Final .Dissociative Diosreders DR Anila Slides
Final .Dissociative Diosreders DR Anila Slides
DISORDERS
Dr Anila Sadaf
Key Features Of Dissociative
Disorders
Dissociative
Dissociation
Disorders
Some aspect of cognition or experience becomes inaccessible to consciousness
Avoidance response
Some types of dissociation are harmless and common (e.g., losing track of time)
Cognitive
Extreme stress usually enhances rather than impairs memory
Implicit memory
Underlies behaviors based on experiences that cannot be consciously recalled
e.g., playing tennis, writing a check
Memory Deficits and Dissociation
Distinguishing other causes of memory loss from dissociation:
Dementia
Memory fails slowly over time
Is not linked to stress
Accompanied by other cognitive deficits
Inability to learn new information
Symptoms
Persistent or recurrent experiences of feeling detached from one’s mental processes or body.
During the experience of depersonalization, reality testing remains intact, one is aware of his/her
experiences are unusual.
The depersonalization experience does not occur during the course of another mental disorder and is not
due to the physiological effects of a substance or a general medication.
Duration And Intensity
The mean age at onset of depersonalization/derealization disorder is 16 years, although the
disorder can start in early or middle childhood; a minority cannot recall ever not having had the
symptoms.
Less than 20% of individuals experience onset after age 20 years and only 5% after age 25 years.
Onset in the fourth decade of life or later is highly unusual.
Prognosis
Treating depersonalization disorder is challenging. Outpatient and Inpatient treatment programs for DD do have a
good track record of success, but they require hard work and dedication,
Differential Diagnosis
Illness anxiety disorder. Although individuals with depersonalization/derealization disorder can
present with vague somatic complaints as well as fears of permanent brain damage, the diagnosis of
depersonalization/derealization disorder is characterized by the presence of a constellation of typical
depersonalization/derealization symptoms and the absence of other manifestations of illness anxiety
disorder.
Major depressive disorder. Feelings of numbness, deadness, apathy, and being in a dream are not
uncommon in major depressive episodes. However, in depersonalization/derealization disorder, such
symptoms are associated with further symptoms of the disorder.
Obsessive-compulsive disorder. Some individuals with depersonalization/derealization disorder can
become obsessively preoccupied with their subjective experience or develop rituals checking on the status
of their symptoms.
2.The disturbance does not occur exclusively during the course of dissociative identity disorder, dissociative fugue,
posttraumatic stress disorder (PTSD), acute stress disorder, or somatization disorder.
3.Does not result from the direct physiological effects of a substance or a neurological or other general medical
condition.
4.This disturbance can be based on neurobiological changes in the brain caused by traumatic stress
Duration and Intensity
• Onset of generalized amnesia is usually sudden. Less is known about the onset of
localized and selective amnesias because these amnesias are seldom evident, even to the
individual. Although overwhelming or intolerable events typically precede localized amnesia,
its onset may be delayed for hours, days, or longer.
• Individuals may report multiple episodes of dissociative amnesia. A single episode may
predispose to future episodes. In between episodes of amnesia, the individual may or may not
appear to be acutely symptomatic. The duration of the forgotten events can range from
minutes to decades.
Risk Factors
1. Trauma caused by human assault rather than natural disaster
2. Repeated traumatization as opposed to single traumatic events
3. Longer duration of trauma
4. Fear of death or significant harm during trauma
5. Trauma caused by multiple perpetrators
6. Close relationship between perpetrator and victim
7. Betrayal by a caretaker as part of abuse
8. Threats of death or significant harm by perpetrator if the victim discloses his or her
identity or information regarding the traumatic experience
Prognosis
• Acute dissociative amnesia frequently spontaneously resolves once the person is removed to safety
from traumatic or overwhelming circumstances.
• Some patients do develop chronic forms of generalized, continuous, or severe localized amnesia and
are profoundly disabled and require high levels of social support, such as nursing home placement or
intensive family caretaking.
• Clinicians should try to restore patients' lost memories to consciousness as soon as possible;
otherwise, the repressed memory may form a nucleus in the unconscious mind around which future
amnestic episodes may develop.
Differential Diagnosis
• Dissociative identity disorder. Individuals with dissociative amnesia may report depersonalization and auto-
hypnotic symptoms. Individuals with dissociative identity disorder report pervasive discontinuities in sense of self
and agency, accompanied by many other dissociative symptoms.
