Seminar presentation

on
Dissociative Disorders

Moderator Dr Elias G.
Presenters
 Abenezer kifle
 Aboma Abdisa
 Bemnet beyene
 Bezuneh endala
 Bilal Muhye
Outline
 Dissociation
 Dissociative disorder
1)Dissociative Amnesia
 Clinical Features
 Diagnosis and DDX
 Treatment
2)Depersonalization / derealization
disorder
3)Dissociative Identity Disorder
 Clinical Features
 Diagnosis and DDX
 Treatment
 the term dissociation describes a wide array
of experiences from mild detachment from
immediate surroundings to more severe
detachment from physical and emotional
experience.

 The major characteristic of all dissociative

phenomena involves a detachment from
reality, rather than a loss of reality as in
psychosis
 dissociation is defined as an unconscious defense
mechanism involving the segregation of any group
of mental or behavioral processes from the rest of
the person’s psychic activity.
 Dissociative disorders involve this mechanism so

that there is a disruption and /or discontinuity in

one or more mental functions, such as
 Memory
 Identity
 Perception
 Consciousness
 Motor behavior.
 The signs and symptoms of the disorder are often
caused by Psychological Trauma
 Dissociative symptoms are experienced as

A) Unbidden intrusions into awareness and behavior,

with accompanying losses of continuity in subjective
experience i.e., "positive“ dissociative symptoms such
as fragmentation of

Identity,

Depersonalization

Derealization
B) Inability to access information or to control mental
functions that normally are readily amenable to access
or control (i.e., '"negative" dissociative symptoms such
as amnesia).
DISSOCIATIVE AMNESIA
 Dissociative amnesia is an inability to recall
important autobiographical information that

1) Should be successfully stored in memory and

2) Ordinarily would be readily remembered

 Dissociative amnesia differs from the permanent
amnesias in that it is always potentially reversible
because the memory has been successfully stored.
Etiology

 Traumatic experiences such as physical or sexual

abuse can induce the disorder.

 Conflicts over unacceptable urges or impulses,

such as intense sexual, suicidal, or violent
compulsions.

 (betrayal trauma In some cases the trauma is

caused by a betrayal by a trusted, needed other).
This betrayal is thought to influence the way in
which the event is processed and remembered
Clinical presentation
 Classical presentation The classic disorder is
an overt
dramatic clinical disturbance that quickly
presents for medical attention.
A history of extreme acute trauma is typical. It
also commonly develops, however,
 profound intrapsychic conflict or emotional
stress.
Clinical presentation
 Patients may present with physical symptoms
 alterations in consciousness,
 depersonalization, derealization, trance statet
 There is a significant risk of depression and suicidal
ideation.
 Risk factors
 Prior adult or childhood abuse or trauma
Clinical presentation
 Nonclassical Presentation.
These patients frequently come to treatment
for a variety of symptoms such as
 depression or mood swings,

 substance abuse,

 sleep disturbances,

 somatoform symptoms,

 anxiety and panic,

 Some individuals with dissociative amnesia report
dissociative flashbacks (i.e., behavioral re
experiencing of traumatic events).

 Many have a history of self mutilation, suicide

attempts, and other high-risk behaviors.

 Sexual dysfunctions are common.

 Types of Dissociative Amnesia
 Localized amnesia is the inability to recall events
related to a circumscribed period of time.It may be
broader than amnesia for a single traumatic event
(e.g., months or years associated with child abuse
or intense combat)
 Generalized amnesia is failure to recall ones entire
life.
 Continuous amnesia is failure to recall successive
events as they occur
 Systematized amnesia is failure to remember a
category of information such as all memories
relating to ones’ family or to a particular person
 Generalized amnesia has an acute onset.
 It is frequently found in those who have
experienced extreme acute trauma.
 Many of these patients have prior histories adult or
childhood abuse or trauma.
 Generalized amnesia may be more common among
sexual assault victims, and individuals experiencing
extreme emotional stress or conflict.
Diagnosis

A. An inability to recall important autobiographical

information, usually of a traumatic or stressful

nature, that is inconsistent with ordinary forgetting.

B. The symptoms cause clinically significant distress

or impairment in social, occupational, or other

important areas of functioning.

C. The disturbance is not attributable to the physiological
effects of a substance e.g., alcohol or other drug or a

neurological or other medical condition (e.g., partial complex

seizures, transient global amnesia, head injury/ traumatic

brain injury, other neurological condition).

