PTSD and Dissociative Disorders

formerly called multiple personality disorder, this is characterized by 2+ personality states and an inability to recall everyday events, important personal info and/or traumatic/stressful events that wouldnt typically be lost w ordinary forgetting. pts will also have sudden intrusive discontinuities in speech/affect/behavior

dissociative identity disorder

when does dissociative identity disorder start

can start at any age, from early childhood to late in life

what form of dissociative identity disorder has outside agents, typically a supernatural being or spirit who has taken control of the person with different identities that are very overt

possession form

what form of dissociative identity disorder tends to be less overt, with a sudden alteration in their sense of self or identity and recurrent dissociative amnesia

nonpossession form

dissociative identity disorder cause

occurs in people who experiences overwhelming stress or trauma during childhood. abuse is chronic and severe (sexual, physical or general trauma or combo). if they had no abuse they experienced an important early loss

general dissociative identity disorder symptoms

amnesia,

depersonalization (feeling detached or estranged from one’s self),

derealization (feeling the external world is strange or unreal),

self-alteration (the sense that one part of ones self if super different from another part of one’s self),

trance state (narrowing of awareness of one’s immediate surroundings or stereotyped behaviors/movements experienced as being beyond one’s control)

possession form dissociative identity disorder symptoms

readily apparent to family members and associates, patients speak and act in an obviously different manner as though another person or being has taken over and who may demand punishment for past actions

non-possession form dissociative identity disorder symptoms

different identities are often not as apparent to observers, although the person ,ay display a sudden shift in affect or interpersonal manner

feelings of depersonalization

body feels different and doesnt belong to them

sudden thoughts/impulses/emotions that dont seem to belong to them that manifest as multiple confusing thought streams or as voices

dissociative identity disorder diagnosis criteria

disruption of identity characterized by 2+ distinct personality states which may be described in some cultures as an experience of possession (involved marked discontinuity in sense of self and agency, with related alterations in behavior, consciousness, memory, perception, cognition and/or sensory motor functioning that may be observed by others or self reported)

recurrent gaps in recall of everyday events, important personal information and/or traumatic events that are inconsistent w ordinary forgetting

symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning

disturbance is not a normal part of a broadly accepted cultural or religious practice (or imaginary friends/pretend play in kids)

sx are not attributable to the physiological effects of a substance (alc) or another medical condition (complex partial seizures)

dissociative identity disorder treatment

supportive care, meds (for associated sx), therapy (long term integration of identity states), hypnosis, modified exposure techniques (desensitize pts to traumatic memories)

dissociative identity disorder prognosis

varies widely and sx wax and wane spontaneously but pts do well w dissociation and trauma focused tx

persistent or recurrent feelings of being detached from one’s body or mental processes and/or feeling of being an outside observer in ones life (depersonalization) or of being detached from ones surroundings (derealization) often triggered by stress

depersonalization/derealization disorder

what % of the pop ever meet the criteria for having depersonalization/derealization disorder

2%

what % of the pop has had at least one transient experience of depersonalization or derealization in their life

50%

what else can trigger depersonalization/ derealization besides depersonalization/derealization disorder (which we can only diagnose if the depersonalization/derealization occurs independently)

can occur as a symptom in many other mental disorders as well as in physical disorders like seizure disorders

when does depersonalization/derealization disorder start

equally in men and women, often starts around 16 and rarely begins after 40

depersonalization/derealization disorder risk factors

being emotionally abused or neglected during childhood, physical abuse, witnessing domestic violence, severely impaired or mentally ill parent, family member or close personal friend dies unexpectedly, triggered by interpersonal/financial/occupational stress

depersonalization/derealization disorder comorbid conditions

depression, anxiety, OCD, avoidant personality disorder, borderline personality disorder

feeling detached from ones body/mind/feelings and/or sensations, pts feel like an outside observer of their life, feel unreal or like a robot/automation, feel emotionally and physically numb or detached w little emotion

depersonalization

feeling detached from their surroundings, which seem unreal. pts may feel like theyre in a dream/fog or as if a glass wall or veil separates them from their surroundings. say the world seems lifeless, colorless or artificial. subjective distortion of the world is common and sx are almost always distressing and (if severe) profoundly intolerable (anxiety and depression are common)

derealization

depersonalization/derealization disorder DSM criteria

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

during the depersonalization or derealization experiences, reality testing remains intact

the sx cause clinically significant distress or impairment in social, occupational or other important areas of functioning

the disturbance is not from from a substance (drugs or meds) or another medical condition (seizures)

the disturbance isnt better explained by another mental disorder

depersonalization/derealization disorder treatment

(must address all stresses associated w onset of the disorder as well as earlier stresses) therapy (meds dont work great)

what kinds of therapy can be used to treat depersonalization/derealization disorder

cognitive techniques to block obsessive thinking

behavioral techniques to distract from the depersonalization and derealization

grounding techniques to connect to the world and feel more real in the moment

psychodynamic therapy

moment to moment tracking

depersonalization/derealization disorder prognosis

often improves w/o intervention. complete recovery is possible for many pts, esp if sx result from treatble or transient stress. may only cause minimal impairment but some pts may become disabled by the chronic sense of estrangement and by the accompanying anxiety/depression

