Dissociative

Disorders
• The essential feature of the dissociative
disorders is a disruption in the usually
integrated functions of consciousness,
memory, identity, perception or motor
behavior.
– sudden or gradual
– transient or chronic.
• Strongly related to an antecedent history of
traumatic or stressful experiences but
controversial.
• High-profile legal cases have been the center
of debate.
• Cases have been the subject of considerable
media attention.
 History
• End of the 18th century- study on hysteria and
dissociation began.
• Classified as Hysterical neurosis until DSM III
• Pierre Janet's research and clinical theory
regarded as foundation for modern view
1. emphasized on the role of traumatic antecedents of
dissociation.
2. recognized that the underlying mental mechanisms of
somatoform and dissociative disorders were similar.
3. treatment using hypnotic and trauma-focused
methods combined with cognitive therapy, behavioral
therapy, and life-skills building.
• Freud- focused on intrapsychic conflicts &
defenses.
• 20th century - interest in dissociation waned
and shifted to psychoanalysis.
• Interests reoccurred after the World Wars
– observation of amnesia, fugues, and conversion
symptoms in traumatized soldiers.
Types
• Dissociative amnesia,
• Dissociative fugue,
• Dissociative identity disorder,
• Depersonalization disorder and
• Other specified and unspecified dissociative
disorder
 Dissociative Amnesia
• Is an inability to recall important personal
information, usually of a traumatic or stressful
nature.
• Not due to organic cause, substance use or
normal forgetfulness.
• 2- 6% of general population.
• M:F-1:1??, late adolescent and adulthood.
• found in those who have experienced extreme
acute trauma.
• Patients experience intolerable emotions of
shame, guilt, despair, rage, and desperation.
• Traumatic experiences such as physical or
sexual abuse can induce the disorder.
• Usually alert before and after the amnesia.
• Depression and anxiety are common.
Types
Localized amnesia
– Events related to a specific period of time

