(Call Girls) in Lucknow Real photos of Female Escorts 👩🏼❤️💋👩🏻 8923113531 ➝...
L11-Trauma and Stressor Related Disorders AND Dissociative Disorders-1.pptx
1. Trauma and Stressor Related
Disorders
Dr. Edgar Munga
MBChB, Mmed (Psychiatry)
2. • Include disorders in which exposure to a traumatic or stressful event
is listed explicitly as a diagnostic criterion.
• These include reactive attachment disorder, disinhibited social
engagement disorder, posttraumatic stress disorder (PTSD), acute
stress disorder, and adjustment disorders.
3. • Major psychological stress involves threat or loss. Reactions to a
broad range of major stressors are often similar in nature
and involve:
i. emotional responses (fear from threat and sadness at loss);
ii. physical symptoms (autonomic arousal and/or fatigue);
iii. psychological responses, which may be conscious (e.g. avoidance
behaviour) or unconscious (e.g. denial or dissociation).
4. Reactive Attachment Disorder
• A mental health disorder in which infants and young children (usually
before the age of 5 years) are unable to form healthy social
relationships (attachments), particularly with a primary caregiver.
5. • Attachment is the relationship the baby develops with its caregivers.
• John Bowlby studied the attachment of infants to mothers and
concluded that early separation of infants from their mothers had
severe negative effects on children's emotional and intellectual
development.
• Mary Ainsworth found that the interaction between mother and
baby during the attachment period influences the baby's current and
future behavior significantly.
7. Reactive Attachment Disorder
• This disorder is one that is limited to infancy (at least 9 months old) or early
childhood (evident before the age of 5 years).
• The disorder is the result of extremes of insufficient care such as social neglect or
deprivation, repeated changes of primary care givers or contexts where there are
limited opportunities to form stable attachments.
• This results in a consistent pattern of inhibited, emotionally withdrawn behaviour
toward adult caregivers such as not seeking comfort when distressed or not
responding to comfort when provided.
• The child also exhibits persistent social and emotional disturbances such as limited
responsiveness, limited positive affect and periods of unexplained irritability,
sadness or fearfulness (APA, 2013).
• It is generally accepted that children with this disorder have the capacity to form
attachments; however, due to their environments they have not been given the
opportunity to do so (APA, 2013).
• The main cause of this disorder is serious neglect, however, what is of note is that
not all children that are exposed to extreme neglect, develop this disorder (APA,
2013).
8. Diagnostic Criteria
• A. A consistent pattern of inhibited, emotionally withdrawn behavior
toward adult caregivers, manifested by both of the following:
1. The child rarely or minimally seeks comfort when distressed.
2. The child rarely or minimally responds to comfort when distressed.
B. A persistent social and emotional disturbance characterized by at
least two of the following:
1. Minimal social and emotional responsiveness to others.
2. Limited positive affect.
3. Episodes of unexplained irritability, sadness, or fearfulness that are
evident even during nonthreatening interactions with adult
caregivers.
9. • C. The child has experienced a pattern of extremes of insufficient care
as evidenced by at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having
basic emotional needs for comfort, stimulation, and affection met by
caregiving adults.
2. Repeated changes of primary caregivers that limit opportunities to
form stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to
form selective attachments (e.g., institutions with high child-to-
caregiver ratios).
10. • D. The care in Criterion C is presumed to be responsible for the
disturbed behavior in Criterion A (e.g., the disturbances in Criterion A
began following the lack of adequate care in Criterion C).
E. The criteria are not met for autism spectrum disorder.
F. The disturbance is evident before age 5 years.
G. The child has a developmental age of at least 9 months.
11. • Specify if:
Persistent: The disorder has been present for more than 12 months.
Specify current severity:
Reactive attachment disorder is specified as severe when a child
exhibits all symptoms of the disorder, with each symptom manifesting
at relatively high levels.
12. Risk factors for R.A.D
• Living in an orphanage
• Institutional care/ prolonged hospitalization
• Frequent changes in foster care or caregivers
• Extreme neglect or poverty
• Physical, sexual or emotional abuse
• Post partum depression in the mother
14. • Psychotherapy
Dyadic Developmental Psychotherapy
Maintain an affectively attuned relationship
• Attachment Therapy
Play therapy, paint therapy, child-parent intervention
• Behavioral Management Therapy
Treats the behavioral symptoms
Acts more as a band aid
Treatments
15. Disinhibited Social Engagement Disorder
• In this case a child actively approaches and interacts with unfamiliar
adults in an impulsive, incautious, and overfamiliar way.
