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Psychiatry II

Dissociative Disorders & Eating Disorders

Dra. Aireen Capitan
4th Shifting/Jan. 15, 2009
Yvette, Ralph, Honey, Jam

DISSOCIATIVE DISORDERS  clouding of consciousness surrounding it

DISSOCIATIVE AMNESIA  Depression and anxiety – common predisposing
 May provide protective (primary/secondary) gain –
 ~6% of the general population blocking memories
 Incidence  Occurs in 3 forms
 More often in women and young adults (Can
occur at any age)
 Localized amnesia –memory loss for a
short time (hours to days)
 Increased Prevalence
 in times of war  Generalized amnesia –a whole lifetime of
 natural disasters experience
 sexual abuse Selective or systematized amnesia –
 physical abuse failure to recall some details
 emotional abuse  Confabulation, note taking, stopping
 Late adolescence and adulthood activities – coping/adaptive strategy
 Preadolescent children Differential Diagnosis
 difficult to assess because limited ability to  Ordinary Forgetfulness and Nonpathological Amnesia
describe subjective experience.  Dementia, Delirium, and Organic Amnestic Disorders
Etiology:  Posttraumatic Amnesia
 Emotional Content of the Memory  Seizure Disorders
 State-dependent learning  Substance-Related Amnesiay cannot be reversed.
 memory of a traumatic event, and the  Transient Global Amnesia
emotional state may be so extraordinary that  Other Dissociative Disorders
it is hard for an affected person to remember  Acute Stress Disorder, Posttraumatic Stress Disorder,
information learned during that state and Somatoform Disorders
 psychoanalytic approach  Malingering and Factitious Amnesia
 defense mechanism Course and Prognosis:
 a way of dealing with an emotional conflict or  Symptoms usually terminate abruptly
an external stressor  Recovery generally complete
 Secondary defenses
 Patients with secondary gain◊ condition may last a
 Repression
longer time
 Denial  Clinicians◊ try to restore patients lost memories ASAP
DSM-IV-TR Criteria:  Pharmacological
A. Predominant disturbance is one or more episodes of
 Non pharmacological
inability to recall important personal information, usually
of traumatic or stressful nature, that is too extensive to  Hypnosis
be explained by ordinary forgetfulness  relaxing patients to facilitate recall
B. Disturbance does not occur exclusively during the of dissociated memories
course of dissociative identity disorder, dissociative  Group Psychotherapy
fugue, PTSD, ASD, or somatization disorder and is not
 recommended to help patients
due to the direct physiological effect of a substance or
incorporate the memories into their
other medical condition
conscious states
C. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important
Clinical Features: • 0.3 to 3 % of general psychiatric hospital patients
meet the diagnostic criteria
 Occur spontaneously
• 5 : 1 to 9 : 1 female to male ratio
 Precipitated by emotional trauma
• Common in late adolescent and young adult
 sexual fantasy or aggressive impulse • Mean age of diagnosis; 30 years old
 Abrupt onset • Frequently coexist with anxiety, mood, somatoform
 May upset the patient or may feel indifferent/ and other disorders
unconcerned • Suicide is also common.
 usually conscious before/after the event Etiology:

