Dissociative Disorders PDF

Depersonalization, Derealization, & Dissociative Disorders Clinical Medicine Behavioral Health Spring 2024 Professor Caroline Cerio, PA-C This group of disorders are characterized by disruption of consciousness, memory, identity, emotion, perception, body representation, motor function, and behavior...

Depersonalization, Derealization, & Dissociative Disorders Clinical Medicine Behavioral Health Spring 2024 Professor Caroline Cerio, PA-C This group of disorders are characterized by disruption of consciousness, memory, identity, emotion, perception, body representation, motor function, and behavior The symptoms can be described as positive (fragmentation of identity, depersonalization, derealization) or negative (amnesia) Patients with dissociative disorders typically are able to answer questions appropriately and interact in a normal manner with other people which often results in other individuals perceiving the patient as “fine” during an episode Reality testing is intact Depersonalization Depersonalization refers to persistent and/or recurrent feelings of unreality or detachment from one’s mind, self, or body. Patients may report feeling a loss of personal identity or sense of self, difficulty feeling emotions even when aware that they are present, difficulty processing thoughts, or difficulty feeling one’s body, body parts, or sensations Patients may also report feeling like they are “a robot” or like they have no control over their own actions Patients may describe feeling as if one part of their body is observing another part or that they are having a full “out of body” experience Derealization Derealization refers to experiences of unreality or detachment from one’s surroundings. Patients may feel as if they are in a fog, dream, or bubble or that they are separated from their surroundings by a veil or a glass wall. Visual distortions like blurriness, heightened acuity, changes in visual field, change of perception (may be flattened into 2D or may be exaggerated 3D), or changes in distances or size of objects are often reported Depersonalization/Derealization Disorder Depersonalization/Derealization Disorder (DPDR) is characterized by detachment from one’s environment and/or one’s own self Diagnosis requires presence of persistent or recurrent experiences of depersonalization, derealization, or both Up to 50% of the adult population report experiencing at least one lifetime episode of depersonalization or derealization however it is far more rare for symptoms to be persistent and/or recurrent enough to meet diagnostic criteria with overall lifetime prevalence approximately 2% Mean age of symptom onset is 16 A Swiss artist named Lulu created a comic called “Planet McLulu” in which she describes her experiences living with DPDR: Therapy (cognitive behavioral or psychodynamic) is the mainstay of treatment SSRIs may be helpful to treat concurrent anxiety and/or depression Clomipramine (Anafranil) or lamotrigine (Lamictal) may be used as adjunctive treatment Transcranial magnetic stimulation may be considered for refractory cases Dissociative Amnesia Dissociative amnesia presents as inability to recall autobiographical information (i.e. patients cannot recall information about themselves) which is often of a stressful nature and which goes beyond normal forgetting Dissociative amnesia may be localized (involves an event or period of time), selective (involves only a specific aspect of an event),or generalized (involves entire identity and/or life history) Patients with this symptom typically are not aware that amnesia is occurring Symptom onset is typically sudden The duration of forgotten events can be as short as minutes or as long as decades Patients often report history of trauma, child abuse, victimization, combat service, or similar experience Diagnosis is often made by exclusion of other potential causes of memory loss (PTSD, seizures, dementia, delirium, substance abuse) Treatment of choice is therapy Dissociative fugue refers to a specific type of dissociative amnesia in which the individual purposefully travels away from home or work Dissociative fugue is less common than dissociative amnesia Episodes can last hours or months and there is decreased ability to form new memories during the fugue state Mr.. A, a 20-year-old man with no past medical and psychiatric history, was brought to the emergency department by his mother.. According to his mother, he was doing fine until 2 days ago …when Mr. A was at work, the mother got a call from Mr. A’s supervisor at his office stating that he did not recognize his friends and that he was asking what he was supposed to do at work. Considering the situation, Mr. A’s supervisor sent him