• As was the case with the previous disorder, this disorder also seems to be
the result of extreme neglect before the age of 2 years (APA, 2013).
• This disorder, which is also limited to children, can almost be described as
the inverse of Reactive Attachment Disorder (RAD).As opposed to RAD,
children with this disorder readily approach strangers without fear and
with excessive familiarity.
• This familiarity includes a readiness to hug and accept comfort, food or
toys from an unknown person (APA, 2013).
• As is the case with RAD, serious social neglect is a diagnostic requirement
for this disorder, but again, not all seriously neglected children develop
this disorder.
• Although unconfirmed, it seems as if children who develop this disorder
may have a neurobiological vulnerability to this disorder (APA, 2013).
16. Diagnostic Criteria
• A. A pattern of behavior in which a child actively approaches and interacts
with unfamiliar
adults and exhibits at least two of the following:
1. Reduced or absent reticence in approaching and interacting with
unfamiliar adults.
2. Overly familiar verbal or physical behavior (that is not consistent with
culturally sanctioned and with age-appropriate social boundaries).
3. Diminished or absent checking back with adult caregiver after venturing
away, even in unfamiliar settings.
4. Willingness to go off with an unfamiliar adult with minimal or no
hesitation
17. • B. The behaviors in Criterion A are not limited to impulsivity (as in
attention-deficit/hyperactivity disorder) but include socially disinhibited
behavior.
C. The child has experienced a pattern of extremes of insufficient care as
evidenced by
at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having
basic emotional needs for comfort, stimulation, and affection met by
caregiving adults.
2. Repeated changes of primary caregivers that limit opportunities to form
stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form
selective attachments (e.g., institutions with high child-to-caregiver ratios).
18. • D. The care in Criterion C is presumed to be responsible for the
disturbed behavior in Criterion A (e.g:, the disturbances in Criterion A
began following the pathogenic care in Criterion C).
E. The child has a developmental age of at least 9 months.
Specify if:
Persistent: The disorder has been present for more than 12 months.
Specify current severity:
Disinhibited social engagement disorder is specified as severe when
the child exhibits all symptoms of the disorder, with each symptom
manifesting at relatively high levels.
21. Posttraumatic Stress Disorder (PTSD)
• Severe psychological disturbance following a traumatic event
characterized by involuntary re-experiencing of elements of the
event, with symptoms of hyperarousal, avoidance, emotional
numbing.
• ICD-10 states that onset is usually within six months of stressor
(although it may rarely exceed this); DSM-5 that symptoms persist for
at least one month.
22. Epidemiology
• Risk of developing PTSD after a traumatic event 8–13% for men, 20–
30% for women. Lifetime prevalence estimated as 7.8% (M:F =
1:2).Cultural differences exist. Some types of stressor are associated
with higher rates of PTSD (e.g. rape, torture, being a prisoner of war).
• Although PTSD can appear at any age, it is most prevalent in
young adults, because they tend to be more exposed to precipitating
situations.
23. • The disorder is most likely to occur in those who are
single, divorced, widowed, socially withdrawn, or of low
socioeconomic level, but anyone can be effected.
24. Aetiology
1. Psychological: ‘re-experiencing symptoms’. Fear response to
harmless situations associated with original trauma, perhaps due to
emotional memories (i.e. having personal significance).
2. Biological: neurophysiological changes leading to permanent
neuronal changes as a result of the effects of chronic stress or
persistent re-experiencing of the stressful event. Neurotransmitters
implicated—cathecholamines, 5-HT, GABA, opioids, and
glucocorticoids.
25. 3. Neuroimaging:reduced hippocampal volume (may relate to
appreciation of safe contexts and explicit memory deficits).
Dysfunction of the amygdala, hippocampus, septum, and prefrontal
cortex may lead to enhanced fear response.
4. Genetic: higher concordance rates seen in MZ than DZ twins.
5. Psychodynamic: The psychoanalytic model of the PTSD hypothesizes that
the trauma has reactivated a previously quiescent, yet unresolved
psychological conflict. The revival of the childhood trauma
results in regression and the use of the defense mechanisms of
repression, denial, reaction formation, and undoing.