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Dissociative Disorders & Eating Disorders
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• Trauma 3. History gathering and mapping
• Physical and/or sexual abuse 4. Metabolism of trauma
– 85-97% among those with Dissociative 5. Working through of recovered materials across the
Identity Disorders alters
• Genetic Factors 6. Integration-Resolution
Clinical Signs and Symptoms: 7. Learning new coping skills
• Memory symptoms 8. Solidification
• Processing symptoms 9. Follow-Up
• Dissociative alterations of identity Principles for Successful treatment
• Child and adolescent presentations  Secure treatment frame and firm, consistent
Diagnosis: boundaries.
DSM-IV Criteria for DID  Focus on mastery and patient’s active participation.
A. The presence of 2 or more distinct identities or  Based on strong therapeutic alliance.
personality states with its own relatively enduring
 Uncovering and abreaction.
pattern of perceiving, relating to, and thinking about
 Collaboration of the alters.
the environment and self
B. At least 2 or 3 identity states take recurrent control  Clear and straight communication.
of the person’s behavior  Consistency across all alters.
C. Inability to recall important personal information that  Restore morale and inculcate realistic hope.
is too extensive to be explained by ordinary  Rule of thirds.
forgetfulness  Responsibility.
D. The disturbance is not due to the direct  Taking a warm stance.
physiological effects of a substance or a general  Correcting cognitive errors.
medical condition
Differential Diagnosis: Epidemiology:
• Imitative Dissociative Identity Disorder
• Genuine Dissociative Identity Disorder
• Rare disorder
• Schizophrenia and other psychoses • Estimated to affect just 0.2% of the population, nearly
• Rapid-cycling Mood Disorder all of them adults.
• Borderline Personality Disorder • Prevalence increases significantly following a
• Malingering and Factitious Disorder stressful life event, such as wartime experience,
• Partial Complex Seizure Disorder accidents an natural disasters
• Posttraumatic Stress Disorder Etiology:
Course: • Stressor or traumatic event (most common): person
 Children may be physically and mentally escaping a
 Boys>Girls threatening environment or intolerable situation
 Sxs: trancelike accompanied by depression,
amnesic period, hallucinatory voices, • Chronic Stress (Bankruptcy)
disavowal of behaviors, suicidal • Depression or Dysphoria
• Histories of Childhood Abuse or Neglect (not yet
 Adolescents
 Girls>Boys
Clinical Features:
 2 Symptom pattern: • Last from minutes to months
1. Chaotic life with promiscuity, drug use, suicide attempts • May be multiple
2. Withdrawal and childlike behaviors • “Waking fugue”
 Males: trouble with law or school officials • Brief and involve only short distances in children
Prognosis: • May be terminated by perplexity, confusion, trance-
 Determining variables: number, type, chronicity like behaviors, depersonalization, derealization,
 If diagnosed early, children have excellent prognosis conversion symptoms or generalized dissociative
 Adolescents have poorer prognosis than children and amnesia
adults • May display mood disorder symptoms, intense
 Adult prognosis is dependent on attitude toward suicidal ideation, PTSD and other anxiety disorder
treatment symptoms
 Number of alter personalities has moderate effects • Alter identity created under auspices the patient lives
on outcome for a period of time
 Poorer in patients with comorbid illness Diagnosis:
Treatment: DSM-IV Criteria for Dissociative Fugue
 Insight-Oriented A. Predominant disturbance is sudden, travel away
Psychotherapy from home or work place, with inability to recall
one’s past
 Hypnosis
B. Confusion about personal identity or assumes new
 Pharmacotherapy? identity (partial or complete)
Stages of Therapy for DID
1. Establishing psychotherapy
2. Preliminary interventions
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C. Does not occur exclusively during dissociative – Mean age of onset: 16 years old
identity disorder and not due to GMC or effects of Etiology:
substance use 1. Psychodynamic - emphasizes the disintegration of the
D. Cause clinical distress on areas of functioning ego; an affective response in defense of the ego
- triggered by overwhelming painful experiences or
Differential Diagnosis: conflictual impulses
• Dementia 2. Traumatic Stress – 1/3 – 1/2 of patients report histories of
• Delirium significant trauma
• Complex partial epilepsy - as much as 60% of accident victims
• Dissociative amnesia 3. Neurobioligical Theories - N-Methyl-D-aspartate (NMDA)
• Malingering subtype of the glutamate receptor as central to the
• General medical condition genesis of depersonalization symptoms
• Toxic and substance-related disorders - serotoninergic involvement
• Bipolar disorder Diagnosis:
• Schizoaffective disorder DSM-IV-TR Criteria for Depersonalization Disorder
• Schizophrenia A. Persistent or recurrent experiences of feeling
Course & Prognosis: detached from, and as if one is an outside observer
• Lasts for hours to days of, one’s mental process or body (e.g., feeling like
• Less commonly months one is in a dream).
• Involves extensive travel (thousands of miles) B. During the depersonalization experience, reality
• Spontaneous recovery testing remains intact.
• Possible to recur C. The depersonalization causes clinically significant
Treatment: distress or impairment in social, occupational, or
• Most widely accepted technique requires mixture of other important areas of functioning.
abreactions of the past trauma and integration of the D. The depersonalization experience does not occur
trauma into a cohesive self that no longer requires exclusively during the course of another mental
fragmentation to deal with the trauma disorder, such as schizophrenia, panic disorder,