home.. When he reached home, Mr. A failed to recognize his mother, dog, siblings, and belongings…[he later] left the house without telling anybody...they were able to locate him in the parking lot of a convenience store. Mr. A did not recall how or why he came to the parking lot. At admission to the inpatient psychiatry unit, Mr. A’s urine drug screen tested negative for any illicit substances. Findings of a head computed tomography scan and magnetic resonance imaging were within normal limits. Results of other routine investigations including complete blood count, complete metabolic profile, ammonia level, B12 level, thyroid function tests, and liver function tests were also within normal limits. The human immunodeficiency virus and rapid plasma regain tests were also negative. When asked how he was doing, Mr. A said, “confused.” His mood was “okay,” and his affect seemed flat and somewhat guarded with no concern for his memory loss (la belle indifference). He was oriented in time, place, and person but had impaired attention and concentration at the time of the examination. The immediate recall was intact, but he was unable to provide important details pertaining to his life. He denied hallucinating and had no intentions to harm himself or anyone else… When asked about any recent stressor, the mother recalled that about a week ago Mr. A had broken up with his partner. They were in a relationship for about 1 year, but his mom did not notice emotional changes in Mr. A after the breakup. The family was not opposed to Mr. A’s sexual orientation. During hospitalization, the neurology department was consulted, and after complete neurologic workup, including electroencephalogram and brain imaging, the neurology team ruled out organic causes of transient amnesia. Malingering was also an important differential diagnosis; therefore, psychology consultation was requested...During his psychiatric inpatient stay, Mr. A continued to have no autobiographic memory...It was evident that he was forming fresh memories and could recall most events after he was found in the parking lot of the convenience store, which is an important feature of dissociative amnesia, in which the patient has no anterograde amnesia.10,11 After ruling out other causes of transient amnesia, Mr. A was diagnosed with dissociative amnesia with dissociative fugue (DSM-5 criteria) and was discharged with close psychotherapy follow-up. Mr. A was followed as a psychotherapy patient in our outpatient clinic. During the first few sessions, he continued to have difficulties remembering events from his past, stating, “I am a new person.” However, he did not have any problem with forming new memories (no anterograde amnesia). The psychotherapy team used persuasion and suggestive techniques and tried to provide a sense of safety and security. He was given a home assignment to look at his family photo album and review details of his job with his coworker. Simultaneously, the psychotherapy team continued supportive psychotherapy and empathic validation. Initially, Mr. A felt good about being a “brand new person” so that he did not have to think about the painful aspect of the past. After multiple sessions, Mr. A started to recall memories about his past. He talked about how “painful” his previous relationship was when he broke up with his partner because Mr. A had been unfaithful. This incident happened 2 weeks prior to his admission to the inpatient unit. His partner refused to continue the relationship, even after several attempts at reconciliation by Mr. A. He said he felt “numb” when he woke up on Sunday morning. Mr. A said, “I lost everything, shame, guilt, being rejected and wished to be a new man,” so that he could be accepted by his ex-boyfriend. After a series of sessions over a period of 12–16 weeks, Mr. A continued to show progress by returning to his job and started remembering details from his past. Dissociative Identity Disorder (DID) Referred to in pop culture as “split personality”, formerly known as “multiple personality disorder” Diagnosis requires disruption of identity characterized by 2+ distinct personality states Each state involves “marked discontinuity” in sense of self and sense of agency along with changes in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning Recurrent gaps in memory of daily events, important personal information, and/or traumatic events beyond normal forgetting are present Symptoms may be perceived as “possession” in some cultural contexts Prior history of trauma is commonly reported with approximately 90% of patients with DID reporting either physical and/or sexual abuse in childhood Symptoms of DID often appear in childhood Patients with DID are at high risk for self-harm