dissociative disorders

Depersonalization/Derealizaition Disorder

- characterized by the persistence or recurrence of depersonalization and/or derealization that cause clinically significant distress or impairment in the presence of intact reality testing

Self-alteration

the sense that one part of one's self is markedly different from another part of one's self.

Symptoms of Dissociative Amnesia

-Confused, Depressed, Anxious, Attain unexplained possessions -Inexplicable changes in relationships -Loss of Procedural Memory: forgetting motor skills -Loss of Semantic Memory: Objects, facts, concepts -Loss of Episodic Memory: specific events

Comorbidities of DDD:

-DDD appears to have high rates of comorbidity with other psychiatric disorders: -Unipolar depression, Any anxiety disorder -Obsessive-compulsive disorder -Avoidant personality disorder -Borderline personality disorder

A 19-year-old college student who was suffering from sleep deprivation at the onset of depersonalization disorder. The young man experienced increased anxiety as he struggled to meet his responsibilities as a scholarship-dependent student athlete. Teammates expressed concern about his apparent distress to their coach, who arranged for the young man to speak with a therapist. The young man described feeling as though he were observing the interactions of others as if it were a film. The young man's anxiety was determined to contribute to severe sleep deprivation, which triggered episodes of depersonalization. Which Dissociative disorder does he most likely have?

Depersonalization/Derealization disorder!

Depersonalization

a feeling of detachment or estrangement from one's self, for example, feeling outside of one's body, or that one is observing oneself from the outside.

Derealization

a feeling that the external world is strange or unreal

Treatment of DDD

-First-line treatment: psychotherapy, in particular CBT -Therapy should include education about the disorder and reassurance and maintaining hope for the future. Psychotherapy should be provided weekly for a minimum of three months. -In patients with DDD and significant comorbid depression or anxiety, CBT should target both conditions. >>If comorbid depression, the patient can be started on an SSRI (paroxetine recommended). >>If comorbid anxiety, the patient can be started on a benzodiazepine (clonazepam recommended). -If the patient suffers from pronounced emotional numbing that is not responding to CBT, then they can be started on naltrexone.

Dissociative Identity Disorder (DID)

-Formerly known as "Multiple Personality disorder" - presents with a disruption of identity characterized by the presence of two or more distinct personality states and recurrent gaps in recall of personal information or events. Manifestations of the disorder can include alterations in affect, behavior, consciousness, perception, cognition, and/or sensory-motor functioning -Distinct personality states in DID are reported to be experienced by the patient or others as having different characteristics, such as ages, genders, sexual orientation, and abilities.

Dissociative Amnesia

-Is a potentially reversible memory impairment that primarily affects autobiographical memory -A person may block out parts of their memory due to a stressful or traumatic event >>Psychological trauma in the form of sexual abuse, military combat, or torture are strong triggers. -Different from simple amnesia. Memories exist with dissociative amnesia but they are hidden away until they resurface due a trigger or something around a persons surroundings. -7.3 to 11.4 % of psychiatric patients have Dissociative Amnesia, Women > men

Types of Dissociative Amnesia

-Localized: Can't remember specific period of time -Selective: Inability to remember some, but not all -Systematized: Won't be able to remember certain categories -Continuous: Won't be able to remember successive events as they occur -Generalized: Can't recall whole life

Risk Factors for DDD

-Men=women -Acute and chronic trauma or severe stress- Childhood abuse or neglect & Unexpected death of a loved one -Growing up with a seriously mentally ill parent -Sexual orientation conflicts in adolescence -Serious family or work stressors -Psychiatric conditions, most commonly anxiety or depressive disorders -Substance abuse -Some patients do not have any clearly identifiable cause or trigger!

Diagnosis of Dissociative Amnesia

-No lab tests to diagnose, but may be done to r/o other conditions DSM 5 Criteria include -Inability to remember important autobiographical information, typically from a traumatic or stressful event -Symptoms cause considerable distress or impairment in social, occupational, or other areas -Amnesia is not related to physiological effects of a substance. For instance, alcohol, drugs, or other medical condition. -Not clearly diagnosed to be dissociative identity disorder, PTSD, acute stress disorder and etc...

