Dissociative Disorders

Dissociative Disorders
• Dissociative identity disorder
• Dissociative amnesia,
• Depersonalization/derealization disorder.
• Other specified dissociative disorder
• Unspecified dissociative disorder.
 Dissociative Disorders
• disturbance of or alteration in the normally well-integrated functions
of identity, memory, and consciousness.
 Dissociative Disorders
• In these situations, it has been suggested that dissociation serves an
adaptive function by allowing the mind to process the events of daily
life. In some people, however, the dissociative process becomes
distorted and actively interferes with one’s functioning, causing
distress and disability.
• Symptoms can be experienced as unwanted intrusions into awareness
and behavior with accompanying loss of continuity in subjective
experience, or as an inability to access information or control mental
functions that are normally amenable to access or control
 Dissociative Identity Disorder
• presence of two or more distinct personality states, which in some cultures
may be likened to possession
• According to DSM-5, this involves a marked discontinuity in sense of self
and sense of agency, accompanied by related alterations in affect, behavior,
consciousness, memory, perception, cognition, and/or sensory-motor
functioning, as observed by others or reported by oneself.
• For example, people with dissociative identity disorder may feel they have
suddenly become outside observers of their own speech and actions,
which they may feel powerless to stop. Most lay conceptions of dissociative
identity disorder, which has been described for centuries, are based on
media portrayals, the most famous of which are found in the film
adaptations of the books The Three Faces of Eve and Sybil.
 Dissociative Identity Disorder
• Prevalence
• around 1.5% in the general population.
• 5%–15% in inpatient and outpatient psychiatric settings.
• Most persons diagnosed with dissociative identity disorder are women.
• Onset: childhood, usually before 9 years.
• Course: chronic.
• Prognosis: the worst among all dissociative disorders.
• The disorder is reported to run in families and as occurring in multiple
generations.
• Dissociative identity disorder may results from
• severe physical and sexual abuse in childhood.
• self-induced hypnosis, used by the individual to cope with abuse, emotional maltreatment, or
neglect
 Dissociative Identity Disorder
• Cindy, a 24-year-old woman, was transferred to the psychiatry service to facilitate community placement. Over the years, she had
received many different diagnoses, including schizophrenia, borderline personality disorder, schizoaffective disorder, and bipolar
disorder. Dissociative identity disorder was her current diagnosis.

• Cindy had been well until 3 years before admission, when she developed depression, “voices,” multiple somatic complaints,
periods of amnesia, and wrist cutting. Her family and friends considered her a pathological liar because she would do or say things
that she would later deny.