• TOC: Expressive-Supportive Psychodynamic acute stress disorder, o another dissociative
Psychotherapy disorder, and is not due to the direct physiological
• Psychotherapy-help patients incorporate precipitating effects of a substance (e.g., temporal lobe
stressors in a healthy manner epilepsy).
• Psychiatric and drug-assisted interviewing
Clinical Features:
• Hypnosis-helps to reveal the psychological stressors • central characteristic: quality of unreality and
that precipitated the fugue episode estrangement
• feel different and no longer appear to have any
DEPERSONALIZATION DISORDER relation or significance to the person parts of the
• a persistent or recurrent alteration in the perception of body or the entire physical being may seem foreign as
self to the extent that a person’s sense of his or her well as mental operations and accustomed behavior.
own reality is temporarily lost
• Feeling of “mechanical, “in a dream”, “detached from Hemidepersonalization – feeling that half of the body is
their bodies” unreal or does not exist may be related to
• ego-dystonic episodes contralateral parietal lobe disease.
• patients realize unreality of symptoms
• Anxiety is often included
Depersonalization vs Derealization • Complains of distortions in their senses of time and
Depersonalization: feeling that the body or the personal space
self is strange and unreal • May feel that the point of consciousness is outside
their bodies—as if they were totally different people.
Derealization: perception of objects in the external world • Reduplicative paramnesia / double orientation -
as strange and unreal
believing that the patient is in two places at the same
• Patient is aware of the disturbances in their sense of
• An occasional isolated experience
• Common and not necessarily pathological
Differential Diagnosis:
• Occur in 70% of population
Temporal Lobe Seizures ( epilepsy )
– No significant difference between men and
Atypical forms of Migraine and Headache
– Children: develop capacity for self-
Acute Stress Disorder
Panic Disorder
– Adults: temporary sense of unreality while
Another Dissociative Disorder – Fugue - Identity
Drug Abuse
• Recent studies
– Women 2x as frequent as in men
Course and Prognosis:
– Rare in >40 years old
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• Symptoms appear suddenly. Few report a gradual D. In postmenarcheal females, amenorrhea
• Start = 15 & 30 y/o, but can be seen as young as 10
• Occur less frequently after age 30 Clinical Features:
• In more than 50% of cases, it tends to be long lasting. • Physchological/Behavioral
• It usually run a steady course w/o significant • Physical
fluctuations in intensity
• Little is known about precipitating factors
• Observed to begin during a period of relaxation after a
person experienced psychological stress.
• Sometimes accompanied w/ acute anxiety, frequently
by hyperventilation.
• usually recommended only if the disorder persists, Differential Diagnosis:
recurs, or causes distress
• Any stresses associated with the beginning of the Disorder Similarities Distinguishing
depersonalization disorder must also be addressed Features
• Approaches:
– Psychotherapy Depressive Depressed Decreased appetite;
– Cognitive therapy Disorders feelings, crying depressive agitation; not
– Medication spells, sleep preoccupied with recipes,
– Family therapy disturbance, caloric content of foods,
– Creative therapies (art therapy, music obsessive and preparation of
therapy) ruminations, gourmet feasts; no
– Clinical hypnosis occasional suicidal intense fear of obesity or
thoughts disturbance of body
• Greek term for “loss of appetite” Somatization Weight Weight loss not as severe
• a Latin word implying nervous origin. Disorder fluctuations, as that of anorexia
• Anorexia nervosa is a syndrome characterized by vomiting, peculiar nervosa; does not
three essential criteria: food handling express morbid fear of
– Self-induced starvation to a significant becoming overweight
– Relentless drive for thinness or a morbid fear
of fatness
– Presence of medical signs and symptoms
resulting from starvation Schizophrenia Bizarre eating Delusions about food are
• Anorexia nervosa is often associated with habits seldom concerned with
disturbances of body image caloric content; they
Types: believe to be poisoned;
 Restricting Type rarely preoccupied with a
fear of becoming obese;
 Binge-Eating/Purging Type do not have hyperactivity
• 4 percent of adolescent and young adult students.
• Female > male
• The most common ages of onset: Bulimia Nervosa begin after a more concerned about
• Midteens period of dieting by pleasing others, being
people who are attractive to others, and
• DSM-IV-TR: between 14 and 18 years fearful of becoming having intimate
• Up to 5% have the onset early 20s. obese, driven to relationships; more
Etiology: become thin, sexually experienced and
• Biological Factors preoccupied with active; display fewer of
• Social Factors food, weight, and the obsessive qualities;
• Psychological & psychodyanamic Factors appearance, and more likely to have long
Diagnosis: struggling with histories of mood swings,
DSM-IV-TR Criteria feelings of becoming easily
A. Refusal to maintain body weight at or above a depression, frustrated or bored, and
minimally normal weight for age and height anxiety, and the have trouble coping
B. Intense fear of gaining weight or becoming fat, even need to be perfect; effectively or controlling
though underweight. disturbed attitudes their impulses; more
C. Disturbance in the way in which one's body weight or towards eating medical complications
shape is experienced, undue influence of body
weight or shape on self-evaluation, or denial of the
seriousness of the current low body weight.
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Course and Prognosis: Psychological Factors:

