What is dissociation?

literally a dis-association of memory person suddenly becomes unaware of some

aspect of their identity or history

Dissociative responses occur when anxiety will be overwhelming and the personality become Disorganized…

Dissociative DisordersGroup of conditions involving disruptions in a

person’s normally integrated functions:ConsciousnessMemoryIdentityPerceptionMotor behavior

An Overview of Dissociative Disorders

ACC.To DSM-IV

Depersonalization Disorder Dissociative Amnesia Dissociative Fugue Dissociative Trace Disorder Dissociative Identity Disorder

ACC.To DSM-IV

Depersonalization Disorder Dissociative Amnesia Dissociative Fugue Dissociative Trace Disorder Dissociative Identity Disorder

ACC. To ICD 101.F44 Dissociative [conversion] disorders2.F44.0 Dissociative amnesia3.F44.1 Dissociative fugue4.F44.2 Dissociative stupor5.F44.3 Trance and possession disorders6.F44.4 Dissociative motor disorders

7. F44.5 Dissociative convulsions8.F44.6 Dissociative anesthesia and

sensory loss9.F44.7 Mixed dissociative [conversion]

disorders10.F44.8 Other dissociative [conversion]

disorders11. F44.9 Dissociative [conversion]

disorder, unspecified

Signs and symptomsMemory loss for certain time periods, events

and peopleMental health problems including depression

and anxietyA sense of being detached from

yourself(depersonalisation)A blurred sense of identity

Dissociative AmnesiaFailure to recall previously stored personal

information.It cannot be explained by ordinary

forgetfulnessThere is no evidence of an underlying brain

disorderPersons retain the capacity to learn new

information

Epidemiology 6% of general populationNo difference in men and womanCases are mostly seen in early adolescence

and adulthood

Etiology Amnesia and extreme intra psychiatric

conflict: this usually results from conflicts unacceptable over unacceptable urges or impulses such as intense sexual, suicidal or violent compulsions

Brtrayel trauma:the negative impact of a trauma

Diagnostic criteria One or more episodes of inability to recall

important personal informationClinically significant distress for impairment

in social, occupational or the important areas of functioning

Clinical features Depression or mood swingsSubstance abuseSleep disturbanceAnxiety and panic stateSuicidal or self mutilating impulses and actsViolent outburstsInterpersonal problems

Dissociative amnesia may be: localized –losses all memory within a period of time (most common)

selective- remember some but not all generalized- may forget identityContinuous- unlike others there is not an end

Dissociative fugueA sudden unexpected travel away

from home or ones customary places of daily activities with inability to recall some or all of one’s past.

Dissociative fugue Person also departs from home surroundings Forget personal details, identity, and flee to an

entirely new location Tend to end abruptly Majority regain most of memories without a

recurrence Must face consequences of their fugue Illegal or violent activity etc…

Etiology Traumatic circumstances(rape, recurrent

childhood sexual abuse, natural disasters)leading to an altred state of consciosness

Diagnosis and clinical featuresFor a definite diagnosis there should be:A feature of dissociative amnesiaPurposeful travel beyond the usual everyday

changeConfusion about personal identity or

assumption of a new identityMay display mood disorder symptoms.

Suicidal ideation, PTSD and anxiety symptoms

Dissociative Identity DisorderPatient manifests two or more distinct identities or personality states in which only one is being manifest at one timeMust alternate in taking control of behavior.

Rare.Starts in childhood.

Etiology Severe experiences of child hood traumaPhysical and sexual abuse

Features Affect modulation is disturbedMood swingsImpulse control is often impairedLeading to risk taking behaviorSelf destructive behaviorSuicidal tendancy

Generalized irritabilitydepressionDisturbence in sense of self

Dissociative stuporThere is a positive evidence of psychogenic

causation in the form of either resent stressful events or prominent interpersonal or social problems

The individual lies or sits largely motionless for long period of time

Speech and spontaneous movements are completely or almost completely absent

Dissociative disorders of movement and sensationThere is loss or interference with movement

and loss of sensationPatients therefore presents as having

physical disorder, none can be found that would explain the symptoms

Assessment of patients mental state suggests that the disability resulting from the loss of function is helping the person to escape the unpleasant conflict

Attention seeking behavior may present

Dissociative motor disordersLoss of ability to move whole or part of the

limb or limbsParalysis may be partial with movements are

weak, slowAtaxia may be evident in the legs resulting

inability to stand unaided

Dynamics/ transactional model of stress adaptation Precipitating event

Dysfunctional neurological processesRepression of painful mental condition

Poor coping mechanismAbsence of support systems

cognitive appraisal

Primary

Real or perceived threat to self concept

secondary

Because of weak ego strength, patient is unable to use coping mechanisms

effectively(used are denial, repression, suppression, regression)

Quality of response

ANXIETY

Adaptive maladaptive

Mild moderate severe panic

neurosis psychosis

dissociative disorders

Theoretical PerspectivesPsychodynamic

trauma (abuse, warfare, severe $ problems, averting punishment) plays a role.

Dissociating helps to block out troubling memories.

Adults with DID are easy to hypnotize.Use repression.

Learning:Individual learns not to think about disturbing

thoughts to avoid guilt/shame.Negative reinforcement when relieved from

anxiety.Learned through observational learning.

Etiology / ExplanationsPsychodynamic

Caused by excessive memory repressionBehavioral

Operant conditioning in which forgetting is reinforced by drop in anxiety

State-Dependent LearningExtremely rigid state-to-memory links

Self-HypnosisSelf induced hypnotic amnesia

Treatment Dissociative DisorderThree Major Goals1) Help recognize fully the nature of their

disorder2) Recover gaps in their memory3) Integrate their personalities into one

functioning personalityFusion- final merging of 2 or more alters

Goal is integrationHelp each alter to understand they are part

of one personUse alters names for convenience not to

confirm existence of separate autonomyAll alters should be treated with fairnessEncourage empathy amongst the altersGentleness and supportiveness are needed in

consideration of childhood traumas

Treatment usually consists of 2 partsFirst: early treatment directed towards

symptom reductionSecond: long term treatment- resolution of

conflicts and prevention of further episodes

PsychotherapyPsychotherapyBehavior therapyAbreactionPsycho analysis and psychodynamic psycho

therapyDrug therapyHospitalizationFamily and marital therapyGroup

Topics for client /family education

Nature of illnessDefine and describe symptoms of all the

types of dissociative disordersDiscuss etiologies of each disordersDiscuss possibility of long term course,

particularly in the case of DID.

Management of illnessDiscuss ways to identify onset of escalating anxietyDiscuss ways to intervene to prevent exacerbation of

symptoms.Teach relaxation techniquesTeach assertiveness techniques

Discuss pharmaco thgerapy-teach about any medication that may be used

to treat symptoms associated with dissociative disorders or disorders of co morbidity

1.Anxiolytics2.Antipsychotics3.antidepressants

Support servicesSupport groupsIndividual psychotherapy