26. 6. Cognitive Behavioural Factors: The cognitive model of PTSD posits
that affected persons cannot process or rationalize the trauma that
precipitated the disorder. They continue to experience the stress ad
attempt to avoid experiencing it by avoidance techniques.
27. Risk Factors
• low education, lower social class, female gender, low self-esteem/neurotic
traits, previous (or family) history of psychiatric problems (esp.
mood/anxiety disorders), previous traumatic events (including adverse
childhood experiences and abuse).
• Peri-traumatic factors: trauma severity, perceived life threat, peri-
traumatic emotions, peri-traumatic dissociation.
• Protective factors: high IQ, higher social class, Caucasian, male gender,
psychopathic traits, chance to view body of dead person.
28. Comorbidity: Depressive/mood disorders, other anxiety disorders, alcohol and
drug misuse disorders, somatization disorders.
Diagnostic Criteria
A. Exposure to actual or threatened death, serious injury, or sexual violence in one
(or
more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close
friend. In cases of actual or threatened death of a family member or friend, the
event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s) (e.g., first responders collecting human remains: police officers repeatedly
exposed to details of child abuse).
29. • Note: Criterion A4 does not apply to exposure through electronic media, television,
movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or
aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are
related to the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if
the traumatic event(s) were recurring. (Such reactions may occur on a continuum,
with the most extreme expression being a complete loss of awareness of present
surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
30. 4. Intense or prolonged psychological distress at exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble
an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after
the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations,
activities, objects, situations) that arouse distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s).
31. • D. Negative alterations in cognitions and mood associated with the
traumatic event(s),beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic
event(s) (typically due to dissociative amnesia and not to other
factors such as head injury, alcohol, or drugs)
32. • 2. Persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world (e.g., “I am bad,” “No one can be
trusted,” ‘The world is completely dangerous,” “My whole nervous
system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences
of the traumatic event(s) that lead the individual to blame
himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt,
or shame)
33. • E. Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic event(s)
occurred, as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation)
typically expressed as verbal or physical aggression toward people or
objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless
sleep).
34. • F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1
month.
G. The disturbance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a
substance (e.g.,
medication, alcohol) or another medical condition.
35. • Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for
posttraumatic stress disorder, and in addition, in response to the stressor, the individual
experiences persistent or recurrent symptoms of either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from,
and as if one were an outside observer of, one’s mental processes or body (e.g.,
feeling as though one were in a dream; feeling a sense of unreality of self or body
or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings
(e.g., the world around the individual is experienced as unreal, dreamlike, distant,
or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication)
or another medical condition (e.g., complex partial seizures).
36. • Specify if:
With delayed expression: If the full diagnostic criteria are not met
until at least 6 months after the event (although the onset and
expression of some symptoms may be immediate).
37. • Suicide risk: Traumatic events such as childhood abuse increase a
person's suicide risk. PTSD is associated with suicidal ideation and
suicide attempts, and presence of the disorder may indicate which
individuals with ideation eventually make a suicide plan or actually
attempt suicide.
38. Management
A. Psychological: Meta-analyses support the superior efficacy of
trauma-focused treatments, specifically trauma-focused CBT and
EMDR. These are recommended as first-line treatments in all recent
guidelines.
CBT: includes elements of: education about the nature of PTSD, self
monitoring of symptoms, anxiety management, breathing techniques,
imaginal reliving, exposure to anxiety-producing stimuli in a
supportive environment, cognitive restructuring (esp. for complicated
trauma),anger management.
39. Eye movement desensitization and reprocessing (EMDR): novel
treatment using voluntary multi-saccadic eye movements to reduce
anxiety associated with disturbing thoughts and help process the
emotions associated with traumatic experiences
Other Psychological Rx: Psychodynamic therapy, stress Mx,
Hypnotherapy, supportive therapy
40. B. Pharmacological: Medication may be considered when there is
severe ongoing threat, if the patient is too distressed or unstable to
engage in psychological therapy, or fails to respond to an initial
psychological approach.
• SSRIs (e.g. paroxetine 20–40mg/day; sertraline 50–200mg/day) are
licensed for PTSD. Other unlicensed possibilities include: fluoxetine,
citalopram, escitalopram, and fluvoxamine.
