para>Decrease in frequency and intensity of dissociative symptoms; medication side effects are more likely.
Pediatric Considerations
Suspect abuse or neglect
EPIDEMIOLOGY
Incidence
- Predominant age: adolescents and young to middle-aged adults; rare as a new illness in the elderly. If untreated, it may linger from childhood into adulthood and old age.
- Predominant sex: female > male (2:1)
Prevalence
- Transient symptoms of depersonalization or derealization in the general population are common.
- Lifetime prevalence rate is 26-74%.
- 31-66% occurring at the time of a traumatic event
- Up to 70% of young adults report short periods of dissociative experiences that are self-limiting and resolve spontaneously without any treatment.
- Dissociative amnesia occurs in 2-7% of the general population.
ETIOLOGY AND PATHOPHYSIOLOGY
Common link to a history of emotional/physical trauma
RISK FACTORS
- Exposure to neglect, abuse, and trauma in childhood (2)[A],(3)[B]
- Physical, emotional, verbal, or sexual abuse in childhood and adolescent years
- Sudden and severe trauma or threat to psychological or physical integrity
- Sudden and unexpected exposure to watching others being killed or severely injured (as in industrial or car accident)
- Tendency to cope with life's stresses by excessively using an escape mechanism of daydreaming and/or dissociation
- A tendency of coping with trauma, internal, and interpersonal conflicts by the use of dissociation
- Psychological/social support to cope with the trauma/abuse was unavailable.
- Family history of dissociative disorders or posttraumatic stress disorder (PTSD)
GENERAL PREVENTION
- Child abuse prevention via parent education and community agency intervention
- Crisis intervention following individual trauma or disasters may prevent dissociative disorders.
COMMONLY ASSOCIATED CONDITIONS
PTSD, anxiety disorders, depression, somatoform disorders, chronic pain, insomnia, gender dysphoria
DIAGNOSIS
HISTORY
- All disorders share symptoms that
- Cause significant distress or impairment in social, occupational, or other areas of functioning
- Are not due to the direct physiologic effects of a substance (e.g., drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy) (1)[A]
- Dissociative identity disorder (300.14) (1)[A]
- Presence of ≥2 distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self), which may be described as an experience of possession in some cultures.
- Inability to recall important personal information that cannot be explained by ordinary forgetfulness
- At least two of these identities or personality states recurrently take control of the person's behavior.
- Reports of lapses in memory, time, and distortion
- Experiencing voices from inside one's head
- History of childhood abuse and/or trauma
- Referring to self as he/she, we, they, us
- Abnormal eating behaviors
- Feelings of depersonalization/derealization
- Amnesia about important childhood events
- Disowning unrecalled behaviors
- Different handwriting styles/signatures and names
- Sudden mood changes.
- Sudden behavioral changes (e.g., from adult to young child)
- Episodes of d ©j vu and d ©j entendu
- Self-inflicted violence such as wrist cutting
- Dissociative amnesia without fugue (300.12) (1)[A]
- Inability to recall important personal information inconsistent with ordinary forgetting
- Symptoms cause significant distress or impairment in social, occupational, or other activities of daily living (ADLs).
- Not occurring during another psychiatric illness and not due to effects of chemical substances (e.g., alcohol, drug abuse or medication)
- Not due to a neurologic or other medical condition (e.g., epilepsy, head trauma)
- Above symptoms do not occur during course of dissociative identity disorder.
- Dissociative amnesia with fugue symptoms (300.13) (1)[A]
- Sudden unexpected travel away from home or work with an inability to recall one's past
- Confusion about personal identity or assumption of a new identity connected with travel episodes
- Depersonalization/derealization disorder (300.6) (1)[A]
- Persistent or recurrent experiences of depersonalization, derealization, or both
- Depersonalization: experiences of unreality, detachment, or being an outside observer with respect to one's thoughts, feelings, sensations, physical body, or actions
- Derealization: experiences of unreality or detachment with respect to one's surroundings
- During the depersonalization/derealization experience, reality testing remains intact.
- The depersonalization/derealization causes clinically significant distress or impairment in social, occupational, and other areas of functioning.
- The depersonalization/derealization experience does not occur exclusively during the course of another mental disorder, such as depression, schizophrenia, panic and stress disorders, or other dissociative disorders, and is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).