• Variable • Difficulties with adolescent demands.
– full recovery (40-60%) • More outgoing, angry, and impulsive than those with
– fluctuating pattern of weight gain followed by anorexia nervosa.
a relapse (75% ) • Associated with alcohol dependence, shoplifting, and
– progressively deteriorating course over many emotional lability (including suicide attempts).
years (5-18%) • Experience uncontrolled eating as more ego-dystonic
– Death (causes: starvation, electrolyte than anorexia nervosa patients and so seek help
imbalance, heart failure, and suicide) more readily.
• Indicators of GOOD outcome:
- admission of hunger Social Factors:
- lessening of denial & immaturity • Tend to be high achievers and respond to societal
- improved self-esteem pressures to be slender.
• Indicators of POOR Outcome: • Many are depressed and have increased familial
- Childhood depression, but their families are generally less close
- Neuroticism and more conflictual than the families of anorexia
- Parental conflict nervosa patients.
- Bulimia nervosa • Describe their parents as neglectful and rejecting.
- Vomiting
- Laxative abuse Clinical Features:
- Behavioral manifestations • Vomiting – most common feature
• Depression – called ‘post binge anguish
Co-morbidity: • Concerned about body image and appearance
• Depression – 65% Diagnosis:
• Social phobia – 34% DSM-IV-TR Diagnostic Criteria
• Obsessive-compulsive disorder – 26% (1) Episodes of binge eating occur relatively
Management: frequently (twice a week or more) for at least 3
• Hospitalization months;
– nutritional state (2) Compensatory behaviors are practiced after
binge eating to prevent weight gain, primarily self-
HOSPITALIZATION PSYCHO- PHARMACO- induced vomiting, laxative abuse, diuretics, or
THERAPY THERAPY abuse of emetics (80 percent of cases), and, less
Nutritional State • Cognitive- • Cyprohepta- commonly, severe dieting and strenuous exercise
Behavioral Dine (Periactin) (20 percent of cases)
Therapy • Amitriptyline (3) Weight is not severely lowered as in anorexia
• Individual nervosa; and
(4) The patient has a morbid fear of fatness, a
• Dynamic • Clomipramin
relentless drive for thinness, or both and a
psycho- e disproportionate amount of self-evaluation depends
therapy • Pimozide on body weight and shape
• Family (Orap)
Therapy • Chlorpromaz Summary:
• Group ine • Recurrent episodes of binge eating
Therapy (Thorazine) • A sense of lack of control over eating during the
• Fluoxetine eating binges
• Self-induced vomiting
• The misuse of laxatives or diuretics
• More prevalent than anorexia • Excessive exercise to prevent weight gain
• More prevalent in women • Persistent self-evaluation unduly influenced by body
• One-tenth found in men shape and weight
• 1-3% women have a history of obesity • Binging precedes vomiting by about 1 year
• 40% found in college women Course and Prognosis:
 Higher rates of partial and full recovery than anorexia
Biologic Factors: nervosa
• Cycles of binging and purging can be associated with  Treated patients
various neurotransmitters.  fare much better than untreated
• Serotonin and norepinephrine have been implicated.  10 yr follow-up study: women who continued
• The feeling of well-being after vomiting that some of to meet full criteria for bulimia nervosa has
these patients experience may be mediated by raised declined as the duration of follow-up
endorphin levels. increased
• According to DSM-IV-TR, there is an increased  Untreated: remain chronic; show unimpressive
frequency of bulimia nervosa in first-degree relatives improvements
of persons with the disorder.
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 30% continue to engage in recurrent binge-eating or

purging behaviors
Substance use
Longer duration of disorder before treatment
Prognosis depends on:
 Age of onset
 Types of purging behaviours
 Presence of any other psychiatric
conditions or disorders
Better prognosis than Anorexia Nervosa
At 5 to 10 years, half of the patients fully recover, while 20%
continued to meet full diagnostic criteria
If left untreated, spontaneous remission occurs in 1 to 2 years

◊ 18-20 sessions over 5-6 mos
1. Interrupt the self maintaining behavioral cycle of self
bingeing and dieting
2. Alter the individuals dysfunctional conditions; belies
about food, weight, body image and overall self-
• FLUOXETINE (60-80 mg/day)
• Imipramine (Tofranil)
• Desipramine (Norpramine)

◊Needs hospitalization if:
• Exhibits additional psychiatric
symptoms: suicidal and substance
• Has electrolyte and metabolic
First line tx: PSYCHOTHERAPY

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