• Other antidepressants; TCAs, MAOi
41. Symptomatic Mx
• Sleep disturbance; Mirtazapine (45mg/day), Zolpidem
• Anxiety Sx: Use of benzodiazepines (Clonazepam), Propranolol
• Intrusive thoughts/hostility/impulsiveness: some evidence for use of
carbamazepine, valproate, topiramate, or lithium.
• Psychotic symptoms/severe aggression or agitation: may warrant use of an
antipsychotic (some evidence for olanzapine, risperidone, quetiapine,
clozapine, aripiprazole)
42. Prognosis
• Approximately 50% will recover within first year while 30% will run a
chronic course
• Outcome depends on initial symptom severity
• Recovery will be helped by: good social support; lack of –ve responses
from others; absence of ‘maladaptive’ coping mechanisms (e.g.
avoidance, denial, ‘safety behaviours’, not talking about the
experience, thought suppression, rumination); no further traumatic
life events (secondary problems such as physical health, acquired
disability, disfigurement, disrupted relationships, financial worries,
litigation)
43. Acute Stress Disorder
• The essential feature of acute stress disorder is the development of
characteristic symptoms lasting from 3 days to 1 month following
exposure to one or more traumatic events.
• Traumatic events that are experienced directly include, but are not
limited to, exposure to war as a combatant or civilian, threatened or
actual violent personal assault (e.g sexual violence, physical attack,
active combat, mugging, childhood physical and/or sexual violence,
being kidnapped, being taken hostage, terrorist attack, torture),
natural or human made disasters and severe accidents.
44. Acute Stress Disorder
Diagnosis I
Symptom following the direct
experience or indirect experience
of(hearing about) a traumatic event
1. One symptom in each category
1. Re-experiencing the trauma
• Recurring flashbacks, bad dreams or
frightening thoughts
2. Altered cognitions and mood
• Forgetting details
• Irrational beliefs or thoughts about
the cause of the trauma
3. Avoidance or numbing
• Shunning any reminders
• Feeling emotionally
numb
• Detachment from people
4. Increased arousal or
reactivity
• Hypervigilance, sleep
problems
• Irritability, recklessness
• Impaired concentration
45. Acute Stress Disorder
Diagnosis II
2. Onset or duration
• Symptoms last at least 2 days and less
than 1 month
• Occur within 4 weeks of the event
47. Management
Psychological:
• Debriefing—may be useful for certain individuals (needing supportive-
therapy), but reviews suggest there is little positive benefit of single session
debriefing and may worsen outcome!
• CBT- brief interventions (education, relaxation, cognitive restructuring)
Pharmacological
• TCAs, SSRIs, and BDZs may be useful for clinically
significant symptoms (evidence lacking).
49. Adjustment Disorders
• Adjustment disorders were previously a separate category in the DSM-IV-TR, but it
has now been reconceptualised in the DSM-5 as a stress-response syndrome, and
therefore fits into the category of Trauma- and Stressor-Related Disorders.
• Previously these disorders were almost seen as residual disorders, i.e. where a
person did not meet the clinical threshold for other disorders such as Major
Depression, Generalized Anxiety Disorders and the likes.
• In essence these disorders are seen to be emotional or behavioural responses to
an identifiable stressor (APA, 2013).
• The response may be due to a single (e.g. divorce) or multiple stressors
(cumulative stressful life events).
• Furthermore, these stressors may be recurrent or continuous, and may affect only
the individual or groups such as families or communities (APA, 2013).
• The stressor can take on any form such as interpersonal difficulties, natural
disasters, health, financial, family or work problems.
• Typically the disorder develops within three months of the onset of the stressor
and lasts no longer than six months after the stressor has ceased (APA, 2013).
50. • The symptom complex that develops may involve
anxious or depressive affect or may present with a disturbance
of conduct.
• Subtypes include: adjustment disorder with depressed mood, mixed
anxiety and depressed mood, disturbance of conduct, mixed
disturbance of emotions and conduct, features of acute stress
disorder or posttraumatic stress disorder (PTSD), bereavement, and
unspecified type.
51. Epidemiology
• Prevalence 2-8% of the general population
• M:F 1:2 (Single women mostly affected)
• Stressors include: school problems, parental rejection and divorce,
and substance abuse, these are seen in adolescents. In adults
stressors include marital problems, divorce, moving to a
new environment, and financial problems.
52. Aetiology
By definition the problems are caused by an identifiable stressor. Individual
predisposition plays a greater role than in other conditions, but symptoms would
not have arisen without the stressor.
