01 - Chapter 11 Dissociative Disorders

Chapter 11 Dissociative Disorders

CHAPTER 11 DISSOCIATIVE DISORDERS Dissociative Amnesia..............................................................................................................136 Diagnosis and DSM-5 Criteria.............................................................................................136 Epidemiology/Etiology......................................................................................................136 Treatment..........................................................................................................................136 Depersonalization/Derealization Disorder..............................................................................137 Diagnosis and DSM-5 Criteria.............................................................................................137 Epidemiology/Etiology......................................................................................................137 Course and Prognosis.........................................................................................................137 Treatment..........................................................................................................................137 Dissociative Identity Disorder (Multiple Personality Disorder).................................................138 Diagnosis and DSM-5 Criteria.............................................................................................138 Epidemiology/Etiology......................................................................................................138 Course and Prognosis.........................................................................................................138 Treatment..........................................................................................................................138 Other Specified Dissociative Disorder......................................................................................139 DSM-5 Examples................................................................................................................139

136 DISSOCIATIVE DISORDERS WARDS QUESTION Q: When do dissociative responses typically occur? A: During stressful and traumatic events. Dissociative Amnesia KEY FACT Dissociative amnesia refers to disruption in the continuity of an individual’s memory. Patients with dissociative amnesia report gaps in the recollection of particular events, usually traumatic ones. WARDS TIP DIAGNOSIS AND DSM-5 CRITERIA Patients suffering from dissociative amnesia can experience periods of flashbacks, nightmares, or behavioral reenactments of their trauma. KEY FACT Although dissociative fugue is now considered a subtype of dissociative amnesia disorder, it more commonly occurs in patients with dissociative identity disorder. EPIDEMIOLOGY/ETIOLOGY ■ Lifetime prevalence is 6–7%. ■ Higher incidence in female patients. ■ Amnesia often develops after trauma. KEY FACT TREATMENT ■ Important to establish the patient’s safety. Abreaction: The strong emotional reaction patients may experience while retrieving traumatic memories. Dissociation can be understood as a disruption in the integrated sense of self. This may involve lapses in autobiographical memory (amnesia) and feelings of detachment from one’s self (depersonalization) or from one’s surroundings (derealization). These symptoms often develop in the context or aftermath of significant trauma, particularly during childhood. Dissociation may initially help buffer the impact of a trauma, but can also become pathological and maladaptive. While the dissociative disorders are closely related to the stressorand trauma-related disorders, they are classified separately in the DSM-5. Individuals with dissociative amnesia are unable to remember important personal information or history, often traumatic in nature. Procedural memory (e.g., how to ride a bike) is preserved, distinguishing dissociative amnesia from other conditions resulting in memory loss (e.g., major neurocognitive disorders/dementias). The unrecalled autobiographical information has been stored in memory and is thus potentially retrievable. Dissociative amnesia rarely generalizes to encompass complete memory loss. More commonly, a single period of time (localized amnesia) or certain events (selective amnesia) are forgotten. Affected individuals often do not have insight regarding their deficits. There is a significant incidence of comorbid major depressive disorder or persistent depressive disorder (dysthymia) and an increased risk for suicide—particularly as amnesia resolves and the overwhelming memories return. ■ An inability to recall important autobiographical information, usually involving a traumatic or stressful event, that is inconsistent with ordinary forgetfulness. ■ May present with dissociative fugue: Sudden, unexpected travel away from home, accompanied by amnesia for identity or other autobiographical information. ■ Not due to the physiological effects of a substance, another medical or neurological condition (e.g., traumatic brain injury), or another mental disorder. ■ Symptoms cause significant distress or impairment in daily functioning. ■ Psychotherapy (e.g., supportive, CBT, hypnosis) is the mainstay of treatment. ■ Medications have not demonstrated efficacy in dissociative amnesia.

