the main symptoms of
dissociative identity disorder, including
depersonalization/derealization and dissociative amnesia, along with
flashbacks, and trauma-based symptoms.
11.9.
Which somatic treatment strategy is most useful for patients
with dissociative identity disorder?
A. Selective serotonin reuptake inhibitor (SSRI) treatment
should be initiated as first-line therapy
B. Stick with smaller doses of alpha-antagonists to best help
with nightmares
C. Treat comorbid symptoms present across most
personalities
D. Use typical antipsychotics to decrease anxiety and
flashbacks
E. Utilize electroconvulsive therapy (ECT) for those with
persistent psychotic features
11.9. C. Treat comorbid symptoms present across most
personalities
Various medications might be useful in the treatment of dissociative
identity disorder. Often nightmares are responsive to higher doses of
alpha-adrenergic antagonists, such as prazosin, if tolerated.
Antidepressant medications including SSRIs, tricyclics, and
monoamine oxidase inhibitors (MAOIs) can be helpful in reducing
depression and stabilizing mood. Atypical neuroleptics are more
effective and better tolerated compared to typical ones for helping
with severe anxiety and PTSD symptoms. However, the most
effective strategy is to target comorbid symptoms that are present
across most or all personalities. Given rapid symptom fluctuations in
this disorder, it is important to avoid chasing each symptom with a
new medication or change in dose.
11.10.
After depression and anxiety, which of the following is the
third most commonly reported psychiatric symptom?
A. Attentional/focusing issues
B. Auditory/visual hallucinations
C. Body checking/restricting
D. Delusions/paranoia
E. Depersonalization/derealization
11.10. E. Depersonalization/derealization
Transient experiences of depersonalization/derealization can be
prevalent in both normal and clinical populations and are the third
most commonly reported psychiatric symptom following depression
and anxiety. A lifetime prevalence is estimated to be anywhere from
26% to 74%.
