CLINICAL FEATURES & AETIOLOGY

By Pranay Javeri 192199017

Under the Guidance of Ms. Mariella D'Souza
Dept. of Psychiatry, KMC, Mangalore
 F44.0 Dissociative amnesia
 F44.1 Dissociative fugue
 F44.2 Dissociative stupor
 F44.3 Trance and possession disorders
 Dissociation is defined as an unconscious defense mechanism involving the
segregation of any group of mental or behavioral processes from the rest of the
person’s psychic activity.
 In a daze, Norma entered the mental health centre, tears streaming

down her face. “I have no idea where I live or who I am! Will somebody
please help me?”

 The crisis team helped her search her purse, but could find nothing

other than a photograph of a blond-haired little girl. She appeared

exhausted and was taken to a bed, where she promptly fell asleep.

 They called the local police to find out if there was a report of a missing

person. As it turned out, the little girl in the photograph was Norma’s
daughter. She had been hit by a car in a shopping centre parking lot.
 Although badly injured with a broken leg, the child was resting
comfortably in a hospital paediatrics ward. Her mother, however,
had disappeared.

 Norma had apparently been wandering around for several hours,

leaving her wallet and other identifying papers with the hospital
social worker in the emergency room.

 When Norma awoke, she was able to recall who she was and the
circumstances of the accident, but she remembered nothing of what
had happened since.
 partial or complete loss of the normal integration between
memories of the past, awareness of identity and immediate
sensations, and control of bodily movements.
 ability to exercise a conscious and selective control is impaired.
 "psychogenic" in origin.
 traumatic events, insoluble and intolerable problems, or disturbed
relationships.
 onset and termination – sudden
 Individuals show a striking denial of problems or difficulties.
 Depersonalization/derealization disorder - not included.
 General Criteria for diagnosis:
A. Clinical Features.
B. no evidence of a physical disorder
C. psychological causation - stressful events and problems
or disturbed relationships
 Included depersonalization/derealization disorder

 Diagnostic Criteria:
A. Disruption of identity - involves marked discontinuity in sense of self and
sense of agency, accompanied by related alterations.
B. Recurrent gaps in recall - inconsistent with ordinary forgetting.

C. Significant distress or impairment

D. Not broadly accepted by cultural or religious practice. (Note: In children,
the symptoms are not better explained by imaginary playmates or other fantasy
play.)
E. Not attributable to the physiological effects of a substance or another
medical condition.
 Loss of memory.
 usually centred on traumatic events.
 usually partial and selective.
 persistent common core that cannot be recalled
 Perplexity, distress, and varying degrees of attention-
seeking behaviour may be evident
 Young adults are most commonly affected.
 Localized amnesia: Inability to recall events related to a
circumscribed period of time.
 Selective amnesia: Ability to remember some, but not all, of the
events during a circumscribed period of time.
 Generalized amnesia: Failure to recall the whole life of the patient.
 Continuous amnesia: Failure to recall successive events as they
occur.
 Systematized amnesia: Amnesia for certain categories of memory
such as all memories relating to one's family or a particular person.
 A definite diagnosis requires:
 (a) amnesia, either partial or complete, for recent, traumatic or
stressful events (other informants);
 (b) absence of organic brain disorders, intoxication, or
excessive fatigue.
1. Organic mental disorders: disturbance in the nervous

system; signs of clouding of consciousness,

disorientation, and fluctuating awareness.

2. "Blackouts" due to abuse of alcohol or drugs

3. Korsakov's syndrome: immediate recall is normal but

recall after only 2 - 3 minutes is lost.

4. Amnesia following concussion or serious head injury

is usually retrograde; severe cases – anterograde.

5. Postictal amnesia in epileptics, and stupor or mutism

occasionally found in schizophrenic or depressive

illnesses.

