dissociative disorders

what are dissociative d/o

mental d/o that involve experiencing a disconnection and lack of continuity between thoughts, memories, surroundings, actions, and identity

why do dissociative d/o typically develop

reaction to trauma, help keep difficult memories at bay

types of dissociative d/o

dissociative identity d/o, dissociative amnesia, depersonalization/derealization d/o

depersonalization frequently cooccurs w/

anxiety d/o, PTSD, severe depression

normal dissociation is

adaptive defense used to cope w/ overwhelming psychic trauma (disasters, criminal assault, sudden loss, war)

disruption of identity characterized by two+ personality states

dissociative identity d/o

marked discontinuity in sense of self/agency, alterations in affect, behavior, consciousness, memory, perception, cognition, sensory-motor functioning

dissociative identity d/o

micro dissociations

discontinuities fo thought and “thought slippages” occurring from intrusion of traumatic themes into stream of consciousness

cardinal feature of DID

multiple personalities, 2+ entities w/ characteristic and separate personality, history, affect, values, and function

common DID alter types

host, child, persecutor, opposite sex, internal helper, brazen/promiscuous, demon, “no one”

when/how do alters usually emerge

during childhood in form of imaginary protectors that help child cope w/ recurrent abuse/fear

what will often elicit an alter

exploration of puzzling events or lost time

DID ddx

partial complex seizures, schizophrenia, bipolar d/o, MD with psychotic features, Munchausen syndrome, malingering

DID/schizophrenia similarities

quasi delusions, ideas of being externally controlled, auditory hallucinations, ideas of thought loss

DID/schizophrenia differences

lack of emotional incongruity, dramatic presentation, hx of severe trauma, alter personalities, high scores on dissociation scales

what may be helpful in distinguishing DID vs schizophrenia

hypnosis

DID and bipolar d/o ddx

rapid cycling bipolar d/o sometimes confused w/ mood swings by alter switching in DID

DID and MD c psychotic features ddx

many DID pts have associated depressive mood, in MD c psychotic features auditory hallucinations and delusions are consistent w/ depressive mood

DID major tx approaches

integrate alters, seek harmony btwn alters, leave alters alone and focus on improving adaptation to present time, regard alters as artifacts (ignore them and tx other sx)

pt c DID are likely to be hypersensitive to

deceit, impatience, authoritarianism, may be distrustful or deceptive, clinicians must tolerate uncertainty and avoid premature reassurance

once DID is identified and dx communicated pt will experience

anxiety

what should be noted for each alter

name, age, sex, developmental origin, dominant affect, unique sxs/dysfxns

how to elicit specific alter

ask to speak to alter by name or behavior, ask for signal of alter’s willingness to appear

who may be most reliable informant when mapping alters

internal helper alter

types of DID tx

supportive or integrative, integrative more complex and risky

contraindications for integrative therapy in DID

severe ego defect, severe pervasive comorbid pathology, poor environmental support, incapacity of clinician to tolerate pt behavior, inability to maintain therapeutic alliance

DID integrative therapy goals

uncover dissociated/repressed traumatic experience, integrate personality fxn, replace dissociation w/ other defenses, promote confluence of entire system, improve contribution of each fragment to overall fxn

inability to recall important autobiographical information usually of traumatic/stressful nature inconsistent w/ ordinary forgetting

dissociative amnesia

localized/selective amnesia for specific event(s) or generalized amnesia for identity and life hx, may occur w/ dissociative fugue

dissociative amnesia

localized amnesia

complete amnesia for events during period of time

selective amnesia

failure to remember some but not all events during period of time

generalized amnesia

affecting entire period of life

continuous amnesia

failure to remember anything after a specific date

1st stage of dissociative amnesia

pt progresses from acute altered state of consciousness (confusion, HA, preoccupation w/ single thought/emotion)

2nd stage of dissociative amnesia

loss of personal identity

3rd stage of dissociative amnesia

rare, pt assumes new identity, usually more uninhibited and chatty than previous

dissociative amnesia ddx

delirium, dementia, vitamin deficiencies, head trauma, CO poisoning, encephalitis, secondary causes, retrograde amnesia of head, seizure d/o, transient global amnesia from cerebral vascular insufficiency

dissociative amnesia tx

patience and expectation that memory loss will soon clear, key is safe environment removed form source of stress and trusting therapeutic relationship, hypnotherapy or narcoanalysis sometimes required to facilitate recall

dissociative amnesia prognosis

dissociative amnesia and dissociative fugue usually short lived

presence of persistent/recurrent experiences of depersonalization, derealization, or both

depersonalization/derealization d/o

depersonalization

experiences fo unreality, detachment, or being an outside observer to one’s thoughts, feelings, sensations, body, or actions

derealization

experiences of unreality or detachment regarding surroundings

depersonalization/derealization ddx

merges imperceptibly w/ other d/o, anxiety d/o, other dissociative d/o, depression, borderline personality d/o, schizophrenia, substance abuse, epilepsy

depersonalization in epilepsy

may be aura, part of seizure, or btwn seizures, likely more associated w/ sterotypic movements, senseless words/phrases, LOC

depersonalization/derealization d/o tx

tx primary d/o, effectiveness of supportive psychotherapy, hypnosis, family therapy, CBT unknown

depersonalization/derealization d/o

some are transient, can evolve into chronic intractable and disabling d/o