dissociative

Dissociative Disorders

  • Dissociative Fugue

    • Definition: Characterized by sudden and unexpected travel away from home accompanied by an inability to recall one’s past.

    • Possible behavior: The individual may assume a new identity and might be unaware of their memory loss.

  • Dissociative Identity Disorder (DID)

    • Definition: Involves two or more distinct personality states that control the individual's behavior.

    • Symptoms: The individual experiences memory gaps, particularly regarding daily events or personal information.

  • Reactive Attachment Disorder (RAD)

    • Definition: A disorder that occurs in children who have experienced neglect or unstable caregiving.

    • Symptoms: Children show minimal emotional response to caregivers and actively resist comfort from them.

  • Disinhibited Social Engagement Disorder (DSED)

    • Definition: A disorder where the child displays no normal fear of strangers and readily approaches unfamiliar adults.

    • Connection: Often linked to a history of neglect or institutional care.

Medication Classifications

SSRIs (Selective Serotonin Reuptake Inhibitors)

  • Common medications: Paroxetine, Sertraline, Fluoxetine, Escitalopram, Fluvoxamine

  • Action: They selectively block the reuptake of serotonin, thereby increasing the availability of serotonin in the synaptic cleft, which improves mood.

  • Common Side Effects:

    • Nausea

    • Diarrhea

    • Insomnia

    • Headache

    • Sexual dysfunction

    • Sweating

  • Serious Side Effects:

    • Serotonin syndrome

    • Hyponatremia

    • Increased risk of gastrointestinal bleeding

    • Suicide risk

  • Contraindications:

    • MAOIs: A 14-day washout is required; extend to 5 weeks if taking fluoxetine.

    • Caution when prescribed with seizure disorders, bipolar disorder, and anticoagulants.

  • Patient Education:

    • Effects take 2–4 weeks to become noticeable.

    • Medication should be taken in the morning, except for paroxetine.

    • Report any signs of serotonin syndrome.

    • Taper off medication rather than stopping abruptly.

    • Avoid alcohol, NSAIDs, and St. John's Wort.

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

  • Common medication: Venlafaxine

  • Action: They block the reuptake of both serotonin and norepinephrine, enhancing their mood-improving and pain-relieving effects.

  • Common Side Effects:

    • Nausea

    • Anorexia

    • Insomnia

    • Sweating

    • Dizziness

    • Sexual dysfunction

  • Serious Side Effects:

    • Increased blood pressure/hypertension

    • Withdrawal syndrome

    • Serotonin syndrome

    • Hyponatremia

    • Suicide risk

  • Contraindications:

    • Avoid using in conjunction with MAOIs and uncontrolled hypertension; caution in individuals with bipolar disorder, glaucoma, and hepatic/renal disease.

  • Patient Education:

    • Take medication with food.

    • Regularly monitor blood pressure.

    • Taper slowly when discontinuing treatment.

    • Report any signs of serotonin syndrome and avoid alcohol.

TCAs (Tricyclic Antidepressants)

  • Common medications: Amitriptyline, Imipramine

  • Action: Block the reuptake of norepinephrine and serotonin, increasing their levels to improve mood.

  • Common Side Effects:

    • Sedation

    • Weight gain

    • Dry mouth

    • Constipation

    • Blurred vision

    • Urinary retention

    • Orthostatic hypotension

  • Serious Side Effects:

    • Cardiac toxicity (arrhythmias, QT prolongation)

    • Seizures

    • Suicide risk

    • Confusion (especially in the elderly)

  • Contraindications:

    • Avoid with MAOIs, recent myocardial infarction, and seizure disorders; caution advised for elderly patients, those with glaucoma, benign prostatic hyperplasia, and liver/renal diseases.

  • Patient Education:

    • Effects take 2–4 weeks to become apparent.

    • Should be taken at bedtime due to sedative properties.

    • Change positions slowly to prevent falls.

    • Oral care should be maintained to combat dry mouth.

MAOIs (Monoamine Oxidase Inhibitors)

  • Common medication: Phenelzine

  • Action: They block the enzyme monoamine oxidase, which increases levels of serotonin, dopamine, and norepinephrine, thus alleviating depression.

  • Common Side Effects:

    • Weight gain

    • Orthostatic hypotension

    • Insomnia

    • Sexual dysfunction

  • Serious Side Effects:

    • Hypertensive crisis

    • Serotonin syndrome

    • Hepatotoxicity

  • Contraindications:

    • Do not use with SSRIs, SNRIs, TCAs, St. John's Wort, sympathomimetics, and meperidine; avoid in patients with cardiovascular, liver, or kidney disease or uncontrolled hypertension.

  • Patient Education:

    • Avoid foods that contain tyramine (such as aged cheese, cured meats, wine, soy, and avocado) to prevent hypertensive crises.

    • Report any severe headache or chest pain.

    • Maintain a 14-day washout period prior to starting this medication (increase to 5 weeks if discontinuing fluoxetine).

    • Wear a medical alert bracelet if on MAOIs.

NaSSA (Noradrenergic and Specific Serotonergic Antidepressants)

  • Common medication: Mirtazapine

  • Action: Enhances norepinephrine and serotonin transmission by blocking presynaptic alpha-2 receptors, which improves mood and sleep.

  • Common Side Effects:

    • Sedation

    • Increased appetite

    • Weight gain

    • Dry mouth

    • Constipation

    • Dizziness

  • Serious Side Effects:

    • Agranulocytosis (rare)

    • Increase in cholesterol and triglycerides levels

    • Suicide risk

    • Serotonin syndrome (rare)

  • Contraindications:

    • Caution with MAOIs; special consideration needed for individuals with bone marrow suppression, hepatic or renal impairment, or seizure disorders.

  • Patient Education:

    • It should be taken at bedtime.

    • Report fever or sore throat immediately.

    • Increased appetite and weight gain are common.

    • Taper off gradually; avoid alcohol or sedatives.

Beta Blockers

  • Common medication: Propranolol

  • Action: Blocks beta-adrenergic receptors which leads to decreased heart rate, lowered blood pressure, and alleviation of physical anxiety symptoms.

  • Common Side Effects:

    • Fatigue

    • Dizziness

    • Bradycardia

  • Serious Side Effects:

    • Bronchospasm

    • Severe bradycardia

    • Hypotension

    • Heart block

  • Contraindications:

    • Avoid prescribing in cases of asthma, severe bradycardia, heart block, or uncompensated heart failure.

  • Patient Education:

    • Advice to change positions slowly to minimize dizziness.

    • Monitor pulse regularly.

    • Do not stop the medication abruptly due to the risk of rebound hypertension.

Peripherally Acting Antiadrenergic

  • Common medication: Prazosin

  • Action: Blocks alpha-adrenergic receptors, which relaxes blood vessels, leading to lower blood pressure.

  • Common Side Effects:

    • Dizziness

    • Headache

    • Nasal congestion

  • Serious Side Effects:

    • Severe orthostatic hypotension

    • Syncope

    • Priapism

  • Contraindications:

    • Caution is advised in history of syncope and in patients with renal or hepatic impairment.

  • Patient Education:

    • Take the medication at bedtime to prevent side effects upon rising.

    • Advise patients to rise slowly and to report any prolonged erection.