Dissociative Disorder Flashcards
Define
A form of a Medically Unexplained Symptom (MUS) = physical complaints without evidence of underlying organic cause
ICD-10 general definition = partial or complete loss of the normal integration between memories of the past, awareness of identify and immediate sensations, and control of bodily movements
- Acute – tend to remit after a few weeks/months, esp. if onset associated with a traumatic life event
- Chronic (i.e. paralyses) – if onset associated with chronic problems or interpersonal difficulties
Dissociative disorder = disorders of physical functions under voluntary control and loss of sensation
- Physical functions
- Conversion disorder – an internal conflict which is ‘converted’ into physical manifestations
- Somatisation disorder = disorders involving pain or autonomically-controlled sensations
Pain and sensation
- Sub-types (from ICD-10 but written in a nicer format):
Dissociative Amnesia: Loss of memory (too great to be explained by ordinary forgetfulness)
Dissociative Fugue: “Travel Far and Wide” Dissociative amnesia + purposeful travel beyond normal everyday range
Dissociative Stupor: Lack of voluntary movement / normal responses to external stimuli (light, noise, touch) Evidence of stress from recent event
Trance & Possession Disorders: Temporary loss of personal identity and full sense of awareness of surroundings
Dissociative Motor Disorders: Loss of ability to move whole/part of a limb/s Close resemblance to ataxia, apraxia, akinesia, aphonia, dysarthria, dyskinesia, seizures…
Dissociative Convulsions: Mimic epileptic seizures (however, tongue-biting, bruising from falls and incontinence rare) Consciousness maintained or replaced by a state of stupor or trance
Dissociative Anaesthesia: Areas of anaesthesia do not follow normal dermatomal distribution May be accompanied by paraesthesia
Aetiology
Psychogenic in origin, being associated closely with traumatic events, insoluble and intolerable problems, or disturbed relationships – thought to be a method of adaptation to negative feelings
Symptoms may develop closely with psychological stress, and often appear suddenly
May be related to previous traumatic experience or tendency to develop more physical than psychological symptoms when stressed
Biological approach:
- Functional brain scan differ between healthy controls with motor abnormality and people with a similar conversion motor symptom
- Suggests that dissociation involves different areas of the brain
Risk factors: physical, sexual or emotional abuse during childhood
- Thought to be a way of adapting to negative feelings and experiences
Usually classed into THREE types (which falls along a spectrum of severity):
- Depersonalisation/ derealisation- LEAST SEVERE
- Depersonalisation- feeling detachment from oneself
- Derealisation- feeling that the world around you is NOT fully real
2.Dissociative amnesia
- Localised (most people)
- Generalised
- Systematised
3.Dissociative identity disorder (multiple personality disorder)- MOST SEVERE
- Covert (more common)
- Overt
All types tend to remit after a few weeks or months, particularly if their onset is associated with a traumatic life event
Symptoms
Onset = acute, specific, dramatic, following sudden stress or conflict
Presentation:
- Paralysis
- Blindness
- Aphonia (cannot speak)
- Seizures
- Psychogenic amnesia (loss of all memories, including own identity)
- Multiple personalities
- Fugue (loss of memory entirely and wander away from home): Stupor
- May show a relative lack of concern despite showing worrying symptoms (i.e. seizures)
Investigations
- Diagnosis usually based on clinical history and examination
- Dissociative experience scale- screens for features of dissociative experience
- Rule out organic causes
E.g., raised prolactin after normal seizure but not raised after dissociative convulsion
- Identify and treat any co-morbid depression
General Management
Self-limiting spontaneous recovery – 75% return to normal
Supportive therapy:
- Encourage return to normal activity
- Avoid reinforcing behaviour (i.e. providing a wheelchair for dissociative stupor/motor disorders)
- Address physical stressors rather than focus on physical manifestations
Specific management
RISK ASSESSMENT!
- Explain the illness to the patient and their family
- These disorders develop to adapt to severe/ prolonged trauma
- Depersonalisation/ derealisation disorder- disruption in normal perception of events
- Dissociative amnesia- disruption in memory
- Dissociative identity disorder- problem with having a single, complete identity
- Explore life stresses may help
- Patients should be supported to address triggering stressors
- Provision of a rehabilitation programme that addresses both physical and psychological needs and problems of the patient
- Graded and mutated agreed for a return to normal function led by the appropriate therapist
E.g. speech therapist for dysphonia, physiotherapy for paralysis
- Encourage return to normal activities and avoid reinforcing symptoms or disability in conversion disorders (e.g. by providing a wheelchair)
- A psychotherapeutic assessment
- Determine the appropriate form of psychotherapy
Psychotherapy
- Helps process trauma safely
- In dissociative identity disorders- facilitates fusion of identities
BMJ Best Practice
- 1ST Line: Eclectic Psychotherapy
- CBT
- Psychoeducation about mind-body connection and attribution of psychiatric or psychological causes rather than purely neurological or medical causes
- Mindfulness
- Interpersonal psychotherapy
- General psychotherapy
- Hypnotic therapy
Psychotherapy applied while in a hypnotic trance
Any conversion disorder patient may benefit from learning self-hypnosis as a tool to control symptoms
Biofeedback training
- Helps patients influence autonomic, involuntary bodily functions and better understand the mind-body connection by measuring bodily functions
- Benzodiazepines
1st Line: Lorazepam
2nd Line: Diazepam
2nd Line: Further Psychotherapy
- Psychodynamic therapy
- Family therapy
- Group therapy
- Eye-movement desensitisation-reprocessing
Complications / Prognosis
Complications
Can potentially endanger the individual
Depression
Anxiety
Suicidal ideation- suicidal rates are high in those with overt (3/4 will/ have tried at least once in their life)
Substance use/ abuse
Prognosis
Most cases of recent onset recover quickly with treatment
Cases that last > 1 year are likely to persist
25% of those who exhibit short-term resolution of symptoms after reassurance will relapse or develop new conversion symptoms over time