Selective amnesia
– Some of the events

Generalized amnesia
– Failure to recall one's entire life

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 to a particular person
 Depersonalization Disorder
• Persistent or recurrent feeling of detachment from
one's self.
• Feels as if in a dream or watching himself or herself in a
movie, may feel out of control.
• Reality testing is intact.
• Transient experiences extremely common.
• It is common in seizure patients and migraine sufferers.
• They can also occur with use of drugs like marijuana,
lysergic acid diethylamide (LSD)and less frequently as a
side effect of some medications, such as anticholinergic
agents.
• They have been described after certain types of
meditation, deep hypnosis, and sensory deprivation
experiences.
• They are also common after mild to moderate head
injury, wherein little or no loss of consciousness
occurs.
• 1 year prevalence of 19 % in the general population.
• 2-4x more common in Females.
• Seen in late adolescence or early adulthood in most
cases.
Psychodynamic
• viewed depersonalization as an affective
response in defense of the ego.
• These explanations stress the role of
overwhelming painful experiences or
conflictual impulses as triggering events.
Neurobiological Theories
• The association of depersonalization with
migraines and marijuana,
• its generally favorable response to selective
serotonin reuptake inhibitors (SSRIs),
• and the increase in depersonalization
symptoms seen with the depletion of L-
tryptophan, a serotonin precursor, point to
serotoninergic involvement.
 Dissociative Fuge
• Sudden, unexpected but organized travel
away from home or one's customary place of
daily activities.
• Unable to recall some or all of one's past.
• Confusion about personal identity or
assumption of a new identity*but not alter
identity.
• Display normal behavior and don’t attract
attention.
• Traumatic circumstances (i.e., combat, rape,
recurrent childhood sexual abuse, massive social
dislocations, natural disasters), leading to an altered
state of consciousness dominated by a wish to flee,
are the underlying cause of most fugue episodes.
• In some cases, instead of, or in addition to,
external dangers or traumas, the patients are
usually struggling with extreme emotion or
impulses (i.e., overwhelming fear, guilt,
shame, or intense incestuous, sexual,suicidal,
or violent urges) that are in conflict with the
patient’s conscience or ego ideals.
• No adequate data exist to demonstrate a
gender bias to this disorder.
• Most cases describe men, primarily in the
military and adults.
 Dissociative Identity Disorder
• Previously called multiple personality disorder.
• The presence of two or more independent
identities that recurrently take control of the
individual's behavior, with only one evident at
a time.
• Tone of voice, mannerisms, and other personality
characteristics change.(at least 2, range 5-10)
• Inability to recall important personal
information, amnestic about the other states.
• The symptoms of all the other dissociative
disorders are commonly found in patients with
dissociative identity disorder.
• Few epidemiological data, F:M- 5 : 1 to 9:1
• Onset from childhood to adolescence.
• Dissociative identity disorder is strongly linked
to severe experiences of early childhood
trauma, usually maltreatment ( 85-97%).
• Physical and sexual abuse are the most
frequently reported sources of childhood
trauma.
• Not yet found evidence of a significant genetic
contribution.
Memory and Amnesia Symptoms.
• Ask about losing time, blackout spells, and major
gaps in the continuity of recall for personal
information.
• Dissociative Alterations in Identity.
• Clinically, may first be manifested by odd first-
person plural or third-person singular or plural self-
references.
• In addition, patients may use as “the body,” when
describing themselves and others.
• Patients often describe a profound sense of
concretized internal division or personified
internal conflicts between parts of themselves.
• In some instances, these parts may have proper
names like “the angry one” or “the wife.”
• Patients may suddenly change the way in which
they refer to others, for example, “the son”
instead of “my son.”
• Other Associated features
– 2/3 attempt suicide
– 70% meet criteria for PTSD
– 60% for somatization d/o
– Conversion d/o
– Mood d/o- mostly depressive
– Anxiety d/o
– OCD
– Eating d/o
– Sleep d/o
 OTHER SPECIFIED OR UNSPECIFIED
DISSOCIATIVE DISORDER
Dissociative Trance Disorder
• is manifest by a temporary, marked alteration
in the state of consciousness or by loss of the
customary sense of personal identity without
the replacement by an alternate sense of
identity.
• In this possessed state, the individual exhibits
stereotypical behaviors or experiences being
controlled by the possessing entity.
• Brainwashing
• Recovered memory syndrome
• Ganser syndrom
 Course and Prognosis
• Amnesia Little is known about the clinical course of
dissociative amnesia.
- acute spontaneously resolves if removed to safety
– Some chronic forms of generalized, continuous, severely
disabling
• Depersonalization - resolves by itself if underlying cause is
corrected.
– Can be episodic, relapsing and remitting or chronic, disabling
• Fuge - lasts from minutes to months.
– Some multiple fugues
– refractory dissociative amnesia may persist
– Desirable outcome is fusion of identities
Dissociative identity disorder
• Tends to be chronic and recurrent
• If untreated severely disabling
• Incomplete recovery
• Poorer prognosis in
– Early onset
– Comorbid organic mental disorders
– Severe medical illnesses
– Refractory substance abuse
– Antisocial personality features,
– Current criminal activity,
– Repeated adult traumas.
 Management
* Always r/o
– Medical conditions- including trauma
– Neurological conditions
– Substance related d/o-intoxication, withdrawal,
side effect of medication
– Other disorders
• Psychiatric conditions-ASD, PTSD, Schizophrenia, Panic
d/o, mood d/o
• Conversion d/o
• Malingering and factitious d/o
 Management
• Amnesia and fugue (usually spontaneously
remit):
– Supportive counseling
– Treat depression and stress
• Depersonalization disorder (slower
spontaneous remission)
– Alleviate feelings of anxiety, depression,
fear of going insane.
– Occasionally behavioral therapy
Psychotherapy
• Psychodynamic
• Cognitive- history of trauma  to correct cognitive
distortions.
– Slow response
• Distraction techniques, relaxation training and physical
exercise.
• Group therapy
• Family therapy
• Self -help groups
• Hypnosis - to facilitate controlled recall of
dissociated memories; to provide support and
ego strengthening, integration of dissociated
material/identities.
– In DID
• Personalities introduce selves to patient (in
hypnosis) and recall traumatic
experiences/memories which developed them
• Therapist suggests personalities served a
purpose but now alternative coping strategies
will be more effective.
• Integrate personalities.
• Somatic therapy
– Sodium Amobarbital, Thiopental, oral
benzodiazepines facilitated interview
– To treat underlying depression, anxiety
– SSRI- helpful in Depersonalization d/o but
controversial
• The atypical neuroleptics, such as risperidone ,
quetiapine , ziprasidone , and olanzapine , may be
more effective and better tolerated for
overwhelming anxiety and intrusive PTSD
symptoms in patients with dissociative identity
disorder.
• Occasionally, those who have not responded to
trials of other neuroleptics, responds favorably to a
trial of clozapine.
 References
1. K & S ,comprehensive 9th edition
2. K & S , synopsis 10th edition
3. Guide to primary care psychiatry, 2nd edition
4. Wikipedia
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