Psychodynamic Factors: Three important factors the nature of the stressor, the
conscious and unconscious meanings of the stressor, and the patient's preexisting
vulnerability.
Same stress can produce a range of responses in various persons.
Emphasis also placed on the role of the mother and and the rearing environment
in a person's later capacity to respond to stress.
53. Family and Genetic Factors: Twin studies indicate
that life events and stressors are modestly correlated in twin
pairs, with monozygotic twins showing greater concordance
than dizygotic twins.
54. Diagnostic Criteria
• A. The development of emotional or behavioral symptoms in response to an identifiable
stressor(s) occurring within 3 months of the onset of the stressor(s).
B. These symptoms or behaviors are clinically significant, as evidenced by one or both of
the following:
1. Marked distress that is out of proportion to the severity or intensity of the stressor,
taking into account the external context and the cultural factors that might influence
symptom severity and presentation.
2. Significant impairment in social, occupational, or other important areas of functioning.
C. The stress-related disturbance does not meet the criteria for another mental disorder
and is not merely an exacerbation of a preexisting mental disorder.
55. • D. The symptoms do not represent normal bereavement.
E. Once the stressor or its consequences have terminated, the symptoms do not persist
for more than an additional 6 months.
Specify whether:
309.0 (F43.21) With depressed mood: Low mood, tearfulness, or feelings of
hopelessness are predominant.
309.24 (F43.22) With anxiety: Nervousness, worry, jitteriness, or separation anxiety
is predominant.
309.28 (F43.23) With mixed anxiety and depressed mood: A combination of depression
and anxiety is predominant.
309.3 (F43.24) With disturbance of conduct: Disturbance of conduct is predominant.
309.4 (F43.25) With mixed disturbance of emotions and conduct: Both emotional
symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant.
309.9 (F43.20) Unspecified: For maladaptive reactions that are not classifiable as one
of the specific subtypes of adjustment disorder.
57. Treatment
Psychotherapy
• Treatment of choice
• Group therapy
• Supportive psychotherapy to enhance the capacity to cope with a
stressor that cannot be reduced or removed, and to establish
sufficient support (esp. practical help, e.g. provision of
carers/childcare, financial support and benefits, occupational therapy
[OT] assessment, contact with specific support groups) to maximize
adaption.
58. • Ventilation/verbalization of feelings may be useful in preventing
maladaptive behaviours (e.g. social isolation, destructive behaviours,
suicidal acts)
Pharmacological
• Pharmacological: the use of antidepressants or anxiolytics/hypnotics
may be appropriate where symptoms are persistent and distressing
(e.g. prolonged depression/dysphoria), or where psychological
interventions have proved unsuccessful.
59. Prognosis
• 5-yr follow-up suggests recovery in approx. 70% (adolescents: 40%),
intervening problems in 10% (adolescents: 15%), and development of
major psychiatric problems in 20% (adolescents: 45%).
• In adults, further psychiatric problems are usually depression/anxiety
or alcohol-related problems.
60. Bereavement and Grief
Definitions
• Bereavement: any loss event, usually the death of someone.
• Grief: feelings, thoughts, and behaviour associated with
bereavement.
61. Normal Grief
• Symptoms include: Disbelief, shock, numbness, and feelings of unreality;
anger; feelings of guilt; sadness and tearfulness; preoccupation with the
deceased; disturbed sleep and appetite and, occasionally, weight loss;
seeing or hearing the voice of the deceased. Usually these symptoms
gradually reduce in intensity, with acceptance of the loss and readjustment.
• A typical ‘grief reaction’ lasts up to 12mths (mean 6mths), but cultural
differences exist. Intensity of grief is usually greatest for the loss of a child,
then spouse or partner, then parent.
62. Abnormal (pathological/morbid/complicated) grief
• Very intense, prolonged, delayed (or absent), or where symptoms
outside normal range are seen, e.g. preoccupation with feelings of
worthlessness, thoughts of death, excessive guilt, marked slowing of
thoughts and movements, a prolonged period of not being able to
function normally, hallucinatory experiences (other than the image
or voice of the deceased
63. Dissociative Disorders
• Dissociative disorders are characterized by a disruption of and/or
discontinuity in the normal integration of consciousness, memory, identity,
emotion, perception, body representation, motor control, and behavior.
