Table of Contents
In the Dissociative Disorders, there is dissociation between thoughts, memories, actions, emotions and sense of oneself. They are characterized by escape from reality. They affect perception, behavior and feelings. In whole they disturb every aspect of mental functioning.
People from all races, different age groups are affected equally. All regions and socioeconomic groups are equally affected.
There is 2 % incidence that females are more likely to be diagnosed as compared to males.
Dissociative Identity Disorder
Definition of Dissociative Identity Disorder
Dissociative identity disorder is a condition that is characterized by the presence of two or more distinct personalities. The mere presence of distinct personalities is not enough for the diagnosis, as dissociation is needed for the diagnosis to be made.
Patients should show amnesia of certain life events that are not expected to be forgotten, impaired behavior, affect, consciousness and cognitive impairment. Memory loss and memory gaps are also essential for the diagnosis.
Etiology of Dissociative Identity Disorder
The most likely etiology for dissociative identity disorder is childhood trauma. Sexual abuse, physical abuse or other forms of trauma need to be continuous and intense for dissociation to happen. On the other hand, rape victims who have one acute episode of significant trauma can also have dissociation symptoms and dissociative amnesia, but rarely dissociative identity disorder.
The exact brain changes in dissociative identity disorder are not known, but recent structural and functional brain imaging studies have pointed towards hippocampal, temporal, prefrontal and medial frontal lobe abnormalities.
Management of Dissociative Identity Disorder
Some psychiatrists believe that the identification of the traumatic event in any case of dissociation is essential; therefore, hypnosis or drug-assisted interviews can be used to identify the traumatic event that might have caused dissociation. Patients with dissociative identity disorder should undergo psychodynamic therapy with the aim of fusing as many personalities as possible in one coherent personality that the patient can later assume.
Stable fusion is dependent on the patient’s doctor rapport and long-term treatment; therefore, continuous support and treatment are recommended. Stable fusion has been reported in one-third of the cases after a decade of successful fusion.
Definition of Dissociative Amnesia
Dissociative amnesia is a condition that is characterized by the loss of certain autobiographical memories that the patient is not expected to forget. Dissociative amnesia can be localized to certain traumatic life events or very rarely generalized.
Generalized amnesia is more common after natural disasters and at wartime, whereas localized amnesia can be seen after rape.
Etiology of Dissociative Amnesia
The exact etiology of dissociative amnesia is unknown, but acute trauma or stress is usually involved. The most common stressors include rape, wars and natural disasters.
Certain communities have a higher prevalence of dissociative amnesia compared to the general population such as sex workers and strippers. This can be explained by the increased risk of experiencing sexual or physical abuse in these lines of work. Drug addicts are also more likely to develop dissociative amnesia compared to the general population.
Management of Dissociative Amnesia
The management of dissociative amnesia is dependent on the identification of the cause of the dissociation. Drug-assisted interviews or hypnosis might be needed to help the patient recall the traumatic events. Once the patient remembers the causative events, he or she might be overwhelmed and the risk of suicide becomes very high.
Antidepressants and anxiolytic therapy have been used in patients with dissociative amnesia. The goal is to treat the associated depression and anxiety, but these treatments will not fix the dissociation. Psychotherapy and remembering the traumatic events are the only ways to recover from dissociative amnesia.
Patients with severe dissociative amnesia might create a completely new identity to compensate for the lost identity.
Definition of Dissociative Fugue
A dissociative fugue is a severe form of dissociative amnesia that is characterized by the complete loss of one’s own identity and fleeing from one’s normal surroundings. Wandering and traveling are very essential for fugue to be diagnosed; therefore, patients with complete loss of identity but without fleeing behavior cannot be diagnosed with fugue but may be diagnosed with severe dissociative amnesia.
Etiology of Dissociative Fugue
Dissociative fugue has also been linked to severe traumatic life events such as rape, wars or other stressors. Patients with fugue have been found to have abnormal frontal and temporal function on brain imaging studies.
Dissociative fugue is very rare compared to localized dissociative amnesia. Recovery from dissociative fugue and acute severe dissociative amnesia is good.
Treatment of Dissociative Fugue
Patients with dissociative fugue should be admitted to the hospital. Electroconvulsive therapy is not very useful in such cases. Instead, emphasis should be put on helping the patient remember the traumatic event that led to this state in the first place.
Psychodynamic therapy, drug-assisted interviews, and hypnosis can be used to define the trigger. Once the patient recalls the traumatic event, he or she might be overwhelmed and the risk of suicide is high.
Patients with fugue can also have post-traumatic stress disorder or other anxiety disorders; therefore, benzodiazepines might be needed. Additionally, such patients might be depressed.
Diagnosis is made chiefly on the basis of review of symptoms and past history
Common Differential Diagnoses of Dissociative Disorders
Major Depressive Disorder
Patients with dissociative disorders very commonly have depressive symptoms. Major depressive disorder might present with amnesia. The main difference between depression-related amnesia and a dissociative disorder is that the information lost in the latter is inconsistent with forgetting.
Patients with dissociative personality disorder might be misdiagnosed with bipolar disorders. Patients with bipolar disorders have significant fluctuations in their personality and mood. They can present with psychosis and mania; however, dissociation is not present in bipolar disorders.
Patients with dissociative personality disorder might be misdiagnosed with schizophrenia. It is important to understand that patients with a dissociative personality disorder do not hallucinate, do not have severe and bizarre delusions and, most importantly, cannot remember what they do or did when another personality takes over.
Drug Abuse and Alcohol Intoxication
We have explained that the risk of dissociative disorders is higher among drug addicts, but it is also important to note that patients with dissociative symptoms might be simply intoxicated. Alcohol intoxication can cause blackouts and memory gaps. Cocaine use and the use of other recreational drugs have also been linked to dissociative symptoms.
Seizure’s Related Disorders
Focal seizures with dyscognitive impairment can resemble dissociative disorders in that the patient fails to recall certain events during the seizure. Patients with a history of blackouts, but without any other symptoms or signs suggestive of a dissociative disorder, should be evaluated for the possibility of a seizure disorder.
Complications of Dissociative Disorders
Suicidal attempts and self-injurious behavior are common in these patients. 70% OPD patients with dissociative disorder are reported to have suicide attempts.
Prognosis of Dissociative Disorders
Prognosis depends on severity of symptoms!
Patients with mainly dissociative and post traumatic symptoms respond well to progressive treatment.
Patients with other associated disorders such as personality disorder, eating disorder, any substance abuse and mood disorder show slow improvement and treatment is less successful.
Patients with severe symptoms along with coexisting disorders and deeply attached to drug abuse are challenging to treat and are incurable. Treatment only helps to control the symptoms temporarily with remissions.