BMed - Dissociative D/O - Exam 3

Dissociation

-disturbance in consciousness

-may affect memory, identity, perception, sense of environmental relation

Dissociation Disorders

-involve problems with identity, emotion, memory, behavior, perception, sense of self

-can potentially disrupt every area of mental functioning

Dissociation - Etiology

-sometimes learned defense mechanism that usually begins in childhood

-response to extreme trauma or coping mechanism

-sometimes idiopathic

-extreme sleep disruption, drug/med intoxication/withdrawal, high levels of anxiety or panic

Dissociation D/O - DDX

-Psych: PTSD, malingering, panic d/o, normal amnesia, psychotic d/o, substance intox

-Medical/organic: delirium, brain injury, meds, seizure d/o, neuro conditions causing amnesia

Dissociative Amnesia

-inability to recall important personal information (events) that is more extensive than can be explained by normal forgetfulness

-remembering causes distress or functional impairment

Dissociative Amnesia - S/Sx

-limited eye contact

-speech slow and logical

-recent memory possibly slightly impaired

-attention and concentration limited

-mood is anxious or dysphoric

-affect is constrict

-reasoning and judgment limited, insight lacking

-increased likelihood passive suicidal ideation, violent ideation, sometimes homicidal

Dissociative Amnesia - Occurrence

2-7% of the general population

Dissociative Amnesia - Etiology

-Acute onset after psychologically stressful life event

-onset and termination usually abrupt

-high occurrence: wars, concentration camps, torture, child or sexual abuse, natural disasters

Dissociative Amnesia - Prognosis

-usually recover memory after proper tx

-sometimes develop chronic form of amnesia

-some develop as alternative to suicide

-if memory recovered without proper psychotherapy, can be at risk for suicide

Dissociative Amnesia - Tx

-many resolve spontaneously when removed from stressful situation

-TOC: psychotherapy

-hypnosis may be used

-Hospitalization necessary if clear and present danger to self or others, eval med effects

Dissociative Fugue

-sudden, unexpected purposeful travel away from home or work

-inability to recall important autobiographical information

-confused about identity or partial/complete assumption of new roles, names, life details

Dissociative Fugue - S/S

-MSE varies widely

-Alert and oriented only to self

-reasoning/judgment poor; insight lacking

-thought processes intact; content variable

-Increased violent or homicidal ideation

-Suicidal ideation lacking

-reduced eye contact and social connectedness

Dissociative Fugue - Occurrence

-RARE

-0.2% of the general population

Dissociative Fugue - Etiology

often psychological stress (social dislocation, war)

Dissociative Fugue - Prognosis

-usually lasts a few days, occasionally months

-few extreme cases noted

Dissociative Fugue - Tx

-acute tx in general hospital and psych departments

-often spontaneously recover

-TOC: psychotherapy + additional hypnosis & psychopharmacology (combo most effective)

Dissociative Identity Disorder - DSM5 - Criteria 1

-disruption of identity characterized by 2 or more distinct personality parts; may be observed by others or reported by the patient

-distinct personality states: alter, identity, state, personalities

-Boundaries: dissociative and amnesic

Dissociative boundary

distinct personality state are contained

Amnesic Boundary

degree of dissociation defines the dissociative disorder

DID - DSM5 - Criteria 2

-an alter may take executive control of behavior

-amnesia occurs when a different alter assumes control

-distress or impairment present that is severe enough to disrupt life

-not attributable to normal, religious cultural practices or substance use or a medical condition

DID - Occurrence

1-3% of the gen population

DID - Etiology

-repeated traumatic or overwhelming experiences, especially physical or sexual abuse often beginning in childhood

-painful or prolonged childhood medical experiences

-wartime dislocation or severe social instability

DID - Prognosis

-most cases resolve with sustained tx

-untreated: chronic, recurrent

DID - Tx

-a complex, chronic, trauma-based disorder

-encourage healthy coping behaviors

-log and monitor emotions

-develop a crisis plan

DID - Affect/Mood Sx

-affect labile or irritable

-mood euthymic or anxious

-decreased insight, decreased reasoning, decreased judgment

-eye contact minimal

-increased suicidal or homicidal ideation

DID - Physiologic/Behavioral variability

-variable BP, glucose, vision

-variable drug and tx responses depending on identity

-behavioral shifts depending on which identity is in executive control

DID - Cognitive/Perceptual Changes

-attention fixed on internal experiences or extraneous stimuli

-orientation is "off"

-blackout phases

-dissociative amnesia

-hypervigilance, preoccupations, hallucinations

-fluctuation in personality or talent

-poor long-term memory

-thought/content variability across identities

Depersonalization/Derealization

-intact reality testing

-clinically significant distress/impairment

-rule out psychosis, panic disorder, substances, medical causes

2.4% of gen pop

what is the occurrence of depersonalization-derealization disorder?

depersonalization-derealization disorder - Etiology

-biological and environmental factors might play a role

-often triggered by intense stress or a traumatic event

-usually begins in adolescence; typically with continuous sx

-onset sudden or gradual

-frequently coexists with mood, anxiety, psychotic d/o

Depersonalization

-detachment from self

-experience of being outside observer with respect to one's thoughts, feelings, sensations, body, actions

-perceptual alterations, distorted sense of time, unreal or absent self, numbing

Derealization

-detachment from environment

-experience of unreality or detachment with respect to surroundings

-individuals or objects are experienced as foggy, unreal, lifeless, dreamlike, visually distorted

Depersonalization-Derealization Specification

-mental activity, body, and surroundings changed in quality - unreal, remote, or automatized

-emotional numbing, altered body experience, changes in subjective experiencing of memory

-aware that the unreality is a distortion

-sensorium intact

-emotional expression capacity preserved

Depersonalization-Derealization - Other Disorders

sx may occur within:

-schizophrenia

-depressive d/o

-phobic d/o

-OCD

Depersonalization-Derealization Syndrome - Prognosis

-some degree of relief achieved with tx

-complete recovery possible for many, esp if sx in connection with stresses that can be dealt with during tx

Depersonalization-Derealization - General Tx

-R/O medical causes: amnesia, recent physical trauma, seizures, illicit drugs, meds

-if medical causes ruled out, ask about anxiety sx

-recommend referral for eval/tx with specialist

Depersonalization-Derealization Syndrome - Specific Tx

-no single, reliably effective RX

-occasional response to SSRI or benzo

-Rx alone = minimally helpful or effective

-psychotherapy = helpful

-most viable current tx - assist pt in achieving comfort, stability, away from traumatic events