Dissociative Disorders

DISSOCIATIVE DISORDERS : DISSOCIATIVE DISORDERS Fernando Entenza, MD

PowerPoint Presentation : Dissociative Amnesia (most common) Dissociative Fugue Dissociative Identity D/O (most severe) Depersonali-zation D/O Dissociative D/O NOS Amnesia Other symptoms + + Sudden travel + > 2 Identities - Depersonalization Dissociative symptoms Personal Info + + + - that fail to meet the diagnostic Traumatic or stressful info + + + - criteria for other Dissociative Ds Personal identity amnesia May Confused or assumes new identity Often amnestic of the other identity states - . Precipitating emotional trauma Usually + + - Disruption in the usually integrated Onset Often abrupt Sudden travel Childhood Sudden functions of consciousness, Awareness of amnesia or sxs Usually aware Unaware Usually aware of alternates Aware that the symptoms are unreal memory, identity, or perception of Emotional response Some upset Some indifferent Quiet reclusive existence Variable Ego-dystonic Estrangement the environment. Amnesia time Selective Localized, short > generalized May Generalized Complete Variable Asymmetrical n/a n/a

PowerPoint Presentation : cont. Dissociative Amnesia Dissociative Fugue Dissociative Identity D/O Depersonali-zation D/O Dissociative D/O NOS Predisposing factors -Depression & anxiety -Personal crisis w emotional conflict -Wartime or natural disasters -State-Dependent Learning Theory -Mood disorders -Histrionic / Borderline -Personal crisis w emotional conflict -Wartime or natural disasters -Heavy alcohol abuse -High hypnotizability -Absence of external support -Childhood physical or sexual abuse or a severe traumatic event (witnessing a death) -Depressive & Anxiety Disorders -High hypnotizability -Emotional trauma (i.e. combat or MVA) -Schizophrenia -Sensory deprivation Age / Gender Young adults F > M Adults (0.2% prevalence) Late adolescence -young adult 5 - 9 F >> M < 40 y/o Mean = 16 y/o 2 F > M Alertness before amnesia Good Good Good n/a Alertness after amnesia Good Good Good n/a Symptom termination Abrupt Spontaneous & rapid Incomplete Usually chronic Sometimes episodic Recovery Complete Complete Fluctuating, chronic Wax & wane sxs Recurrences Few Possible Yes Yes Secondary gains May prolong condition Complex Forensic Issues Does not occur exclusively during DID, DF, PTSD ASD, Somat D DID n/a Schiz, PD, ASD, another Dissoc D

Dissociative Disorder NOS examples : Dissociative Disorder NOS examples Identity Disorder Symptoms 1. There are not > 2 distinct personality states or 2. Amnesia for important personal information does not occur Derealization Derealization unaccompanied by depersonalization Derealization = the sense that the external world is strange or unreal Brainwashing or Indoctrination Subjected to periods of prolonged and intense coercive persuasion Often accompanied by PTSD symptoms Dissociative Trance Disorder State of consciousness, identity, or memory that are endogenous to a culture Narrowing of awareness of immediate surrrondings or stereotyped behaviors or movements Experienced as being beyond one’s control Possession Trance = new identity attributed to a spirit, power, deity, or other person Not a normal part of broadly accepted collective cultural or religious practice Loss of Consciousness, Stupor, Coma (Conversion) Not attributable to a General Medical Condition Ganser Syndrome The giving of approximate answers Factitious psychiatric symptom production Typically associated with prison inmates

False Memory Syndrome : False Memory Syndrome Under hypnosis or during psychotherapy An event is recalled that never took place Believes it to be true Accompanied by the appropriate affective response (just like abreaction) Memory is subject to Distortion and Retrospective falsification that may also be influence by Therapist Overzealous interrogators Suggestibility of children