- Other specified dissociative disorder (300.15) (1)[A]
- Predominant feature is a dissociative symptom (e.g., a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment) that does not meet the criteria for any other specific dissociative disorder. Examples include:
- Chronic and recurrent syndromes of mixed dissociative symptoms
- Identity disturbance due to prolonged and intense coercive persuasion
- Acute dissociative reactions to stressful events
- Dissociative trance: single or episodic disturbances in the state of consciousness, identity, or memory that are indigenous to particular locations and cultures. Dissociative trance involves narrowing of awareness, of immediate surroundings, or stereotyped behaviors or movements that are experienced as being beyond one's control.
- Possession trance states are now listed under dissociative identity disorder.
- Ganser syndrome is now listed under other specified dissociative disorder.
- Unspecified dissociative disorder (300.15) (1)[A]
- Applies to presentations of dissociative symptoms that cause clinically significant distress or impairment in social, occupational, or other areas of functioning that do not meet the criteria of any of the other dissociative disorders
- Loss of consciousness, stupor, or coma is not attributed to a general medical condition.
DIFFERENTIAL DIAGNOSIS
- Other mental/CNS disorder: schizophrenia, depression, anxiety disorder, bipolar, PTSD, obsessive-compulsive disorder, identity disorder, phobic disorders, somatoform disorders, eating disorders, and gender dysphoric disorders
- Other: extreme sensory deprivation, epilepsy, dementia, encephalitis, head trauma, migraine, cerebral vascular disease, brain tumors
- Endocrinopathies: hypoglycemia, hypothyroidism, hyperthyroidism, Cushing syndrome
- Miscellaneous: Huntington disease, carbon monoxide poisoning, mescaline intoxication, botulism, hyperventilation
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- Electroencephalogram (EEG) to rule out epilepsy
- Polysomnogram to rule out sleep disorders
Follow-Up Tests & Special Considerations
- Patient's personal history should be complemented with history obtained from a family member.
- Toxicology screening for drugs is helpful.
- CT and MRI of the head to rule out organic brain disorders
- Avoid sleep deprivation.
- Avoid substance abuse.
Diagnostic Procedures/Other
- Neuropsychological testing to rule out learning disabilities and cognitive deficits due to early dementia or borderline mental retardation
- Psychological testing to identify specific disorders, personality structure, and psychodynamics
- Dissociation scales help assess the tendency to dissociate in daily living activities.
- Interviews assisted by amobarbital (Amytal) and hypnosis may be useful in selected cases.
TREATMENT
GENERAL MEASURES
- Individual psychotherapy plus behavior modification, and in selective cases, hypnotherapy (4)[A]
- Adjuncts: group therapy, expressive art therapy, occupational and recreational therapy when not associated with dissociative amnesia or fugue (4)[A]
MEDICATION
First Line
- The essential form of treatment is individual psychotherapy. The following have been helpful (5)[B]:
- Antidepressants for depression
- Benzodiazepines for anxiety
- Propranolol (80 to 400 mg/day) for flashbacks and other dissociative symptoms (off-label)
- Neuroleptics (low doses) for psychotic symptoms
- Mood swings in dissociative disorders do not respond to the use of mood stabilizers.
- Precautions
- Potential abuse with short-acting benzodiazepines
- Overdose/suicide potential with tricyclic antidepressants (TCAs)
- Atypical neuroleptics may be associated with hyperglycemia.
- Significant possible interactions
- Monoamine oxidase inhibitors with TCAs or selective serotonin reuptake inhibitors (SSRIs)
Second Line
- Anxiety symptoms
- Buspirone (BuSpar), 30 to 80 mg/day for anxiety
- Obsessive-compulsive and/or depressive symptoms: Consider psychotropic medications.
- Atypical neuroleptics have recently been found useful for the control of self-inflicted violence or psychotic symptoms. Consider medications with the lowest effective dose.
ISSUES FOR REFERRAL
Dissociative disorders are best treated by a well-trained mental health professional.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Outpatient, individual psychotherapy
- At times of crisis: intensive hospital-based treatment (as a protection for patients with suicidal or homicidal impulses and behaviors)
- Use inpatient care to verify diagnosis with special tests and begin a treatment program.
- Treatment emphasis should be on progress in the adaptive functions with daily living activities, symptom alleviation, ego strengthening, and preventing regressions.
ONGOING CARE
PATIENT EDUCATION
- Self-hypnosis, relaxation exercises, guided imagery, mindfulness meditation
- Encourage patients to become educated about their condition and be inspired by those who got better and recovered:
- Benson H, Klipper MZ. The Relaxation Response. New York, NY: HarperCollins; 2000.
- Kabat-Zinn J. Coming to Our Senses: Healing Ourselves and the World Through Mindfulness. New York, NY: Hyperion; 2006.
