Dissociative Disorders

dissociative disordersد. وليد عزيز العميدي
in psychiatry, 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 in one or more mental functions, such as memory, identity, perception, consciousness, or motor behavior. the disturbance may be sudden or gradual,
transient or chronic, and the signs and symptoms of the disorder are often caused by psychological trauma.
dissociative amnesia : the main feature of dissociative amnesia is an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by normal forgetfulness.the disorder does not result from the direct physiological effects of a substance or a neurological or other general medical condition.
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etiology
in many cases of acute dissociative amnesia, the psychosocial environment out of which the amnesia develops is massively conflictual, with the patient experiencing intolerable emotions of shame, guilt, despair, rage, and desperation. traumatic experiences such as physical or sexual abuse can induce the disorder.
differential diagnosis of dissociative amnesia:
1- ordinary forgetfulness and nonpathological amnesia
2- dementia, delirium, and amnestic disorders due to medical conditions.
3- posttraumatic amnesia.
4- seizure disorders. .
5- substance-related amnesia. .
6- transient global amnesia.
course and prognosis : acute dissociative amnesia frequently spontaneously resolves once the person is removed to safety from traumatic or overwhelming circumstances. at the other extreme, some patients do develop chronic forms of generalized, continuous, or severe localized amnesia and are profoundly disabled and require high levels of social support .
treatment :
cognitive therapy. cognitive therapy may have specific benefits for individuals with trauma disorders. identifying the specific cognitive distortions that are based in the trauma may provide an access into autobiographical memory for which the patient experiences amnesia.
hypnosis. hypnotic interventions can be used to facilitate controlled recall of dissociated memories to provide support and ego strengthening for the patient and, finally, to promote working through and integration of dissociated material.
pharmacologically facilitated interviews using intravenous amobarbital or diazepam (valium) are used primarily in working with acute amnesias.

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 .
transient experiences of depersonalization and derealization are extremely common in normal and clinical populations. they are the third most commonly reported psychiatric symptoms, after depression and anxiety.
diagnosis and clinical features
a number of distinct components comprise the experience of depersonalization, including a sense of (1) bodily changes, (2) duality of self as observer and actor, (3) being cut of from others, and (4) being cut of from one’s own emotions. patients experiencing depersonalization often have great difficulty expressing what they are feeling. trying to express their subjective suffering with banal phrases, such as “i feel
dead,” “nothing seems real,” or “i’m standing outside of myself,” .
course and prognosis
depersonalization after traumatic experiences or intoxication commonly remits spontaneously after removal from the traumatic circumstances or ending of the episode of intoxication. depersonalization accompanying mood, psychotic, or other anxiety disorders commonly remits with definitive treatment of these conditions.
depersonalization disorder itself may have an episodic, relapsing and remitting, or chronic course. many patients with chronic depersonalization may have a course characterized by severe impairment in occupational, social, and personal functioning. mean age of onset is thought to be in late adolescence or early adulthood in most cases.
treatment: ssri antidepressants, such as fluoxetine (prozac), may be helpful to patients with depersonalization disorder.

dissociative fugue : dissociative fugue was deletingd as a major diagnostic category in dsm-5 and is now diagnosed on a subtype of dissociative amnesia. dissociative fugue can be seen in patients with both dissociative amnesia and dissociative identity disorder. dissociative fugue is described as sudden, unexpected travel away from home or one’s customary place of daily activities, with inability to recall some or all of one’s past. this is accompanied by confusion about personal identity or even the assumption of a new identity. the disturbance is not due to the direct physiological effects of a substance or a general medical condition. the symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
etiology
traumatic circumstances (i.e., combat, rape, recurrent childhood sexual abuse, massive social dislocations, natural disasters), leading to an altered state of consciousness dominated by a wish to flee, are the underlying cause of most fugue episodes. the disorder is thought to be more common during natural disasters, wartime, or times of major social dislocation and violence.
course and prognosis
most fugues are relatively brief, lasting from hours to days. most individuals appear to recover, although refractory dissociative amnesia may persist in rare cases.
treatment
dissociative fugue is usually treated with psychodynamically oriented psychotherapy that focuses on helping the patient recover memory for identity and recent experience. hypnotherapy and pharmacologically facilitated interviews are frequently necessary adjunctive techniques to assist with memory recovery.

dissociative identity disorder : 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 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 : dissociative identity disorder is strongly linked to severe experiences of early childhood trauma, usually maltreatment. physical and sexual abuse are the most frequently reported sources of childhood trauma.

other specified or unspecified dissociative disorder
the category of dissociative disorder covers all of the conditions characterized by a primary dissociative response that do not meet diagnostic criteria for one of the other dsm-5 dissociative disorders.
dissociative trance disorder
dissociative trance disorder is manifest by a temporary, marked alteration in the state of consciousness or by loss of the customary sense of personal identity without the replacement by an alternate sense of identity. in this possessed state, the individual exhibits stereotypical and culturally determined behaviors or experiences being controlled by the possessing entity. there must be partial or full amnesia for the event. the trance or possession state must not be a normally accepted part of a cultural or religious practice and must cause significant distress or functional impairment in one or more of the usual domains. finally, the dissociative trance state must not occur exclusively during the course of a psychotic disorder and is not the result of any substance use or general medical condition.
brainwashing : dsm-5 describes this dissociative disorder as “identity disturbance due to prolonged and intense coercive persuasion. it implies that under conditions of adequate stress and duress, individuals can be made to comply with the demands of those in power, thereby undergoing major changes in their personality, beliefs, and behaviors. persons subjected to such conditions can undergo considerable harm, including loss of health and life, and they typically manifest a variety of posttraumatic and dissociative symptoms.
ganser syndrome : found in prisoners and characterized by the giving of approximate answers (paralogia) together with a clouding of consciousness and is frequently accompanied by hallucinations and other dissociative, somatoform, or conversion symptom.