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 Disorders Group of conditions involving disruptions in a person’s normally integrated functions: Consciousness Memory Identity Perception Motor 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 F44 Dissociative [conversion] disorders 2. F44.0 Dissociative amnesia 3. F44.1 Dissociative fugue 4. F44.2 Dissociative stupor 5. F44.3 Trance and possession disorders 6. F44.4 Dissociative motor disorders

7. F44.5 Dissociative convulsions 8.F44.6 Dissociative anesthesia and sensory loss 9.F44.7 Mixed dissociative [conversion] disorders 10.F44.8 Other dissociative [conversion] disorders 11. F44.9 Dissociative [conversion] disorder, unspecified

Signs and symptoms Memory loss for certain time periods, events and people Mental health problems including depression and anxiety A sense of being detached from yourself(depersonalisation) A blurred sense of identity

Dissociative Amnesia Failure to recall previously stored personal information. It cannot be explained by ordinary forgetfulness There is no evidence of an underlying brain disorder Persons retain the capacity to learn new information

Epidemiology 6% of general population No difference in men and woman Cases 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 information Clinically significant distress for impairment in social, occupational or the important areas of functioning

Clinical features Depression or mood swings Substance abuse Sleep disturbance Anxiety and panic state Suicidal or self mutilating impulses and acts Violent outbursts Interpersonal 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 identity Continuous- unlike others there is not an end

Dissociative fugue A 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 features For a definite diagnosis there should be: A feature of dissociative amnesia Purposeful travel beyond the usual everyday change Confusion about personal identity or assumption of a new identity May display mood disorder symptoms. Suicidal ideation, PTSD and anxiety symptoms

Dissociative Identity Disorder Patient manifests two or more distinct identities or personality states in which only one is being manifest at one time Must alternate in taking control of behavior. Rare. Starts in childhood.

Etiology Severe experiences of child hood trauma Physical and sexual abuse Features Affect modulation is disturbed Mood swings Impulse control is often impaired Leading to risk taking behavior Self destructive behavior Suicidal tendancy

Generalized irritability depression Disturbence in sense of self

Dissociative stupor There 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 sensation There is loss or interference with movement and loss of sensation Patients 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 disorders Loss of ability to move whole or part of the limb or limbs Paralysis may be partial with movements are weak, slow Ataxia may be evident in the legs resulting inability to stand unaided

Dynamics/ transactional model of stress adaptation Precipitating event Dysfunctional neurological processes Repression of painful mental condition Poor coping mechanism Absence 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 Perspectives Psychodynamic 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 / Explanations Psychodynamic Caused by excessive memory repression Behavioral Operant conditioning in which forgetting is reinforced by drop in anxiety State-Dependent Learning Extremely rigid state-to-memory links Self-Hypnosis Self induced hypnotic amnesia

Treatment Dissociative Disorder Three Major Goals 1) Help recognize fully the nature of their disorder 2) Recover gaps in their memory 3) Integrate their personalities into one functioning personality Fusion- final merging of 2 or more alters

Goal is integration Help each alter to understand they are part of one person Use alters names for convenience not to confirm existence of separate autonomy All alters should be treated with fairness Encourage empathy amongst the alters Gentleness and supportiveness are needed in consideration of childhood traumas

Treatment usually consists of 2 parts First: early treatment directed towards symptom reduction Second: long term treatment- resolution of conflicts and prevention of further episodes

Psychotherapy Behavior therapy Abreaction Psycho analysis and psychodynamic psycho therapy Drug therapy Hospitalization Family and marital therapy Group

Topics for client /family education

Nature of illness Define and describe symptoms of all the types of dissociative disorders Discuss etiologies of each disorders Discuss possibility of long term course, particularly in the case of DID.

Management of illness Discuss ways to identify onset of escalating anxiety Discuss ways to intervene to prevent exacerbation of symptoms. Teach relaxation techniques Teach 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. Anxiolytics 2. Antipsychotics 3. antidepressants

Support services Support groups Individual psychotherapy