Dissociative Disorders

Overview

All dissociative disorders involve a disruption of consciousness, memory, identity OR perception resulting in significant distress to the patient. Mostly caused by some degree of psychological trauma. The defense mechanism dissociation is prominent (mostly in Dissociative amnesia). r/o Hallucinogens (LSD, mescaline, Piloscybine) and General medical conditions (Head trauma, partial seizures)

Dissociation: Separation of conscious reality from external reality. A defence mechanism – so that you don’t have to deal with things right away.

• Patient presentation
  • **Amnesia (**possibly even to self)
  • Confusion (about self, identity, and events)
  • Abrupt and/or erratic personality changes
• Differentials
  • Dementia/delirium: Older patient, scores poorly on MMSE
  • Substance intoxication: LSD, Mescaline, Psilocybin
  • General medical condition: Head trauma, partial seizure frontal lobe. On Hx (wound or Hx of epilepsy), Get CT or EEG
• How to differentiate a patient with Dissociative disorder from one with dementia/delirium
  • Will score fine on MMSE
  • Will most likely be younger patients who score fine on the MMSE (apart from confusion about self, identity, and events)
• Treatment
  • Psychotherapy (Dissociative disorders are caused by some degree of psychological trauma so the best treatment is therapy)

Changes from DSM-IV to DSM-V

• Depersonalization disorder has been renamed depersonalization/derealization disorder since derealization can be a feature of depersonalization
• Dissociative fugue is no longer technically its own disorder, but rather a subset of Dissociative amnesia

Dissociative Identity Disorder

• A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in the sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
• B. Recurrent gaps in the recall of everyday events, personal information, or traumatic events that are inconsistent with ordinary forgetting
• C. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• D. The disturbance is not a normal part of a broadly accepted cultural or religious practice
  • In children, symptoms are not better explained by imaginary playmates or other fantasy play.
• E. The symptoms are not attributable to the physiological effects of a substance or another medical condition (eg. complex partial epilepsy of the frontal lobe)

Depersonalization/Derealization disorder

Characterized by persistent feelings of depersonalization and derealization. There is usually some level of anxiety with this patient (subclinical).

• Depersonalization
  • The conscious sensation of feeling like one is “watching oneself act”. Has an
  • As if ”I am not real”
  • As if “I am watching from outside my body”
  • As if “this is a dream”
• Derealization
  • The conscious sensation of feeling like one’s surroundings are not actually happening
  • Like deja vu (familiar experience although it has objectively never been experienced before) OR jamais vu (unfamiliar experience although it has been experienced before)
  • A normal situation but can be associated with temporal lobe epilepsy and schizophrenia.
• Differentials
  • Substance-induced depersonalization: Usually presents to the ED. Signs of hallucinogen intoxication (mydriasis, incoordination, tremor). This shows on urine tox screen
  • Panic attack: sudden onset, symptoms of anxiety (nausea, tachycardia etc.), dysphoria
• Treatment
  • Psychotherapy
  • Evaluate for anxiety disorders
• Common drugs associated with depersonalization
  • Amantadine (antiviral, used for Parkinson’s movement sx)
  • Ketamine (anesthesia)
  • Phencyclidine (PCP, patients will be violent + have hallucinations)
  • Dextromethorphan (DM – cough suppressant used universally, also has hallucinogenic properties)
  • Butorphanol (Labor and delivery for anesthesia)

Dissociative amnesia

Characterized by a patient’s inability to recall particular memories, especially those associated with psychological/physical trauma OR those that hold emotional sensitivity. This is the prime manifestation of the defence mechanism of dissociation. Remits gradually. The patient will often have a comorbid mood disorder.

• Differentials
  • General medical condition causing amnesia: Order CT (Hx of trauma), and EEG (if Focal signs of seizure or if Hx of epilepsy)
  • Substance causing amnesia
• Treatment
  • Psychotherapy
  • Sodium thiopental (”truth serum”, used by a psychiatrist)

Dissociative fugue

Characterized by a patient who has abruptly travelled to a new place, cut off communication with contacts AND assumes a new identity. Very sudden and follows an exquisitely threatening psychological stressor. Can last hours to months and beyond. The patient maintains self-care and their behaviour may even appear normal to passers-by.

• Differentials
  • Dementia: Patient scores poorly on MMSE
  • Malingering: Patients do so to escape the law (Like Walter Hardwell White)

Dissociative identity disorder (Multiple Personality Disorder)

Characterized by two or more conflicting personalities existing within the same patient. Personalities harbour their own characteristics and have their own “memories”. Like having 2 or 3 souls in 1 person. More common in women.

• Differentials
  • Bipolar I or Bipolar II disorder w/rapid cycling: will show signs of mania, which are not present in DID. Mania/hypomania may show one personality while MDD may show another.
• Treatment
  • Psychotherapy