D. The disturbance is not better explained by dissociative

identity disorder, posttraumatic stress disorder, acute stress

disorder, somatic symptom disorder, or major or mild

neurocognitive disorder.
Differential Diagnosis
 Dementia,
 Delirium
 Amnestic Disorders due to Medical Conditions\post
operative amnetia,post infectionus amneia,cerebro
vascular accident
 Posttraumatic Amnesia
 Seizure Disorders
 Transient Global Amnesia.
Other DDX
 Ordinary Forgetfulness and Non pathological
Amnesia.
 Substance-Related Amnesia.
 Dissociative Identity Disorders
 Acute Stress Disorder
 Posttraumatic Stress Disorder
 Somatic Symptom Disorder
 Malingering and Factitious Amnesia.
Treatment

 Cognitive Therapy
 As the patient becomes able to correct cognitive

distortions, particularly about the meaning of prior

trauma, more detailed recall of traumatic events

may occur.
 Group Psychotherapy
 During group sessions, patients may recover

memories for which they have had amnesia.

 Supportive interventions by the group members or

the group therapist, or both, may facilitate

integration and mastery of the dissociated material.
 Hypnosis

It is a trance(consciousness )like mental state in

which people experience increasing
attention ,concentration And suggestibility
 this helpTo facilitate controlled recall of

dissociated memories;
 To provide support and ego strengthening for the

patient
 To promote working through and integration of

dissociated material.
DEPERSONALIZATION/DEREALIZATION
DISORDER
Depersonalization
 Is defined as the persistent or recurrent feeling of

detachment or estrangement from one’s self.

 The individual may report feeling like an automaton

or watching himself or herself in a movie

Derealization
 Is somewhat related and refers to feelings of

unreality or of being detached from one’s

environment.
 The patient may describe his or her perception of

the outside world as lacking lucidity and emotional

coloring, as though dreaming or dead.
 Epidemiology

 These are extremely common in normal and clinical populations. 19

percent in the general population
 They are the third most commonly reported psychiatric symptoms,
after depression and anxiety..
 It is common in seizure patients and migraine sufferers and drugs
especially marijuana, lysergic acid diethylamide (LSD), and mescaline
 May occur as a side effect of some medications, such as anti
cholinergic agents.
 After mild to moderate head injury, wherein little or no loss of
consciousness occurs
 After life-threatening experiences, with or without serious bodily
injury.
 Depersonalization is found 2-4x more in women than in men.
 Etiology
Psychodynamic
 An affective response in defense of the ego.
 Overwhelming painful experiences or conflictual impulses as

triggering events
Traumatic Stress.
 Histories of significant trauma. Typically one third to one half
 In life threatening experience 60 % report a transient

depersonalization during or immediately thereafter.

 Military training studies find that symptoms are commonly

evoked by stress and fatigue

Neurobiological Theories.
 The association of depersonalization with migraines and

marijuana, its generally favorable response to selective

serotonin reuptake inhibitors (SSRIs), and the increase in
depersonalization symptoms seen with the depletion of L-
tryptophan
 Individuals with depersonalization/derealization
disorder are characterized by
◦ Immature defenses such as idealization/devaluation,
projection and acting out result in denial of reality and
poor adaptation.
◦ Cognitive disconnection schemata reflect
defectiveness and emotional inhibition and subsume
themes of abuse, neglect, and deprivation.
◦ Over connection schemata involve impaired autonomy
with themes of dependency, vulnerability, and
incompetence.
 There is a clear association between the disorder and
childhood interpersonal traumas in a substantial portion
of individuals.
◦ Emotional abuse and emotional neglect
◦ Physical abuse
◦ witnessing domestic violence
◦ Growing up with a seriously impaired, mentally ill
parent
◦ Unexpected death or suicide of a family member
 Clinical Features

 Episodes of depersonalization are characterized by a feeling of

unreality or detachment from, or unfamiliarity with, one's whole

self or from aspects of the self.

 The individual may feel detached from his or her
◦ Entire being (e.g., "I am no one," "I have no self").
◦ Feelings (e.g., hypoemotionality: "I know I have feelings but I
don't feel them"),
◦ Thoughts (e.g., "My thoughts don't feel like my own," "head
filled with cotton"),
◦ Whole body or body parts
◦ Sensations (e.g., touch, proprioception, hunger, thirst, libido)
 There may also be a diminished sense of agency
(e.g., feeling robotic, like an automaton; lacking
control of one's speech or movements).
 The depersonalization experience can sometimes
be one of a split self, with one part observing and
one participating, known as an "out-of-body
experience"
 Anomalous body experiences (i.e., unreality of the
self and perceptual alterations)
 Emotional or physical numbing
 Temporal distortions with anomalous subjective
recall
 A feeling of unreality or detachment from, or unfamiliarity with, the

world and all surroundings.

 The individual may feel as if he or she were in a fog, dream, or

bubble.
 Surroundings may be experienced as artificial, colorless, or lifeless.
 Subjective visual distortions, such as blurriness, heightened acuity,

widened or narrowed visual field, two-dimensionality or flatness,

altered distance or size of objects (i.e., macropsia or micropsia).