• Posttraumatic stress disorder. Some individuals with PTSD cannot recall part or all of a specific traumatic event.
• Neurocognitive disorders. In neurocognitive disorders, memory loss for personal information is usually embedded
in cognitive, linguistic, affective, attentional, and behavioral disturbances.
• Substance-related disorders. In the context of repeated intoxication with alcohol or other substances/medications,
there may be episodes of "black outs" or periods for which the individual has no memory.
• Catatonic stupor. Mutism in catatonic stupor may suggest dissociative amnesia, but failure of recall is absent.
Other catatonic symptoms (e.g., rigidity, posturing, negativism) are usually present.
• Normal and age-related changes in memory. Memory decrements in major and mild neurocognitive disorders
differ from those of dissociative amnesia, which are usually associated with stressful events and are more specific,
extensive, and/or complex.
Comorbidity
Many individuals with dissociative amnesia develop PTSD at some point during their life, especially
when the traumatic antecedents of their amnesia are brought into conscious awareness.
Many individuals with dissociative amnesia have symptoms that meet diagnostic criteria for a comorbid
somatic symptom or related disorder (and vice versa), including somatic symptom disorder and
conversion disorder (functional neurological symptom disorder).
Many individuals with dissociative amnesia have symptoms that meet diagnostic criteria for a
personality disorder, especially dependent, avoidant, and borderline.
Dissociative Identity Disorder
(DID)
Two or more distinct and fully developed personalities (alters)
Each has unique modes of being, thinking, feeling, acting, memories, and relationships
Primary alter may be unaware of existence of other alters
Recurrent gaps in recalling events or important personal information that are beyond ordinary forgetting
In children, symptoms are not better explained by an imaginary playmate or by fantasy play
Dissociative Identity Disorder (DID)
Epidemiology
No identified reports of DID or dissociative amnesia before 1800 (Pope et al., 2006)
Major increases in rates since 1970s
DSM-III (1980)
Diagnostic criteria more explicit
Sociocognitive Model
DID a form of role-play in suggestible individuals
Could be iatrogenic—occurs in response to prompting by therapists or media
No conscious deception
• The average time period from first symptom presentation to diagnosis is 6-7 years
• Episodic and continuous courses have both been described
• The disorder may become less manifest as individuals age beyond their late 40s, but may reemerge during
episodes of stress or trauma or with substance abuse
Risk Factors
• Dissociative identity disorder is strongly linked to severe experiences of early childhood trauma, usually maltreatment.
• Physical and sexual abuse are the most frequently reported sources of childhood trauma.
• The contribution of genetic factors is only now being systematically assessed, but preliminary studies have not found
evidence of a significant genetic contribution.
Differential Diagnosis
• Major depressive disorder. Individuals with dissociative identity disorder are often depressed, and their symptoms
may appear to meet the criteria for a major depressive episode.
• Bipolar disorders. Individuals with dissociative identity disorder are often misdiagnosed with a bipolar disorder,
most often bipolar II disorder.
• Posttraumatic stress disorder. Some traumatized individuals have both posttraumatic stress disorder (PTSD) and
dissociative identity disorder. Accordingly, it is crucial to distinguish between individuals with PTSD only and
individuals who have both PTSD and dissociative identity disorder.
• Psychotic disorders. Dissociative identity disorder may be confused with schizophrenia or other psychotic disorders. The
personified, internally communicative inner voices of dissociative identity disorder, especially of a childmay be mistaken
for psychotic hallucinations.
• Personality disorders. Individuals with dissociative identity disorder often present identities that appear to encapsulate a
variety of severe personality disorder features, suggesting a differential diagnosis of personality disorder, especially of tiie
borderline type.
Comorbidity
Individuals with dissociative identity disorder usually exhibit a large number of comorbid disorders. In particular, most develop PTSD.
Other disorders that are highly comorbid with dissociative identity disorder include depressive disorders, trauma- and stressor-
related disorders, personality disorders (especially avoidant and borderline personality disorders), conversion disorder
(functional neurological symptom disorder), somatic symptom disorder, eating disorders, substance-related disorders,
obsessive compulsive disorder, and sleep disorders. Dissociative alterations in identity, memory, and consciousness may affect
the symptom presentation of comorbid disorders.