• Dissociative symptoms are experienced as a) unbidden intrusions into
awareness and behavior, with accompanying losses of continuity in
subjective experience (i.e., "positive“ dissociative symptoms such as
fragmentation of identity, depersonalization, and derealization) and/or b)
inability to access information or to control mental functions that normally
are readily amenable to access or control (i.e., '"negative" dissociative
symptoms such as amnesia).
64. • The dissociative disorders are frequently found in the aftermath of
trauma though they are not part of the trauma and stressor related
Disorders.
• The disorders include dissociative identity disorder, dissociative
amnesia, depersonalization/derealization disorder, other specified
dissociative disorder, and unspecified dissociative disorder.
65. Dissociative Identity Disorder
• Previously known as Multiple Personality Disorder
• It is characterized by the presence of two or more distinct identities
or personality states.
• M:F Range from 5:1 to 9:1
66. Aetiology
• Dissociative identity disorder is strongly linked to severe experiences
of early childhood trauma, usually maltreatment.
• Physical and sexual abuse are the most frequently reported sources
of childhood trauma.
• Genetic contribution in the aetiology not as marked
67. Diagnostic Criteria
• A. Disruption of identity characterized by two or more distinct personality states, which
may be described in some cultures as an experience of possession. The disruption in
identity involves marked discontinuity in sense of self and sense of agency, accompanied
by related alterations in affect, behavior, consciousness, memory, perception,
cognition, and/or sensory-motor functioning. These signs and symptoms may be
observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/
or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious
practice.
Note: In children, the symptoms are not better explained by imaginary playmates or
other fantasy play.
E. The symptoms are not attributable to the physiological effects of a substance (e.g.,
blackouts or chaotic behavior during alcohol intoxication) or another medical condition
(e.g., complex partial seizures)
68. • The overtness or covertness of these personality states, however,
varies as a function of psychological motivation, current level of
stress, culture, internal conflicts and dynamics, and emotional
resilience. Sustained periods of identity disruption may occur when
psychosocial pressures are severe and/or prolonged.
• Patients with dissociative disorder often report significant
gaps in autobiographical memory, especially for childhood
events.
70. Mx
• Psychotherapy: Psychoanalytic, Cognitive, behavioural and
hypnotherapy
• Pharmacotherapy: Antidepressants (SSRI, TCA, MAOi), Beta blockers,
Carbamazepine, Benzodiazepines, Atypical antipsychotics (for
intrusive symptoms)
• ECT: For some patients, ECT is helpful in ameliorating refractory mood
disorders and does not worsen dissociative memory problems.
• Expressive and Occupational therapy
• EMDR
71. Dissociative Amnesia
• The main feature of dissociative amnesia is an inability to recall important
personal information, usually of a traumatic or stressful nature, that is too
extensive to be explained by normal forgetfulness.
• Localized amnesia, a failure to recall events during a circumscribed period of
time, is the most common form of dissociative amnesia.
• In selective amnesia, the individual can recall some, but not all, of the events
during a circumscribed period of time. Thus, the individual may remember part of
a traumatic event but not other parts.
• Generalized amnesia, a complete loss of memory for one's life history, is rare.
Individuals with generalized amnesia may forget personal identity.
72. • In systematized amnesia, the individual loses memory for a specific
category of information (e.g., all memories relating to one's family, a
particular person, or childhood sexual abuse).
• In continuous amnesia, an individual forgets each new event as it
occurs.
73. Epidemiology
• The 12-month prevalence for dissociative amnesia among adults in a
small U.S. community study was 1.8% (1.0% for males; 2.6% for
females).
• Single or repeated traumatic experiences (e.g., war, childhood
maltreatment, natural disaster, internment in concentration camps,
genocide) are common antecedents.
74. Diagnostic Criteria
• A. An inability to recall important autobiographical information, usually of
a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
Note: Dissociative amnesia most often consists of localized or selective
amnesia for a specific event or events; or generalized amnesia for identity
and life history.
B. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a
substance (e.g., alcohol or other drug of abuse, a medication) or a
neurological or other medical condition
(e.g., partial complex seizures, transient global amnesia, sequelae of a
closed head injury/traumatic brain injury, other neurological condition).
75. • D. The disturbance is not better explained by dissociative identity disorder,
posttraumatic stress disorder, acute stress disorder, somatic symptom
disorder, or major or mild neurocognitive disorder.