Dissociative Amnesia & Dissociative Fugue : Dissociative Amnesia & Dissociative Fugue Differential Diagnosis Other Dissociative Disorders Amnestic Disorder Due to A General Medical Condition Substance-Induced Persisting Amnestic Disorder Delirium Dementia Sleepwalking Disorder Posttraumatic Stress Disorder / Acute Stress Disorder Somatization Disorder Conversion Disorder Malingering

Amnestic Disorders Due To a GMC : Amnestic Disorders Due To a GMC Anoxic brain injury Cerebral infections Herpes Encephalitis – temporal lobe Cerebral neoplasms Limbic Frontal Metabolic Uremia Hypoglycemia Hypertensive Encephalopathy Porphyria Transient Global Amnesia Seizure Disorder (CPSz) Sleepwalking Disorder Postconcussion Postoperative Wernicke-Korsakoff Syndrome ECT

PowerPoint Presentation : Dissociative Amnesia Amnestic Disorder Dementia Personal information amnesia + _ in advanced cases Anterograde amnesia _ + + Other cognitive symptoms _ _ + General information amnesia _ + + Preserved function + + - Pre-amnestic state Post-amnestic state Age & risk factors Other associated symptoms Alert Alert 20’s to 40’s - Depression & anxiety -Personal crisis w emotional conflict -Wartime or natural disasters Prompt return of memory n/a n/a Older populations - TIA - Vasospastic migraines - Sedative-hypnotic intoxication - Seizures Persistent amnesia n/a n/a Advanced age ApoE4 Down’s Syndrome Persistent amnesia

PowerPoint Presentation : Amnestic Disorder due to TGA Amnestic Disorder due to Epilepsy Sleepwalking Disorder Amnesia Acute, transient Anterograde Recent > remote Acute, transient Anterograde post-ictally For the sleepwalking episode, after falling back asleep Associated symptoms Aware of amnesia. Thus, they often are upset and concerned, unlike dissociative disorders. Aurea, unprotected fall or trauma, incontinence EEG abnormalities Appear to be dreaming Behavior resembles dissociative state: altered state of consciousness; possible vivid hallucinatory recollections; stare into space if their eyes are open; may appear emotionally upset Age 60 to 70’s Onset 4-8 y/o Peak prevalence 12 y/o M > F Risk factors /etiology 1. TIAs affecting limbic midline structures 2. Vasospastic migraines (temporal or thalamic) in younger adults. 3. Sedative-hypnotic intoxications 4. Seizures Initiated in the first third of the night during deep Non-REM sleep (stage 3 & 4) Familial component

Substance-Induced Persistent Amnestic Disorder : Substance-Induced Persistent Amnestic Disorder Sedative-hypnotics (zolpidem, benzos) Anticholinergics Steroids Lithium intoxication ßeta blockers Methyldopa Hypoglycemic agents Pentazocine Alcoholic blackouts Phencyclidine (PCP) Hallucinogens Marihuana

Dissociative Identity Disorder Differential Diagnosis : Dissociative Identity Disorder Differential Diagnosis Schizophrenia Rapid-cycling Bipolar Disorder Borderline Personality Disorder Complex Partial Epilepsy Somatization Disorder Factitious Disorder Malingering

Mental Disorders That Cause Depersonalization Symptoms : Mental Disorders That Cause Depersonalization Symptoms Schizophrenia Depressive disorders Manic episodes Conversion disorder Anxiety disorders Obsessive-Compulsive disorder Personality disorders Phobic-anxiety

Causes of Depersonalization : Causes of Depersonalization Neurologic Epilepsy Migraine Brain Tumors Cerebrovascular disease Cerebral trauma Encephalitis General paresis Alzheimer’s disease Huntington’s disease Spinocerebellar degeneration Right parietal lesion Hemidepersonalization Toxic & Metabolic Hypoglycemia Hypoparathyroidism Carbon monoxide poisoning Mescaline intoxication Botulism Hyperventilation Hypothyroidism In normal persons Exhaustion Boredom; sensory deprivation Emotional shock