1. Dissociative Disorders
Presented by : Shahdan Al Dabbass

2. Dissociation: the separation of thoughts, feelings or experiences from the normal stream of consciousness and memory. IN Dissociative Disorder Severe isolated traumas or repeated traumas may result in impairment of the normal state of awareness or alters one’s sense of identity, memory or consciousness.

3. Epidemiology
Dissociative disorders are prevalent around the world and often occur with other psychiatric disorders such as depression, post traumatic stress disorder, substance use disorders and borderline personality.

4. Dissociative disorders includes:
Dissociative amnesia +/- Dissociative fugue
Dissociative identity disorder
Depersonalization/ derealization disorder

5. Dissociative Amnesia
Inability to recall important personal information usually of a traumatic or stressful condition that is too extensive to be explained by normal forgetfulness. Epidemiology approximately 6% of the general population. Reported in late adolescence and adulthood.. Women > men . Increase incidence during times of war and natural disasters.

6. Diagnostic criteria for dissociative amnesia DSM-IV
One or more episodes of inability to recall personal information.
Disturbance doesn’t occur exclusively during any other dissociative disorder and not due to direct effects of a substance or GMC.
Symptoms cause clinically significant distress or impaired social, occupational .. Etc functioning.

8. Types of amnesia
Localized amnesia: Inability to recall events related to a limited period of time.
Selective amnesia: Ability to remember some, but not all, of the events occurring during a circumscribed period of time.
Systematized amnesia: Amnesia for certain categories of memory, such as all memories relating to one's family or to a particular person
Generalized amnesia: Failure to recall one's entire life.
Continuous amnesia: Failure to recall successive events as they occur.

9. Differential Diagnosis
Ordinary Forgetfulness and Non pathological 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

10. Course and 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.
Recurrences are uncommon

11. Treatment
It is important to help patients retrieve their lost memories in order to prevent future recurrences.
Hypnosis or pharmacologically facilitated interviews by sodium amobarbital, thiopental (Pentothal) to help patients talk freely.
Psychotherapy

12. Dissociative Fugue
dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis (DSM V)
Sudden, unexpected travel with inability to recall one’s past
Assume new identity
May involve new name, job, personality characteristics
More often of brief duration
Remits spontaneously

13. Diagnostic criteria for Dissociative Fugue DSM IV
Sudden unexpected travel away from home or ones customary place of work, with inability to recall one’s past.
Confusion about personal identity or assumes new identity (partial or complete)
Not due to another dissociative disorder or direct effects of substances or GMC
Causes significant distress or impairment in imp areas of functioning

14. Epidemiology
Rare
Predisposing factors include heavy use of alcohol, major depression, history of head trauma and epilepsy.
Course and Prognosis
It usually lasts for few hours to several days but may last longer.
Treatment
Similar as dissociative amnesia

16. Dissociative Identity Disorder (DID)

17. Dissociative Identity Disorder
formerly multiple personality disorder (MPD)
Two or more distinct personalities that take control of an individuals behavior
inability to recall key personal information that is too far-reaching to be explained as mere forgetfulness.
The different identities (alters) may exhibit differences in : 1) speech ,mannerisms , attitudes, thoughts and gender orientations etc
2) in “physical” properties such as allergies , right- or-left handedness

18. Epidemiology
1.3 % prevalence ( avg age 30 yrs)
male :female 1.3:9
history of a sexual or a physical abuse
Over 70% of outpatients with dissociative identity disorder have attempted suicide
Causes
( no one knows the exact root cause of “DID” but those have been the most researched )
Repeated episodes of severe physical or sexual abuse in childhood
Innate ability to dissociate easily
Extreme stress
Other relatives with dissociative symptoms or disorders

19. Criteria (DSM 5)
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 alcohol intoxication) or another medical condition

20. Course and prognosis Usually chronic and incomplete recovery
Worst prognosis of all dissociative disorders
Patients with earlier onset have a poorer prognosis

21. Signs and symptoms Feeling like more than one person
Being called names that are unlike their name
Having blackouts  not recalling how one traveled to a certain area
Not recognizing themselves in the mirror
Finding items that are clearly theirs but not recalling how the items were acquired
Comorbid disorders : PTSD, depressive disorders, trauma- and stressor-related disorders, personality disorders, conversion disorder.

22. to integrate the personalities into a single personality OR
Treatment
The goal :
to integrate the personalities into a single personality OR
To achieve a harmonious interaction among the personalities that allows more normal functioning

23. Cont…
1) psychotherapy with hypnosis ; the therapist seeks to make contact with as many alters as possible to understand their roles and functions in the patient’s life 2) drug therapy ; relieve some specific coexisting symptoms ( anxiety and depression ) 3) Several periods of psychiatric hospitalization maybe necessary to help the patient through difficult time 4) Mutual self-help support groups within larger communities

24. Depersonalization disorder
Depersonalization disorder is characterized by persistent or recurrent feeling of detachment from one’s self, environment or social situations . They are aware of their symptoms and often fear they are going crazy . Often accompanied by anxiety or panic.

25. Criteria DSM 5
A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both: 1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing). 2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted). B. During the depersonalization or derealization experiences, reality testing remains intact. C. The symptoms cause clinically significant distress or impairment in social,occupational, or other important areas of functioning. D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures). E. The disturbance is not better explained by another mental disorder

26. Epidemiology The gender ratio for the disorder is 1:1
Average onset between ages 15 and 30
Increased incidence of co-morbid anxiety disorders and major depression
Severe stress is a predisposing factor

27. Course and prognosis Treatment
Often chronic , but may remit without treatment
Treatment
The goal of treatment, when needed, is to address all stresses associated with the onset of the disorder.
Psychotherapy : Cognitive therapy, Family therapy, Clinical hypnosis, Creative therapies
Antianxiety agents or SSRI to treat associated symptoms of anxiety and major depression

29. Thank you !