OVERVIEW OF DISSOCIATIVE DISORDERS
Dissociation is the fragmentation or separation of aspects of consciousness, including memory, identity, and perception. Some degree of dissociation is always present; however, if an individual's consciousness becomes too fragmented, it may pathologically interfere with the sense of self and ability to adapt. Presenting complaints and findings of dissociative disorders include amnesia, personality change, erratic behavior, odd inner experiences (e.g., flashbacks, deja vu), and confusion.
DISSOCIATIVE AMNESIA
Definition
Significant episodes in which the individual is unable to recall important and often emotionally charged memories.
Risk Factors/Etiology
Psychological stress. More common in women and younger adults. Onset is usually detected retrospectively by the discovery of memory gaps of extremely variable duration.
Symptoms
Amnesia that may be general or selective for certain events.
Course
The amnesia may suddenly or gradually remit, particularly when the traumatic circumstance resolves, or may become chronic.
Associated Problems
Mood disorders, conversion disorder, and personality disorders are commonly present.
Treatment
Diagnostic evaluation for general medical conditions (e.g., head trauma, seizures, cerebrovascular disease) or substances (e.g., anxiolytic and hypnotic medications, alcohol) that may cause amnesia. Hypsnosis, suggestion, and relaxation techiques are helpful. The patient should be removed from stressful situations when possible. Psychotherapy should be directed at resolved underlying emotional stress.
Differential Diagnosis
Major rule outs are amnestic disorder due to a general medical condition, substance-induced amnestic disorder, and other dissociative disorders.
DISSOCIATIVE FUGUE
Definition
Sudden, unexpected travel, accompanied by the inability to remember one's past and by confusion about personal identity, or by the assumption of a new identity.
Risk Factors/Etiology
Psychosocial stressors.
Incidence
0,2%.
Onset
Usually sudden, often following a stressful life event.
Course
Most episodes are isolated and last from hours to months.
Outcome
Resolution is usually rapid, but amnesia may persist.
Associated Problems
Mood disorders, PTSD, and substance-induced disorders.
Treatment
Same as for dissociative amnesia.
Differential Diagnosis
Major rule-outs are complex partial seizures, other dissociative disorders, and factitious disorder and malingering.
DISSOCIATIVE IDENTITY DISORDER (FORMERLY MULTIPLE PERSONALITY DISORDER)
Definition
Presence of multiple, distinct personalities that recurrently control the individual's behavior, accompanied by failure to recall important personal information.
Risk Factors/Etiology
Childhood sexual abuse has been postulated as a risk factor.
Prevalence
More common in women.
Onset
Usually occult; clinical presentation is several years later when disturbances in interpersonal functioning are present.
Key Symptoms
Presence of distinct personalities is often subtle; in some cases, it is discovered only during treatment for associated symptoms.
Associated Problems
Chaotic interpersonal relationships, impulsivity and self-destructive behavior, suicide attempts, substance abuse.
Comorbidity
Borderline personality disorder, PTSD, major depressive disorder and other mood disorders, substance-related disorders, sexual disorders, and eating disorders.
Course
Symptoms may fluctuate or be continuous.
Differential Diagnoses
Borderline personality disorder and other personality disorders, bipolar disorder with rapid cycling, factitious disorder, and malingering.
Treatment
Psychotherapy to uncover psychologically traumatic memories and to resolve the associated emotional conflict.
DEPERSONALIZATION DISORDERS
Definition
Persistent or recurrent feeling of being detache from one's mental processes or body, accompanied by intact sense of reality.
Risk Factors/Etiology
Psychologic stress.
Prevalence
Episodes of depersonalization are common.
Onset
Usually in adolescence or early adulthood. Stressful events may precede the onset of the disorder.
Key Symptoms
- Depersonalization: Often describes as an "out-of-body experience".
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Derealization: Perception of the environment is often distorted or strange during episodes of depersonalization, accompanied by a feeling of being detached from physical surroundings. Jamais vu (a sense of familiar things being strange), deja vu (a sense of unfamiliar things being familiar), and other forms of perceptual distortion may occur.
Associated Symptoms
Are often during episodes.
Treatment
Psychotherapy directed at decreasing anxiety.
Differential Diagnosis
Major rule-outs are substance-induced mental disorders with dissociative symptoms, including intoxication, withdrawal, hallucinogen-induced persisting perceptual disorder, panic disorder, and PTSD.
REVIEW QUESTION
Case Study
A 19-year-old man is brought to the emergency room by volunteers from a homeless shelter. The man claims that he cannot remember who he is. He says that he found himself in Los Angeles but that he cannot remember where he comes from, the circumstances of his trip, or any other information about his life. He has neither identification nor money, but he has a bus ticket from New York.
Which of the following is the most likely diagnosis?
- Depersonalization disorder
- Dissociative amnesia
- Dissociative fugue
- Dissociative identity disorder
- Substance-induced amnestic disorder
Answer: C. The symptoms of amnesia, unexplained travel, and identity confusion are most suggestive of dissociative fugue. Because of the generalized nature of his amnesia, substance-induced amnestic disorder an unlikely diagnosis. There is insufficient evidence of distinct alternative personalities to diagnose dissociative identity disorder.
