DISSOCIATIVE DISORDERS

DSM-5
 DISSOCIATIVE DISORDERS
• Essential feature:
disruption in the usually integrated functions
of consciousness, memory, identity, or
perception of the environment

• The disturbance may be sudden or gradual,

transient or chronic.
 DISSOCIATIVE DISORDERS
DSM-IV-TR DSM-5

1. Dissociative Identity D. 1. Dissociative Identity D.

2. Dissociative Amnesia 2. Dissociative Amnesia
3. Depersonalization Disorder Specify if
4. Dissociative Fugue* With Dissociative Fugue
3. Depersonalization /
5. Dissociative Disorder Not Derealization Disorder
Otherwise Specified (NOS)
4. Other Specified Dissociative
Disorder
5. Unspecified Dissociative Disorder
DISSOCIATIVE AMNESIA
Dissociative Amnesia
• Inability to recall* an important autobiographical
memory, which is usually traumatic or stressful,
but retains the capacity to learn new material.
• No medical explanation; not caused by a drug

• Most common Dissociative D (1.8%); F > M

• More common in adolescents/young adults
• Increases during times of war and disasters
• Etiol: precipitating emotional trauma
Dissociative Amnesia
Classic Presentation*
• may present with somatoform / conversion symptoms,
alterations in consciousness, depersonalization/
derealization, trance states, spontaneous age regression

Nonclassic presentation
• depression or mood swings, substance abuse, sleep
disturbances, somatoform symptoms, anxiety and panic,
suicidal or self-mutilating impulses and acts, violent
outbursts, eating problems, and interpersonal problems
 Types of Dissociative Amnesia
(loss of memory)
• Localized amnesia - of a circumscribed period
• Selective amnesia - some but not all
• Generalized amnesia - entire life

• Continuous amnesia - of successive events

• Systematized amnesia - of certain categories
 Dissociative Amnesia
• With DISSOCIATIVE FUGUE
- apparently purposeful travel or bewildered
wandering that is associated with amnesia for
identity or for other important biographical
information
 Dissociative Amnesia
Differential Diagnosis
• Ordinary Forgetfulness and Nonpathological Amnesia
• Dementia, Delirium, and Organic Amnestic Disorders
• Posttraumatic Amnesia
• Seizure Disorders
• Substance-Related Amnesia
• Transient Global Amnesia
• Acute Stress Disorder, Posttraumatic Stress Disorder,
and Somatoform Disorders
• Malingering and Factitious Amnesia
 Dissociative Amnesia
Prognosis and Treatment
• Spontaneously resolves*
• Some patients develop chronic forms of
generalized, continuous, or severe localized
amnesia and are profoundly disabled
Tx:
• Pyschotherapy : Cognitive therapy, Hypnosis
• Pharmacotherapy : sodium amobarbital (amytal)
thiopental (Pentothal), BZD, amphetamines
DISSOCIATIVE IDENTITY DISORDER
 Dissociative Identity Disorder
• formerly known as Multiple Personality Disorder

• usually the result of traumatic event, often

physical or sexual abuse in childhood

• involves manifestation of two or more distinct

personalities which, when present, will dominate
the person's behaviors and attitudes as if no other
personality existed
 Dissociative Identity Disorder
Etiology

• Severe sexual and psychological abuse in

childhood

• Lack of support from significant others

• Epilepsy may be involved

 Epidemiology
• Prev. 1.5% ; 5% of psychiatric patients; F > M

• mostly late adolescents and young adults

(symptoms may be present for 5 to 10 years
before diagnosis)

• more common in first degree biological

relatives diagnosed with the disorder
 Dissociative Identity Disorder
Diagnosis
• requires the presence of at least two distinct
personality states

• personality is generally amnestic for and

unaware of other personalities

• average of 8 personalities (M); 15 for F

 Dissociative Identity Disorder
Course and Prognosis
• 70% attempt suicide (multiple attempts)
• other self-injurious behavior is common
 Dissociative Identity Disorder
Treatment
• Psychotherapy
 Hypnotherapy
• most efficacious approach
• helpful in obtaining additional history, identifying previously
unrecognized identities and fostering abreaction

• Pharmacotherapy
– antidepressants
– antianxiety
– anticonvulsants
DEPERSONALIZATION / DEREALIZATION
DISORDER
 Depersonalization Disorder
• Persistent or recurrent alteration in the
perception of the self to the extent that a
person’s sense of his or her own reality is
temporarily lost.

• Episodes are ego - dystonic (unacceptable to

oneself) and the patients realize the unreality
of the symptoms.
• DEPERSONALIZATION:
The feeling that the body or the personal self
is strange and unreal.

• DEREALIZATION:
The perception of objects in the external
world as strange and unreal.
 EPIDEMIOLOGY:
• Common phenomenon and is not necessarily
pathological.

• Transient Depersonalization occurs in as

many as 70 % of a popn. M = F

• Rarely found in persons over 40 years of age.

Mean age of onset is about 16 years.
 Etiology
• Neurologic Disorders
Epilepsy, Migraine, Brain tumors, Cerebral tumors, etc.

• Toxic and Metabolic Disorders

Hypoglycemia, hypoparathyroidism, CO poisoning, Botulism,
Hypothyroidism, etc.

• Idiopathic Mental Disorders

Schiz., Depressive D, Manic episodes, Anxiety D, etc.
 Etiology
• In NORMAL PERSONS
Exhaustion
Boredom
Sensory deprivation
Emotional shock

• In Hemipersonalization
Lateralized, usually right parietal focal brain lesions
 CLINICAL FEATURES:
• Central Characteristic :
the quality of unreality and estrangement.

• Parts of the body or the entire physical being may seem

foreign, as may mental operations and accustomed
behaviour.

• Particularly common is the sensation of a change in the

patient’s body; patient may feel that their extremities are
bigger or smaller than usual.
• Anxiety often accompanies the disorder, and many
patients complain of distortion of their senses of time
and space.

• Occasional phenomenon is DOUBLING.

• REDUPLICATIVE PARAMNESIA or DOUBLE ORIENTATION.

• Most patients are AWARE of their disturbed sense of

reality. (SALIENT CHARACTERISTIC).
• In most patients, symptom of depersonalization
disorder may appear suddenly; only few report a
gradual onset.

• Starts most often between ages 15 and 30 years.

• 50% of cases, tends to be a long lasting condition.

• Sometimes ushered by an attack of acute anxiety, freq.

accompanied by hyperventilation.
 Symptoms of depersonalization-derealization
disorder may be related to:

• Childhood trauma
(verbal or emotional abuse or witnessing domestic violence)

• Growing up with a significantly impaired mentally ill parent

• Suicide or unexpected death of a close friend /family member

• Severe stress (relationship/financial /work-related problems)

• Severe trauma (such as a car accident)

 Treatment
• Too few data exist on which to base a specific
pharmacologic treatment.

• Anxiety usually responds to anti-anxiety

agents.

• PSYCHOTHERAPEUTIC approaches are equally

untested.