or suicide (over 70% report 1+ prior suicide attempt) Patients with DID often report episodes of “lost time” or experiences of travelling without being able to remember how they came to be at the destination (e.g. finding themselves in a new location without being able to recall how they got there) Patients may also report “coming to” in the middle of performing a task or activity without being able to explain how they came to be in that situation/position Other signs may include finding unexplained objects among their possessions, unexplained writings or drawings, or unexplained injuries Personality states present with noticeable differences in speech, attitudes, personal preferences, emotions, and impulses Patients may feel as though they have no control over their bodies, loss of a sense of self, or even that their bodies feel different (e.g. smaller or larger in size, childlike, or different gender) Therapy is the mainstay of treatment Medication (SSRI, SNRI) may be helpful to treat comorbid disorders like anxiety and/or depression Hypnotherapy is sometimes utilized Dissociative identity disorder does not typically fully resolve with treatment and goals of care focus mainly on symptom management and control Pop culture representation of DID Recent trends among social media users have shown an increase in content regarding tics / Tourette’s disorder and DID among other mental health conditions Users refer to different personality states as “alters” who live within a “system” Teens in particular are heavy consumers of mental health social media content and there is controversy surrounding the movement with some users asserting spreading awareness of these conditions is helpful while others feel content creators are faking symptoms of real mental health disorders and/or mis-representing the experience of real patients Search of #dissociativeidentitydisorder on TikTok shows > 1 billion views Rolling Stone - Viral ‘Dissociative Identity Disorder’ TikToker Sparks Questions About the Internet’s Effect on Mental Health https://www.rollingstone.com/culture/culture-features/wonderland-system-tiktokdissociative-identity-disorder-1283571/ Dissociative Identity Disorder on TikTok: Why More Teens Are Self-Diagnosing With DID Because of Social Media | Teen Vogue https://www.teenvogue.com/story/dissociative-identity-disorder-on-tiktok TikTok videos causing teens to believe they have mental disorders - Good Morning America https://www.goodmorningamerica.com/wellness/video/tiktok-videoscausing-teens-mental-disorders-81968456 Reported prevalence of formally diagnosed DID in the United States is low (at most 1.5% but some sources report it as low as 0.01%) Patient Story Meet the six personalities living in this woman's head - YouTube https://www.youtube.com/watch?v=UWhICGCXnUE Billy Milligan was arrested in 1977 on charges of robbery and rape. During his trial, he was diagnosed with DID and was found to have 24 alternate personalities His defense alleged the crimes were committed by Billy’s alternate personalities (Ragen and Adalana) and he was found not guilty by reason of insanity in 1978 Objectives 1. Describe positive and negative symptoms of dissociative disorders and differentiate between them 2. Define reality testing 3. Define depersonalization and derealization 4. List DSM-5 TR diagnostic criteria for Depersonalization/Derealization Disorder and Dissociative Identity Disorder (DID) 5. Describe risk factors for, epidemiology of, and symptoms of DID 6. Define dissociative amnesia and dissociative fugue and differentiate between them 7. Create an appropriate treatment plan for DID including pharmacologic and non-pharmacologic options 8. Demonstrate understanding of the goals of treatment of DID Sources DSM-5 Planet McLulu. Artist Creates Comic Illustrating What It’s Like To Live With A Depersonalization Disorder For The Last 3 Years (demilked.com) Approach to Treating Depersonalization/Derealization Disorder. Up To Date. Accessed 24 January 2023. Approach to treating depersonalization/derealization disorder – UpToDate Dissociative Identity Disorder. Cleveland Clinic. Accessed 24 January 2023. Dissociative Identity Disorder: What Is It, Symptoms & Treatment (clevelandclinic.org) Clouden TA. Dissociative Amnesia and Dissociative Fugue in a 20-Year-Old Woman With Schizoaffective Disorder and Post-Traumatic Stress Disorder. Cureus. 2020 May 26;12(5):e8289. doi: 10.7759/cureus.8289. PMID: 32483516; PMCID: PMC7255065. Sharma P, Guirguis M, Nelson J, McMahon T. A Case of Dissociative Amnesia With Dissociative Fugue and Treatment With Psychotherapy. Prim Care Companion CNS Disord. 2015 May 28;17(3):10.4088/PCC.14l01763. doi: 10.4088/PCC.14l01763. PMID: 26644950; PMCID: PMC4578902.