• Chronic depression and recurrent suicidal behavior led to frequent hospitalizations. Cindy had trials of antipsychotics,
antidepressants, mood stabilizers, and anxiolytics, all without benefit. Her condition continued to worsen.
• Cindy was a petite, neatly groomed woman who cooperated well with the treatment team. She reported having nine distinct alters
that ranged in age from 2 to 48 years; two were masculine. Cindy’s main concern was her inability to control the switches among
her alters, which made her feel out of control.
• She reported having been sexually abused by her father as a child and described visual hallucinations of him threatening her with a
knife. We were unable to confirm the history of sexual abuse but thought it likely, based on what we knew of her chaotic early
home life. Nursing staff observed several episodes in which Cindy switched to a troublesome alter. Her voice would change in
inflection and tone, becoming childlike as Joy, an 8-year-old alter, took control. Arrangements were made for individual
psychotherapy and Cindy was discharged. At a follow-up 3 years later, Cindy still had many alters but was functioning better, had
fewer switches, and lived independently. She continued to see a therapist weekly and hoped to one day integrate her many alters.
Ms. A, a 3 3-year-old married woman employed as a librarian in a school for
disturbed children, presented to psychiatric attention after discovering her 5-year-
old daughter ''playing doctor" with several neighborhood children. Although this
event was of little consequence, the patient began to become fearful that her
daughter would be molested. The patient was seen by her internist and was
treated with antianxiety agents and antidepressants, but with little improvement.
She sought psychiatric consultation from several clinicians, but repeated, good
trials of antidepressants, antianxiety agents, and supportive psychotherapy
resulted in limited improvement. After the death of her father from complications
of alcoholism, the patient became more symptomatic. He had been estranged from
the family since the patient was approximately 12 years of age, owing to his
drinking and associated antisocial behavior. Psychiatric hospitalization was
precipitated by the patient's arrest for disorderly conduct in a nearby city. She was
found in a hotel, in revealing clothing, engaged in an altercation with a man. She
denied knowledge of how she had come to the hotel, although the man insisted
that she had come there under a different name for a voluntary sexual encounter.
• On psychiatric examination, the patient described dense amnesia for the first 12 years of her life, with the
feeling that her "life started at 12 years old." She reported that, for as long as she could remember, she had
an imaginary companion, an elderly black woman, who advised her and kept her company. She reported
hearing other voices in her head: several women and children, as well as her father's voice repeatedly
speaking to her in a derogatory way. She reported that much of her life since 1 2 years of age was also
punctuated by episodes of amnesia: for work, for her marriage, for the birth of her children, and for her sex
life with her husband. She reported perplexing changes in skills; for example, she was often told that she
played the piano well but had no conscious awareness that she could do so. Her husband reported that she
had always been "forgetful" of conversations and family activities. He also noted that, at times, she would
speak like a child; at times, she would adopt a southern accent; and, at other times, she would be angry and
provocative. She frequently had little recall of these episodes. Questioned more closely about her early life,
the patient appeared to enter a trance and stated, "I just don't want to be locked in the closet" in a child-like
voice. Inquiry about this produced rapid shifts in state between alter identities who differed in manifested
age, facial expression, voice tone, and knowledge of the patient's history. One spoke in an angry, expletive-
filled manner and appeared irritable and preoccupied with sexuality. She discussed the episode with the
man in the hotel and stated that it was she who had arranged it. Gradually, the alters described a history of
family chaos, brutality, and neglect during the first 12 years of the patient's life, until her mother, also
alcoholic, achieved sobriety and fled her husband, taking her children with her. The patient, in the alter
identities, described episodes of physical abuse, sexual abuse, and emotional torment by the father, her
siblings, and her mother. After assessment of family members, the patient's mother also met diagnostic
criteria for dissociative identity disorder, as did her older sister, who also had been molested. A brother met
diagnostic criteria for PTSD, major depression, and alcohol dependence.
 Dissociative Identity Disorder
• Patients are reported to have smaller hippocampal and amygdalar
volumes, suggesting that early traumatic experiences may affect
neural circuitry alterations in brain areas associated with memory.

• The transition from one alter to another may be sudden or gradual,

often prompted by stressful situations.
 Dissociative Identity Disorder
• Patients with dissociative identity disorder often meet criteria for other mental disorders.
• somatic symptom disorder.
• Headaches and amnesia (“losing time”) are particularly common symptoms.
• Borderline personality disorder, found in up to 70% of dissociative identity disorder patients,
• Many Patients will have a past diagnosis of schizophrenia, schizoaffective disorder, or psychotic
mood disorder. These diagnoses need to be ruled out.
• Patients with dissociative identity disorder tend to report that the voices originate within their heads, are not
experienced with the ears, and are not associated with mood changes; insight generally is preserved.
• By contrast, patients with psychotic disorders usually report that auditory hallucinations “come from the
outside,” and are accompanied by changes in mood; insight is minimal.
• Hallucinations that accompany dissociative identity disorder are probably best considered
pseudohallucinations— that is, hallucinations that are a product of one’s own mind and are
accompanied by the realization that the experience is due to illness and is not real.
 Dissociative Identity Disorder
Treatment:
• Although the core features of dissociative identity disorder do not
respond to medication, these patients often have co-occurring mood
and anxiety disorders that can benefit from medication. For example,
antidepressants may relieve coexisting major depression and block
panic attacks.
• Psychotherapy
 Dissociative Amnesia