Coding note: The code for dissociative amnesia without dissociative fugue
is 300.12
(F44.0). The code for dissociative amnesia with dissociative fugue is 300.13
(F44.1).
Specify if ;
300.13 (F44.1) With dissociative fugue: Apparently purposeful travel or
bewildered wandering that is associated with amnesia for identity or for
other important autobiographical information.
77. Rx
• Cognitive Therapy
• Hypnosis
• Pharmacological facilitated interviews using Benzodiazepines,
Thiopental
• Group psychotherapy
78. Depersonalization/Derealization Disorder
• Depersonalization is defined as the persistent or recurrent feeling of
detachment or estrangement from one's self.
• Derealization refers to feelings of unreality or of being detached from
one's environment.
80. Aetiology
• Psychodynamic: An affective response in defense of the ego
• Traumatic stress
• Neurobiological theories: Serotonergic involvement
81. Diagnostic Criteria
• A. The presence of persistent or recurrent experiences of
depersonalization, derealization, or both:
1. Depersonalization: Experiences of unreality, detachment, or being an
outside observer with respect to one’s thoughts, feelings, sensations, body,
or actions (e.g., perceptual alterations, distorted sense of time, unreal or
absent self, emotional and/or physical numbing).
2. Derealization: Experiences of unreality or detachment with respect to
surroundings (e.g., individuals or objects are experienced as unreal,
dreamlike, foggy, lifeless, or visually distorted).
B. During the depersonalization or derealization experiences, reality testing
remains intact.
82. • C. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The disturbance is not attributable to the physiological effects of a
substance (e.g., a
drug of abuse, medication) or another medical condition (e.g.,
seizures).
E. The disturbance is not better explained by another mental disorder,
such as schizophrenia, panic disorder, major depressive disorder,
acute stress disorder, posttraumatic stress disorder, or another
dissociative disorder.
85. Dissociative Fugue
• Diagnosed on a subtype (specifier) of dissociative amnesia.
• Dissociative fugue can be seen in patients with both dissociative
amnesia and dissociative identity disorder.
• Dissociative fugue is described as sudden, unexpected travel
away from home or one's customary place of daily activities,
with inability to recall some or all of one's past.
86. Other Specified Dissociative Disorders
• This category applies to presentations in which symptoms
characteristic of a dissociative disorder that cause clinically significant
distress or impairment in social, occupational, or other important
areas of functioning predominate but do not meet the full criteria for
any of the disorders in the dissociative disorders diagnostic class.
87. • 1. Chronic and recurrent syndromes of mixed dissociative symptoms: This
category includes identity disturbance associated with less-than-marked
discontinuities in sense of self and agency, or alterations of identity or
episodes of possession in an individual who reports no dissociative
amnesia.
2. Identity disturbance due to prolonged and intense coercive persuasion:
Individuals who have been subjected to intense coercive persuasion (e.g.,
brainwashing, thought reform, indoctrination while captive, torture, long-
term political imprisonment, recruitment by sects/cults or by terror
organizations) may present with prolonged changes in, or conscious
questioning of, their identity.
88. 3. Acute dissociative reactions to stressful events: This category is for acute,
transient conditions that typically last less than 1 month, and sometimes only a few
hours or days. These conditions are characterized by constriction of consciousness;
depersonalization; derealization; perceptual disturbances (e.g., time slowing,
macropsia);
4.Dissociative trance: This condition is characterized by an acute narrowing or
complete loss of awareness of immediate surroundings that manifests as profound
unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness
may be accompanied by minor stereotyped behaviors (e.g., finger movements) of
which the individual is unaware and/or that he or she cannot control, as well as
transient paralysis or loss of consciousness. The dissociative trance is not a normal
part of a broadly accepted collective cultural or religious practice.
89. Unspecified Dissociative Disorder
• This category applies to presentations in which symptoms
characteristic of a dissociative disorder that cause clinically significant
distress or impairment in social, occupational, or other important
areas of functioning predominate but do not meet the full criteria for
any of the disorders in the dissociative disorders diagnostic class.
• The unspecified dissociative disorder category is used in situations in
which the clinician chooses not to specify the reason that the criteria
are not met for a specific dissociative disorder, and includes
presentations for which there is insufficient information to make a
more specific diagnosis (e.g., in emergency room settings).
