Dissociative Disorders
د
.
و
ﯾﻟ
د
ﻋ
ز
ﯾ
ز
ا
ﻟ
ﻌ
ﻣ
ﯾ
د
ي
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.
.
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 off from others, and (4) being cut off 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 deleted 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.