 Auditory distortions can also occur, whereby voices or sounds are

muted or heightened.
Differential Diagnosis
 Seizure disorders  Side effect of medications
 Brain tumors  Panic attacks
 Post concussive syndrome  Phobias
 Metabolic abnormalities  PTSD
 Migraine  Acute stress disorder
 Vertigo  Schizophrenia
 Ménière’s disease  Another dissociative disorder
 Substance intoxication or withdrawal
(THC,MDMA)
 Depersonalization caused by organic
conditions tends to be primarily sensory
without the elaborated descriptions and
personalized meanings common to
psychiatric etiologies.
 Drug-related depersonalization is typically

transient, but persistent depersonalization

can follow an episode of intoxication with a
variety of substances, including marijuana,
cocaine,
 A thorough medical and neurological

evaluation is essential, including standard

laboratory studies, an EEG, and any indicated
drug screens.
 The most common proximal precipitants of
the disorder are
◦ Severe stress (interpersonal, financial,
occupational),
◦ Depression
◦ Anxiety (particularly panic attacks)
◦ Illicit drug use
◦ Marijuana use may precipitate new-onset panic
attacks and depersonalization/derealization
symptoms simultaneously.
 Treatment

Pharmacotherapy
 Singly or in combination: antidepressants, mood stabilizers,

typical and atypical neuroleptics, anticonvulsants, and so forth.

Psychotherapy
 Psychodynamic, cognitive, cognitive-behavioral,

hypnotherapeutic, and supportive.

 Stress management stratégies, distraction techniques,

reduction of sensory stimulation, relaxation training, and

physical exercise may be somewhat helpful in some patients.

DISSOCIATIVE IDENTITY DISORDER
 Previously called multiple personality disorder is
characterized by the presence of two or more distinct
identities or personality states.
 The identities or personality states are sometimes called
alters, self-states, alter identities, or parts, among other
terms.
 They differ from one another in that each presents as
having its own pattern of perceiving, relating to, and
thinking about the environment and self, in short, its
own personality.
 Etiology
 Severe childhood trauma for child and adult patients with DID range

from 85 to 97 percent of cases.

 Physical and sexual abuse are the most frequently reported sources

of childhood trauma.
 Overwhelming early life events such as, multiple long and painful,

early-life medical procedures

 The orbitofrontal cortex, hippocampus, parahippocampal gyrus, and

amygdala have been implicated in the pathophysiology of DID,

 Clinical studies report female to male ratios between 5 to 1 and 9 to

1 for diagnosed cases.

Diagnostic Criteria
A. Disruption of identity characterized by two or more
distinct personality states,
 Which may be described in some cultures as an

experience of possession.
 The disruption in identity involves 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.
 These signs and symptoms may be observed by

others or reported by the individual.

B. Recurrent gaps in the recall of everyday events,
important personal information, and/ or traumatic
events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
D. The disturbance is not a normal part of a
broadly accepted cultural or religious practice.
Note: In children, the symptoms are not better
explained by imaginary playmates or other
fantasy play.
E. The symptoms are not attributable to the
physiological effects of a substance (e.g.,
blackouts or chaotic behavior during)
Triggers of dissociation
 Psychological decompensation and overt
changes in identity may be triggered by
1) Removal from the traumatizing situation
(e.g., through leaving home)
2) The individual's children reaching the same
age at which the individual was originally
abused or traumatized;
3) Later Traumatic experiences, even a minor
motor vehicle accident; or
4) The death of or the onset of a fatal illness in,
their abuser(s).
Clinical features
 Individuals with DID may report the feeling that
they have suddenly become depersonalized
observers of their "own" speech and actions, which
they may feel powerless to stop (sense of self).
 May also report perceptions of voices (e.g., a
child's voice; crying; the voice of a spiritual being).
 In some cases, voices are experienced as multiple,
perplexing, independent thought streams over
which the individual experiences no control.
 Suddenly emerging Strong emotions, impulses,
and even speech or other actions without a sense
of personal ownership or control (sense of agency).
 Individuals may report that their bodies feel
different (e.g., like a small child, like the
opposite gender, huge and muscular).