6. Most difficult differentiation is from conscious

simulation of amnesia (malingering)
 A 45-year-old, divorced, left-handed, male bus dispatcher
complained of left-arm weakness, light-headedness and
memory loss for the previous 12 years(e.g., he did not
recognize his 8-year-old son, insisted that he was unmarried, and
denied recollection of current events, such as the name of the
current president). Physical, laboratory findings, Brain CT scan
were normal. On MSE, the patient displayed intact intellectual
function but insisted that the date was 12 years earlier, denying
recall of his entire subsequent personal history and of current
events for the past 12 years. He was perplexed by the
contradiction between his memory and current circumstances.
 The patient described a family history of brutal beatings and
physical discipline. He was a decorated combat veteran, although
he described amnestic episodes for some of his combat
experiences. In the military, he had been a champion golden glove
boxer noted for his powerful left hand. He was educated about his
disorder and given the suggestion that his memory could return as
he could tolerate it, perhaps overnight during sleep or perhaps over
a longer time. If this strategy was unsuccessful, hypnosis or an
amobarbital (Amytal) interview was proposed. (Adapted from a
case of Richard J. Loewenstein, M.D., and Frank W. Putnam, M.D.)
 All features of dissociative amnesia – present.
 Apparently purposeful journey away from home or
work; self-care is maintained.
 Some cases - new identity may be assumed.
 Organized travel - places previously known and of
emotional significance.
 Individual's behaviour – completely normal to
independent observers.
 For a definite diagnosis there should be:

 (a) the features of dissociative amnesia (F44.0);

 (b) purposeful travel beyond the usual everyday range; and

 (c) maintenance of basic self-care and simple social

interaction with strangers.

 Postictal fugue - after temporal lobe epilepsy - less

purposeful and more fragmented activities and travel

 differentiation from conscious simulation of a fugue

may be very difficult.

 A teenage girl was continually sexually abused by her

alcoholic father and another family friend. The girl became

suicidal but felt that she had to stay alive to protect her
siblings. She precipitously ran away from home after being
raped by her father and several of his friends as a “birthday
present” for one of them. She travelled to a part of the city
with the idea that she would find her grandmother with
whom she had lived before the abuse began.
 She travelled by public transportation and walked the streets,
apparently without attracting attention. After approx. 8 hours, she
was stopped by the police in a curfew check. When questioned,
she could not recall recent events or give her current
address, insisting that she lived with her grandmother. On initial
psychiatric examination, she was aware of her identity, but she
believed that it was 2 years earlier, giving her age as 2 years
younger and insisting that none of the events of recent years had
occurred. (Courtesy of Richard J. Loewenstein, M.D., and Frank
W. Putnam, M.D.)
 no evidence of a physical cause
 psychogenic causation
 profound diminution or absence of voluntary movement
and normal responsiveness to external stimuli such as light,
noise, and touch.
 lies or sits largely motionless for long periods of time.
 Speech and spontaneous and purposeful movement –
absent.
 individual is neither asleep nor unconscious
 For a definite diagnosis there should be:

 (a) stupor, as described above;

 (b) absence of a physical or other psychiatric disorder that

might explain the stupor; and

 (c) evidence of recent stressful events or current problems.

 Catatonic stupor and depressive or manic stupor;

 Stupor of catatonic schizophrenia is often preceded by

symptoms or behaviour suggestive of schizophrenia;

 Depressive and manic stupor usually develop

comparatively slowly.
 Temporary loss of both the sense of personal identity and full

awareness of the surroundings.

 Individual acts as if taken over by some spirit, deity, or "force".

 Attention and awareness may be limited.

 Limited but repeated set of movements, postures, and utterances.

 Involuntary or unwanted - intrude into ordinary activities by

occurring outside religious or other culturally accepted situations -

included here.

 Schizophrenic or acute psychoses with hallucinations or delusions, or

multiple personality should not be included here.

 Closely associated with any physical disorder or with psychoactive

substance intoxication.
 893 patients had been diagnosed with dissociative disorder; 591 (66%) were
outpatients and 302 (34%) were inpatients.
 Proportion: between 1.5 and 15.0 per 1,000 for outpatients and between 1.5 and 11.6
per 1,000 for inpatients.
 Possession states were commonly seen in the Indian population.
 Lifetime prevalence rates of approximately 10% in clinical psychiatric settings and in
the general population.
 In the general population, the lifetime prevalence of dissociative amnesia was 7.0%
 12-month prevalence was 1.8% for both genders—1.0% and 2.6% for men and
women, respectively
 Developmental Perspective:

 Dissociation is the primary defence mechanism for children.