the inability to recall important personal info that wouldn’t typically be lost w ordinary forgetting, often caused by trauma/stress and although forgotten info may be inaccessible to consciousness it sometimes continues to influence behavior

dissociative amnesia

how common is dissociative amnesia

it is likely underdetected

what is the main sx of dissociative amnesia

memory loss thats inconsistent w normal forgetfulness

an inability to remember a specific period of time or a specific event (like a suicide attempt) or a circumscribed period of time (like before age 12, 2nd and 3rd grade, etc)

localized amnesia

inability to remember some but not all of the events during a circumscribed period of time such as parts of a combat experience, sexual assault etc

selective amnesia

inability to remember certain categories of memory such as no recall of ones home-life during 3rd grade but recalling being at school or inability to recall a particular person

systematized amnesia

inability to remember successive events as they occur (ex anterograde dissociative amnesia; may present as dissociatice psuedo-delirium, pseudo-dementia or pseudo-amnestic-confabulatory syndrome

continuous amnesia

failure to recall your whole life

generalized (global) amnesia

dissociative amnesia symptoms

most pts partly or completely unaware they have gaps in their memory

pts seen shortly after they become amnestic may seem confused

pts have trouble forming and maintaining relationships

some pts report flashbacks

depressive and functional neurologic symptoms are common, like suicidal and other self destructive behaviors

a rare symptom when dissociative amnesia is accompanied by sudden, unexpected purposeful travel away from home and bewildered wandering

dissociative fugue

how long can a dissociative fugue last and what can happen during it

can be hours to months or longer

disguises wish fulfillment or the only permissible way to escape from severe distress or embarrassment

during the fugue pts may seem normal or only a little confused

when it ends pts report suddenly finding themselves in the new situation w no memory of how they got there or what they were doing and dx is normally made retrospectively

dissociative amnesia DSM criteria

an inability to recall important autobiographical info, usually of a traumatic or stressful nature thats inconsistent w ordinary forgetting

sx cause clinically significant distress/impairment

disturbance isnt from alc or drugs or other medical issues (seizures/head injury)

disturbance isnt better explained by something else

dissociative amnesia tx

supportive tx, maybe hypnosis

dissociative amnesia prognosis

sometimes memories return quickly like when theyre taken out of the stressful situation, sometimes it can last a really long time but most pts recover their missing memories

disorder that involves the development and persistence of intrusive and avoidance sx, negative changes in thought/mood and arousal/reactivity for at least one month following traumatic event exposure

PTSD

ptsd clinical manifestations

cognitive, affective and behavioral responses to stimuli, leading to flashbacks, severe anxiety and fleeing or combative behavior

attempts to avoid experiences that may begin to elicit sx like emotional numbing, diminished interest in activities and detachment

ppl w ptsd with childhood trauma may have what additional clinical manifestations

greater difficulty with affect regulation (unmodulated anger), demonstrate more dissociation, somatic sx, self destructive behavior and suicidal behavior

pt meets all the diagnostic criteria for PTSD and experience persistent or recurrent dissociative symptoms (specifically depersonalization and derealization)

dissociative subtype PTSD

what may you see on a mental status exam for a PTSD pt

altered thoughts and perceptions (hallucinations, delusions, phobias, suicidal ideation)

generally look disheveled/poorly hygenic (may have physical injuries from traumatic event)

agitated/extreme startle reaction

psychological numbness

orientation affected

forgetful, esp about the details of the traumatic event

poor concentration

poor impulse control

altered speech rate and flow

mood and affect may be changed (see depression, anxiety, guilt and/or fear)

presence of one or more of the following intrusion sx for PTSD including:

recurrent, involuntary and intrusive distressing memories of the traumatic event

recurrent distressing dreams in which the content/affect of the dream is related to the traumatic event

dissociative reactions (flashbacks) where the individual feels/acts like the traumatic events were recurring

intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

persistent avoidance of stimuli associated w the traumatic events evidence by one or both of the following for PTSD including:

avoidance of or efforts to avoid distressing memories, thoughts or feelings about or closely associated w the event

avoidance or efforts to avoid external reminders

negative alterations in cognitions and mood associated w the event seen by 2 or more of the following for PTSD:

inability to remember an important aspect of the traumatic event

persistent and exaggerated negative beliefs or expectations about oneself, others or the world

persistent distorted cognitions about the cause or consequence of the events the lead to pt to blame themselves or others

persistent negative emotional state

markedly diminished interest or participation in significant activities

feelings of detachment or estrangement from others

persistent inability to experience positive emotions

marked alterations in arousal and reactivity associated w the traumatic events, starting or worsening after the traumatic events occurred as seen w 2 or more for PTSD:

irritable behavior and angry outbursts

reckless or self destructive behavior

hyper vigilance

exaggerated startle response

problems w concentration

sleep disturbances

PTSD tx

CBT is the standard of care, SSRIs, trazodone (for sleep issues), prazosin (for nightmares), benzos, valproic acid or carbamazepine (for impulsivity/explosiveness), aripiprazole (for flashbacks/intrusive thoughts)

PTSD prognosis

varies significantly, in 50% of cases sx remit spontaneously after 3mo, or sx may persist for many years

factors associated w better prognosis of PTSD

rapid engagement of tx, early and ongoing social support, avoidance of retraumatization, absense of other psych issues or substance abuse