• Inability to recall important autobiographical information considered

too extensive to be explained by ordinary forgetfulness.
• The most common type of dissociative disorders.
• person is typically confused and perplexed.
• may not recall significant personal information or even his or her own
name.
• The amnesia can develop suddenly and last minutes to days or longer.
 Dissociative Amnesia
• The prevalence of dissociative amnesia has been estimated at around
1%–3% in the general population.
• it affects more women than men.
• It has been reported to occur following severe physical or
psychosocial stressors (e.g., natural disasters, war).
• In a study of combat veterans, between 5% and 20% were amnesic
for their combat experiences.
 Dissociative Amnesia
Types of Dissociative Amnesia
1. Localized amnesia: Inability to recall events related to a circumscribed
period of time
2. Selective amnesia: Ability to remember some, but not all, of the events
occurring during a circumscribed period of time
3. Generalized amnesia: Failure to recall one’s entire life
4. Continuous amnesia: Failure to recall successive events as they occur
5. Systematized amnesia: Failure to remember a category of information,
such as all memories relating to one’s family or to a particular person
 Dissociative Amnesia
Dissociative fugue
• It is a subtype of dissociative amnesia
• inability to recall one’s past and the assumption of a new identity, which may be partial
or complete.
• Onset: usually sudden, unexpected travel away from home or one’s workplace.
• not due to a dissociative identity disorder.
• not induced by a substance or a general medical condition (e.g. temporal lobe epilepsy).
• occur in psychologically traumatic situations (e.g. natural disasters, war, rape, recurrent
childhood sexual abuse, massive social dislocations), personal rejections, losses, or
financial pressures
• It may last for months and lead to a complications.
• Recovery is spontaneous and rapid. Recurrences are possible.
 Dissociative Amnesia
Treatment
• Psychotherapy helps patients to incorporate the memories into
their conscious state.
• Hypnosis  relax the patient sufficiently to recall forgotten
information.
• drug-assisted interviews (e.g. short-acting barbiturates or
benzodiazepine).
 Depersonalization/Derealization
Disorder
• feeling detached from oneself or one’s surroundings, as though one
were an outside observer; some patients experience a dreamlike
state.
• A patient with depersonalization may feel as though he or she were
cut off from his or her thoughts, emotions, or identity. Another may
feel like a robot or automaton.
• Depersonalization may be accompanied by derealization, a sense of
detachment, unreality, and altered relation to the outside world.
 Depersonalization/Derealization
Disorder
• The prevalence is around 2% in the general population;
• equally common in men and women.

• Many people who are otherwise normal transiently experience mild

depersonalization or derealization.
• For these reasons, depersonalization/derealization disorder is
diagnosed only when it is persistent and causes distress.
 Depersonalization/Derealization
Disorder
• Onset: in adolescence or early adulthood but rarely after 40.
• Many persons vividly recall their first episode which may begin
abruptly.
• precipitating event: such as smoking marijuana.
• duration of episodes is highly variable, but they can last hours, days,
or even weeks.
• Usually chronic and continuous, some people experience periods of
remission.
• Exacerbations may follow psychologically stressful situations, such as
the loss of an important relationship.
 Depersonalization/Derealization
Disorder
• Predisposing factors include anxiety, depression, and severe stress.
• 2. May be caused by a psychological, neurologic, or systemic disease.
• 3. Associated with an array of substances including alcohol,
• barbiturates, benzodiazepines, scopolamine, β-adrenergic
antagonists, marijuana, and virtually any phencyclidine (PCP)-like or
hallucinogenic substance.
 Depersonalization/Derealization
Disorder
Treatment :
• Usually responds to anxiolytics and to both supportive and insight-
oriented therapy.
• As anxiety is reduced, episodes of depersonalization decrease.