Stable patterns of emotion regulation form a core of personality.
Thus, there’s a habitual reliance on the coping mechanism of
dissociation.

 Early childhood trauma affects developing patterns of emotion

regulation and that under certain conditions that trauma can
promote dissociative disorders.
 Psychological vulnerabilities in reaction to a disturbed parent-child

relationship

 Attachment theory states that Unresolved-fearful adult attachment

may lead to development of dissociative disorders.

 That is, unresolved, conflictual attachment history of the parent is

likely to co-occur with dissociative symptoms and negatively

impinge on the child's ability to use the parent as a secure base.
 Information-Processing Approach:

 Rachman (1980) discussed the significance of the processes that

underlie the decline of emotional reexperiencing and suggested
that when these processes are impaired, psychopathology surfaces.

 Usually, the frequency and intensity of this emotional

reexperiencing of the trauma gradually diminishes over time.

 Persistence of neurotic symptoms such as intrusive thoughts,

nightmares, excessive feats, and sleep disturbances are signs of
unsatisfactory "absorption" of the emotional experience.
 Environmental Factors:
 Single or repeated traumatic experiences (e.g., war, childhood
maltreatment, natural disaster, internment in concentration
camps, genocide) are common antecedents.
 Dissociative amnesia is more likely to occur with
 1) a greater number of adverse childhood experiences,
particularly physical and/or sexual abuse,
 2) interpersonal violence; and
 3) increased severity, frequency, and violence of the trauma.
Treatment goal: integrating the disparate parts of self, memory, and
time within the person’s consciousness
Phasic process by Loewenstein (1995):
1. First phase: the traumatized individual is assisted to achieve safety
and stability in his or her life.
2. Second phase: processing of traumatic material in greater depth
and overcome persistent amnesia symptoms as well as
resolution of material that is undissociated or less dissociated.
3. Third phase of "resolution" or "reintegration”: "reconnected to
ordinary life”; development of a renewed, reinvigorated life apart
from the symptoms of the trauma.
Hypnotherapy:
 important adjunctive role in the treatment.
 used to contain, modulate, and titrate the intensity of symptoms.
 to facilitate controlled recall of dissociated memories;
 to provide "ego-strengthening”
 promote working through and integration of dissociated material
Group Psychotherapy:
 to promote recovery in traumatic war-related amnesia.
 Highly supportive, structured, reassuring and "educative" approach
 to accomplish the return of the patient to a functional status and to
prevent chronic disability
Cognitive-Behavioural Therapy
 to help clients develop a coherent sense of themselves and their
experiences.
 benefit from questioning their long-held core assumptions about
themselves that are contributing to their symptoms.
 Identifying the specific cognitive distortions that are based in the
trauma may provide an entrée into autobiographical memory for
which the patient experiences amnesia.

Treatment of dissociative disorders often involves not only these

disorders themselves, but also associated disorders of mood, anxiety,
and post-traumatic stress.
Somatic Therapy:
 pharmacologically facilitated interviews.
 variety of agents -sodium amobarbital, thiopental (Pentothal), oral
benzodiazepines, and amphetamines.
 using intravenous amobarbital or diazepam (Valium) are used
primarily in working with acute amnesias and conversion reactions.
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Institute in India - A Selected Review and Patterns Over a Decade. International
Journal of Social Psychiatry. 2009;56(5):533-539.
 2. Sar V. Dissociative Disorders: Epidemiology. 2017.
 3. Whitbourne S. Abnormal psychology. 8th ed. New York: McGraw-Hill Education;
2017.
 4. Michelson L, Ray W. Handbook of dissociation. New York: Plenum Press; 1996.
 5. Sadock B, Sadock V, Ruiz P. Kaplan & Sadock's synopsis of psychiatry. 11th ed.
Wolters Kluwer; 2015.