A 19-year-old male is found wandering several miles from home several days after a missing persons report was filed by his family. He cannot recall his full name or address, even when shown his ID card. His family reports that he recently returned from combat deployment. Likely diagnosis? Dissociative amnesia with dissociative fugue Depersonalization/Derealization Disorder Characterized by repeated experiences of detachment from one’s self or surroundings. Patients may feel as though they are observing themselves from a distance or have an “out-of-body” experience (depersonalization). They may experience the world around them as if in a dream or movie (derealization). DIAGNOSIS AND DSM-5 CRITERIA ■ Persistent or recurrent experiences of one or both: •• Depersonalization—Experiences of unreality or detachment from one’s body, thoughts, feelings, or actions • Derealization—Experiences of unreality or detachment from one’s surroundings. ■ Reality testing remains intact during an episode, as opposed to during psychosis, when one cannot distinguish between what is real and what is not. ■ The symptoms cause significant distress or social/occupational impairment. ■ Not accounted for by a substance (e.g., drug of abuse, medication), another medical condition, or another mental disorder. EPIDEMIOLOGY/ETIOLOGY ■ Lifetime prevalence is 2%. ■ Gender ratio 1:1. ■ Mean age of onset is about 16 years. ■ Increased incidence of comorbid anxiety disorders and major depression. ■ Predisposing factors include severe stress and trauma. COURSE AND PROGNOSIS Often persistent but may wax and wane. TREATMENT ■ Psychodynamic, cognitive-behavioral, hypnotherapy, and supportive therapies may be helpful. ■ There is a lack of evidence for use of medications to treat depersonalization/ derealization disorder. DISSOCIATIVE DISORDERS WARDS TIP Fugue: Think of a forgetful fugitive who runs away and forms a new identity. WARDS QUESTION True or False? Transient experiences of depersonalization or derealization commonly occur in many otherwise healthy individuals. True. Depersonalization and derealization can occur under stress, intoxication with substances, and even in benign circumstances (e.g., staring into a mirror for a prolonged period).

138 DISSOCIATIVE DISORDERS DIAGNOSIS AND DSM-5 CRITERIA EPIDEMIOLOGY/ETIOLOGY ■ Increased prevalence in women. WARDS TIP Symptoms of DID overlap with symptoms in borderline personality disorder or, to an extent, psychotic disorders. COURSE AND PROGNOSIS ■ Course is fluctuating but chronic. TREATMENT Dissociative Identity Disorder (Multiple Personality Disorder) Dissociative identity disorder (DID) is characterized by the presence of more than one distinct personality state resulting from a fragmented sense of self. DID encompasses features of the other dissociative disorders, such as amnesia, depersonalization, and derealization. DID predominantly develops in victims of significant and chronic childhood trauma. Patients diagnosed with DID often cope with posttraumatic stress disorder (PTSD), depression, and suicidality. ■ Disruption of identity manifested as two or more distinct personality states dominating at different times. These symptoms may be observed by others or self-reported. ■ Extensive memory lapses in autobiographical information, daily occurrences, and/or traumatic events. ■ Not due to effects of a substance (drug or medication) or another medical condition. ■ The condition causes significant distress or impairment in social/ occupational functioning. ■ Rare. No epidemiologic studies of the national prevalence, although a few community-based studies claim 1% prevalence. ■ 90% of patients with DID have suffered from childhood physical abuse, sexual abuse, or neglect. ■ Symptoms usually begin to manifest to some extent in childhood but may occur at any age. ■ High incidence of comorbid PTSD, major depressive disorder, eating disorders, borderline personality disorder, and substance use disorders. ■ More than 70% of patients attempt suicide, often with frequent attempts and self-mutilation. ■ Worst prognosis of all dissociative disorders. ■ Psychotherapy is the standard treatment. Goals include maintenance of safety, stabilization, identity integration, and symptom reduction by working directly with traumatic memories. ■ Pharmacotherapy: SSRIs to target comorbid depressive and/or PTSD symptoms (especially hyperarousal). Prazosin may ameliorate nightmares, and naltrexone may reduce self-injurious behaviors.

A 21-year-old female is brought to the clinic by her boyfriend for evaluation of “memory issues.” The patient recently visited her family for the holidays. The boyfriend states that “she had to deal with her abusive, alcoholic father. She seems like someone else ever since.” The patient speaks in a childlike singsong voice and asks to be called by a name different than what is listed on her driver’s license. She denies any concerns. Most likely diagnosis? Dissociative identity disorder (DID). Other Specified Dissociative Disorder Characterized by symptoms of dissociation that cause significant distress or impairment of functioning, but do not meet the full criteria for a specific dissociative disorder. DSM-5 EXAMPLES ■ Identity disturbance due to prolonged and intense coercive persuasion (e.g., brainwashing, cult rituals). ■ Chronic and recurrent syndromes of mixed dissociative symptoms (without dissociative amnesia). ■ Dissociative trance: An acute narrowing or loss of awareness of surroundings manifesting as unresponsiveness, potentially with minor stereotyped behaviors (not part of a cultural or religious practice). ■ Acute dissociative reactions to stressful events (lasting hours/days → 1 month). DISSOCIATIVE DISORDERS

140 DISSOCIATIVE DISORDERS NOTES