- Rossman ML. Guided Imagery for Self-Healing: An Essential Resource for Anyone Seeking Wellness. Novato, CA: New World Library; 2000.
- Sizemore CC. A Mind of My Own: The Woman Who Was Known as "Eve" Tells the Story of Her Triumph Over Multiple Personality Disorder. New York, NY: W. Morrow; 1989.
- Steinberg M, Schnall M. The Stranger in the Mirror: Dissociation-The Hidden Epidemic.. New York, NY: HarperCollins; 2001.
- Tart TC. Living the Mindful Life. Boston, MA: Shambhala Publications; 1994.
PROGNOSIS
- Ranges from spontaneous improvement in cases of dissociative amnesia, dissociative fugue, and depersonalization/derealization disorder to acute and chronic morbidity in others
- Without treatment, a dissociative identity disorder patient may have a healthy functioning facade, with episodes of depression, confusion, or mood swings. With age, the intensity and frequency of dissociative episodes may decrease and crystallize around 1 to 2 identity states.
- Effective treatment produces partial or full recovery for many patients.
COMPLICATIONS
Self-inflicted violence, suicide attempts, substance abuse, chemical dependency
REFERENCES
11 American Psychiatric Association. Dissociative disorders. Diagnostic and Statistical Manual of Mental Disorders. 55th ed. Arlington, VA: American Psychiatric Association; 2013:291-307.22 Mueller-Pfeiffer C, Moergeli H, Schumacher S, et al. Characteristics of child maltreatment and their relation to dissociation, posttraumatic stress symptoms, and depression in adult psychiatric patients. J Nerv Ment Dis. 2013;201(6):471-477.33 Wolf MR, Nochajski TH. Child sexual abuse survivors with dissociative amnesia: what's the difference? J Child Sex Abus. 2013;22(4):462-480.44 International Society for the Study of Trauma and Dissociation. Guidelines for treating dissociative identity disorder in adults, third revision: summary version. J Trauma Dissociation. 2011;12(2):188-212.55 Gentile JP, Dillon KS, Gillig PM. Psychotherapy and pharmacotherapy for patients with dissociative identity disorder. Innov Clin Neurosci. 2013;10(2):22-29.
ADDITIONAL READING
- Bob P, Svetlak M. Dissociative states and neural complexity. Brain Cogn. 2011;75(2):188-195.
- Carlton TG. The integration of science and practice in trauma and dissociation: a clinician's view. J Trauma Dissociation. 2012;13(1):1-8.
- Fine CG. Cognitive behavioral hypnotherapy for dissociative disorders. Am J Clin Hypn. 2012;54(4):331-352.
- Savitz JB, van der Merwe L, Newman TK, et al. The relationship between childhood abuse and dissociation. Is it influenced by catechol-O-methyltransferase (COMT) activity? Int J Neuropsychopharmacol. 2008;11(2):149-161.
- Spiegel D. Divided consciousness: dissociation in DSM-5. Depress Anxiety. 2012;29(8):667-670.
- Spiegel D, Lewis-Fern ¡ndez R, Lanius R, et al. Dissociative disorders in DSM-5. Annu Rev Clin Psychol. 2013;9:299-326.
CODES
ICD10
- F44.9 Dissociative and conversion disorder, unspecified
- F44.0 Dissociative amnesia
- F44.1 Dissociative fugue
- F44.81 Dissociative identity disorder
- F44.89 Other dissociative and conversion disorders
ICD9
- 300.15 Dissociative disorder or reaction, unspecified
- 300.12 Dissociative amnesia
- 300.13 Dissociative fugue
- 300.14 Dissociative identity disorder
SNOMED
- Dissociative disorder (disorder)
- Psychogenic amnesia
- Psychogenic fugue
- Multiple personality disorder
CLINICAL PEARLS
- Focus on improving and maintaining adaptive functioning with activities of daily living.
- Symptom stabilization and ego strengthening come before exploration of past trauma.
- Regularly assess and reassess levels of functioning.
- Prevent unnecessary regressions.
- Communicate regularly with family members to obtain and verify data about patient's level of functioning and other behaviors/symptoms.
- Encourage and reinforce patient's ownership of his or her own behaviors regardless of whether the patient remembers it or not.
- Rule out the presence of abuse or threats of abuse in the patient's living environment.
- If hypnosis is utilized in the treatment, verify that the patient has been fully reoriented to the present reality before the session is concluded and the patient is allowed to leave the office.
- Set up a system of how to deal with emergencies and crises, this is to include names of people and their phone numbers.
- Clarify for the patient and a family member when to go to the nearest hospital emergency room.