Comorbidities of DID

-PTSD 79-100% -Depression 83-96% -Substance Abuse 83-96% -Headaches -Non-epileptic Seizures -Avoidant Personality Disorder -Boarder line Personality Disorder

Treatment of Dissociative Amnesia

-Relief of symptoms should be first goal -Treatment strategies may include -Medications: for depression or anxiety -CBT, Psychotherapy -Creative therapies- Using art or music to help patient express their thoughts

Treatment of DID

-The Dissociative Experiences Scale (DES) is a self-assessment screening tool (a questionnaire) that is useful for identifying people who experience a high degree of dissociation. A definite diagnosis should only be made by a qualified clinician. -Psychotherapy is the mainstay of treatment -Eye movement desensitization and reprocessing (EMDR), a treatment method that integrates traumatic memories with the patient's own resources, is being increasingly used in the treatment of people with dissociative identity disorder. -Hypnosis is sometimes used to help people with DID learn more about their personality states in the hope of their gaining better control of those states. -Medications. There is no medication to treat DID since it is not an organic disorder or a chemical imbalance. However, antidepressants and anxiolytics might help with mood disorders.

Risk Factors of DID

1. Retrospective studies have found that a high proportion of patients diagnosed with DID report a history of severe, chronic childhood trauma, usually childhood physical and/or sexual abuse, which begins before age 6. 2. Childhood sexual abuse, 70 to 100 percent (median 83 percent) 3. Childhood physical abuse, 60 to 95 percent (median 81 percent) 4. Childhood trauma of any type, 77 to 100 percent (median 94 percent)

Symptoms of DDD

5 symptom clusters common in patients with DDD: -Unreality of self, defined as feeling detached from one's physical body, mind and thoughts -Perceptual alterations, which encompasses visual, tactile, and somatosensory distortions -Emotional numbing, characterized by blunted affect, pain & volition -Anomalous subjective recall, which consists of disrupted experiences of time and related imagery -Alienation from surroundings, which comprises symptoms of derealization

DSM-5 diagnostic criteria for dissociative identity disorder (DID)

A. Disruption of identity characterized by two or more distinct personality states. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. >>Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play. E. The symptoms are not attributable to the physiological effects of a substance (eg, blackouts or chaotic behavior during alcohol intoxication) or another medical condition (eg, complex partial seizures

Diagnosis of DDD

A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both: >>1. Depersonalization - Experiences of unreality, detachment, or being an outside observer with respect to one's thoughts, feelings, sensations, body, or actions (eg, perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing). >>2. Derealization - Experiences of unreality or detachment with respect to surroundings (eg, individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted). B. During the depersonalization or derealization experiences, reality testing remains intact. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance is not attributable to the physiological effects of a substance (eg, a drug of abuse, medication) or another medical condition (eg, seizures). E. The disturbance is not better explained by another mental disorder such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.

A 29-year-old female was found in a hotel bathroom unconscious, with no signs of structural or neurologic abnormalities or alcohol or chemical consumption. The woman was sent home but could not remember her name, address, family, or any facts about her home life. The amnesia persisted for nearly 10 months, until the feeling of blood on the woman's fingers triggered the recollection of events from the night of onset of dissociative amnesia, and, subsequently, other facts and events. The woman finally remembered having witnessed a murder that night in China. She recalled being unable to help the victim out of fear for her own safety. She came to remember other aspects of her life; however, some memories remain elusive. Which dissociative disorder does she likely have?

Dissociative amnesia!

A woman who had been physically and sexually abused by her father throughout her childhood and adolescence exhibited at least 4 personalities as an adult. Each personality was of a different age, representing the phases of the woman's experience-a fearful child, a rebellious teenager, a protective adult, and the woman's primary personality. Only one of the personalities, the protective adult, was consciously aware of the others, and during therapy sessions was realized to have been developed to protect the woman during the abusive experiences. When one of the secondary personalities took over, it often led to episodic dissociative amnesia, during which the woman acted out according to the nature of the dominating personality. During intensive therapy sessions, each personality was called upon as necessary to facilitate their integration. Which Dissociative disorder does Mrs. CP most likely have?

Dissociative identity disorder!

Amnesia

Individuals with DID experience recurrent episodes of amnesia. The presence of recurrent gaps in memory is required by DSM-5 diagnostic criteria for DID. Patients typically report that they have periods of time (most often hours) that they cannot remember. From secondary reports, these periods may be associated with certain mood states or behaviors (eg, angry outbursts).

Auditory Hallucinations

Patients with DID may report somatoform symptoms — physical symptoms that suggest a general medical illness that cannot be explained by a presence of a general medical condition, substance use, or other mental disorder.

Depersonalization

a persistent or recurrent feeling of detachment or estrangement from one's self. An individual experiencing depersonalization may report feeling like an automaton or as if in a dream or watching himself or herself in a movie. Depersonalized individuals may report the sense of being an outside observer of their mental processes or their body. They often report feeling a loss of control over their thoughts, perceptions, and actions.

Derealization

a subjective sense of detachment or unreality regarding the world around them (eg, individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).

Trance state

involves a narrowing of awareness of one's immediate surroundings or stereotyped behaviors or movements that are experienced as being beyond one's control