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Dissociative Disorders

Kaplan Ch 20 pp 665-679 Define the criteria and associated features, including, prevalence, course and differential diagnosis of: Dissociative Identity Disorder: Definition: (multiple personality disorder), is characterized by the presence of two or more distinct identities or personality states that recurrently take control of the individuals behavior accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. o The identities or personality states differ from one another in that each presents as having its own relatively enduring pattern or perceiving, relating to, and thinking about the environment and self. o Patients with dissociative disorder often report significant gaps in autobiographical memory, especially for childhood events. o Strongly linked to severe experiences of early childhood trauma, usually maltreatment (physical and sexual abuse). Childhood sexual abuse survivors with psychophysiological disorders are more likely to have a lower threshold for experiencing physiological phenomena as noxious or painful. o Preliminary studies have not found evidence of a significant genetic contribution. o Dissociative alterations in identity: Odd first-person plural or third-person singular or plural self references. Refer to themselves using their own first names Profound sense of concretized internal divisions or personified internal conflicts between parts of themselves. o Other associated symptoms: Most of these patients also meet the diagnostic criteria for PTSD Commonly exhibit multiple types of psychophysiological, somatoform and conversion symptoms. Most patients meet with criteria for a mood disorder (depression). Obsessive compulsive personality traits are common and intercurrent obsessive compulsive disorder symptoms are regularly found. Prevalence: o F:M ratio between 5:1 and 9:1 for diagnosed cases Criteria: o A. the presence of two or more distinct identities or personality states (each with its own relatively enduring pattern or perceiving, relating to, and thinking about the environment and self). o B. at least two of these identities or personality states recurrently take control of the persons behavior.

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C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. D. the disturbance is not due to the direct physiological effects of a substance or a general medical condition. Note: in children, the symptoms are not attributable to imaginary playmates or other fantasy play.

Course: o Little is known about the natural history of untreated dissociative identity disorder. o Some are thought to continue involvement in abusive relationships or violent subcultures, or both, that may result in the traumatization of their children. o Many die by suicide or as a result of risk taking behaviors. o Poor prognosis In patients with comorbid organic mental disorders, psychotic disorders, severe medical illnesses, substance abuse and eating disorders. Significant antisocial personality features, current criminal activity, ongoing perpetration of abuse, and current victimization, with refusal to leave abusive relationships. o Repeated adult traumas with recurrent episodes of acute stress disorder may severely complicate the clinical course. o Child and Adolescent Presentation Younger children have less linear and less continuous sense of time and often are not able to self identify dissociative discontinuities in their behavior. The clinical presentation may be that of an elaborated or autonomous imaginary companionship, with the imaginary companions taking control of the childs behavior, often experienced through passive influence experiences or auditory pseudohallucinations, or both, that command the child to behave in certain ways. Differential Diagnosis: o Affective disorders o Psychotic disorders o Anxiety disorders o Post traumatic stress disorder o Personality disorders o Cognitive disorders o Neurological and seizure disorders o Somatoform disorders o Factitious disorders o Malingering o Other dissociative disorders o Deep trance phenomena, such as the hidden observer or ego states

Depersonalization Disorder: Definition: persistent or recurrent feeling of detachment or estrangement from ones self. o Feeling like an automaton or as if in a dream or watching himself or herself in a movie. o There may be a sensation of being an outside observer of ones mental processes, ones body, or parts of ones body. o Sense of an absence of control over his or her actions o Distinct components comprise the experience of depersonalization Sense of bodily changes Duality of self as observer and actor Being cut off from others Being cut off from ones own emotions o I feel dead, nothing seems real or Im standing outside of myself o Etiology Psychodynamic: disintegration of the ego / affective response in defense of the ego. Traumatic stress: life threatening experiences cause transient depersonalization during the event or immediately thereafter Neurobiological theories: serotoninergic involvement. Strong implication of the NMDA subtype of the glutamate receptor as central to the genesis of depersonalization symptoms Prevalence : o Two to four times more in women than in men o Transient experiences of depersonalization and derealization are extremely common in normal and clinical population. o 1/3 most commonly reported psychiatric symptoms, after depression and anxiety o Common in seizure patients and migraine sufferers o Occur with use of psychedelic drugs, especially marijuana, LSD, and mescaline o Also common after mild to moderate head injury o Also common after lifethreatening experiences, with or without bodily injury Criteria o A. Persistent or recurrent experiences of feeling detached from, and as if one is and outside of , ones mental processes or body (e.g., feeling like one is in a dream) o B. During the depersonalization experience, reality testing remains intact. o C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. o D. The depersonalization experience does not occur exclusively during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder, or another dissociative disorder, and is not due to the direct physiological effects of a substance or a general medical condition (e.g., temporal lobe epilepsy)

Course: o Depersonalization after traumatic experiences or intoxications commonly remits spontaneously after removal from the traumatic circumstances or ending of the episode of intoxication. o Depersonalization accompanying mood, psychotic or other anxiety disorders commonly remits with definitive treatment of these conditions. o Depersonalization disorder itself may have an episodic, relapsing and remitting, or chronic course. Many patients with chronic depersonalization may have a course characterized by severe impairment in occupational, social, and personal functioning o Mean age of onset is late adolescence or early adulthood Differential Diagnosis: o Medical or neurological condition (seizure disorders, brain tumors, post concussive syndrome, metabolic abnormalities, migraine, vertigo, and Meniers disease) o Intoxication or withdrawal (Drug related depersonalization is typically transient, but persistent depersonalization can follow an episode of intoxication with marijuana, cocaine, and other psychostimulants) o Side effect of medications o Panic attacks o Phobias o PTSD o Acute stress disorders o Schizophrenia o Another dissociative disorder

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