 A feeling that these attitudes, emotions, and

behaviors even one's body are "not mine"
and/or are "not under my control."

 many of these sudden discontinuities in

speech, affect, and behavior can be witnessed
by family, friends, or the clinician.
 The dissociative amnesia of individuals with DID
manifests in three primary ways
1) Gaps in remote memory of personal life events
 (e.g., periods of childhood or adolescence; some

important life events, such as the death of a

grandparent, getting married, giving birth);
2) Lapses in dependable memory
 (e.g., of what happened today, of well-learned

skills such as how to do their job, use a

computer, read, drive)
3) Discovery of evidence of their everyday actions
and tasks that they do not recollect doing
 (e.g., finding unexplained objects in their

shopping bags or among their possessions;

finding perplexing writings or drawings that they
must have created; discovering injuries; "coming
to" in the midst of doing something).
 Amnesia in individuals with DID is not limited to

stressful or traumatic events; these individuals

often cannot recall everyday events as well
 Individuals with dissociative identity disorder
vary in their awareness and attitude toward
their amnesias.
 Some of their amnestic behaviors may be

apparent to others as when these persons do

not recall something they were witnessed to
have done or said.
◦ Eg. when they cannot remember their own name, or
when they do not recognize their spouse, children,
or close friends.
 Females present more frequently with acute
dissociative states (e.g., flashbacks, amnesia,
fugue, functional neurological [conversion]
symptoms, hallucinations, self-mutilation).
 Males commonly exhibit more criminal or

violent behavior than females.

 Among males, common triggers of acute

dissociative states include

 Combat
 Prison conditions
 Physical or sexual assaults.
 Over 70% of outpatients have attempted suicide; multiple

attempts are common, and other self-injurious behavior is

frequent.

 They often conceal, or are not fully aware of, disruptions in

consciousness, amnesia, or other dissociative symptoms.

 Many individuals report dissociative flashbacks

 Some individuals experience transient psychotic phenomena

or episodes.
Possession-form identities (overt)
 Typically manifest as behaviors that appear

as if a "spirit" supernatural being, or outside

person has taken control, such that the
individual begins speaking or acting in a
distinctly different manner.
◦ For example, an individual's behavior may give the
appearance that her identity has been replaced by
the "ghost" of a girl who committed suicide in the
same community years before, speaking and acting
as though she were still alive.
 Acculturation or prolonged intercultural contact
may shape the characteristics of the other
identities (e.g., identities in India may speak
English exclusively and wear Western clothes).
 Possession form DID can be distinguished from
culturally accepted possession states in that
◦ It is involuntary, distressing, uncontrollable, and often recurrent or
persistent
◦ Involves conflict between the individual and his or her surrounding
family, social, or work milieu; and is manifested at times and in places
that violate the norms of the culture or religion.
Co morbid disorders
 Most develop PTSD.
 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
co morbid disorders
Child and Adolescent Presentations.
 Younger children, in particular, have a less linear
and less continuous sense of time and often are
not able to self identify dissociative discontinuities
in their behavior.
 Informants, such as teachers and relatives, are
available to help document dissociative behaviors.
 The clinical presentation may be that of an
elaborated or autonomous imaginary
companionship, with the imaginary companions
taking control of the child’s behavior, often
experienced through passive influence
experiences or auditory pseudo hallucinations, or
both, that command the child to behave in certain
ways.
Treatment

Psychotherapy
 These modalities include psychoanalytic

psychotherapy, cognitive therapy, behavioral

therapy, hypnotherapy, and a familiarity with the
psychotherapy and psychopharmacological
management of the traumatized patient.
Cognitive Therapy.
 These patients require a long-term treatment

focus on symptom containment and management

of their overall life dysfunction, as would be the
case with any other severely and persistently ill
psychiatric patient
Hypnosis
 Hypnotherapeutic interventions can often alleviate self-

destructive impulses or reduce symptoms, such as

flashbacks, dissociative hallucinations, and passive-
influence experiences.
 Teaching the patient self-hypnosis may help with crises

outside of sessions.
 Hypnosis can be useful for accessing specific alter

personality states and their sequestered affects and

memories.
 Hypnosis is also used to create relaxed mental states in

which negative life events can be examined without

overwhelming anxiety.
Psychopharmacological Interventions.
 Antidepressant medications are often important in

the reduction of depression and stabilization of

mood.
 benzodiazepines in reducing intrusive symptoms,

hyperarousal, and anxiety in patients with

dissociative identity disorder.
 Occasionally, an extremely disorganized,

overwhelmed, chronically ill patient with

dissociative identity disorder, who has not
responded to trials of other neuroleptics, responds
favorably to a trial of clozapine (Clozaril).
Electroconvulsive Therapy (ECT)
 For some patients, ECT is helpful in ameliorating

refractory mood disorders and does not worsen

dissociative memory problems.
 Clinical experience in tertiary care settings for

severely ill patients with dissociative identity

disorder suggests that a clinical picture of major
depression with persistent, refractory melancholic
features across all alter states may predict a
positive response to ECT.
 This response is usually only partial, however, as

is typical for most successful somatic treatments

in the dissociative identity disorder population.
Reference
 Kalan and Sadock's Synopsis of
psychiatry,11th edition
Thank you