Dissociative disorders

• What is Dissociative Disorders
• Statistics on Dissociative Disorders
• Risk Factors for Dissociative Disorders
• Progression of Dissociative Disorders
• Symptoms of Dissociative Disorders
• Clinical Examination of Dissociative Disorders
• How is Dissociative Disorders Diagnosed?
• Prognosis of Dissociative Disorders
• How is Dissociative Disorders Treated?
• Dissociative Disorders References

What is Dissociative Disorders

Dissociative disorders (as described in the DSM-IV-TR classification system) are disorder with the essential feature of disrupted “consciousness, memory, identity or perception of the environment.” The most common feature is dissociative phenomenon, where patients may assume an entirely new, or multiple types of personality. There are four major types of this disorder:

1. Dissociative Amnesia: The loss of personal memory in the absence of impaired ability to learn new material.
2. Dissociative Fugue: The unexpected and sudden travel away from home, associated with an inability to recall their previous identity. Patients will often assume a new identity.
3. Dissociative Personality Disorder: AKA multiple personality disorder, the patient will assume different identities within the same person.
4. Depersonalisation disorder: Recurrent sensation of being detached from oneself, as if mechanical or within a dream.

Statistics on Dissociative Disorders

There is an approximate prevalence of 3-6 per 1000 in women, with a lower prevalence in men. Most cases begin before the age of 35 years. Dissociation is unusual in the elderly.

Risk Factors for Dissociative Disorders

The most important predisposing factor in this group of conditions is the occurrence of emotional trauma at an early age. This may involve sexual, physical or psychological abuse. The heavy use of alcohol, presence of psychiatric disease and presence of personality disorder, are also risk factors for the development of a dissociative disorder.

The moderate to severe dissociation that occurs in patients with dissociative disorders is understood to result from a set of causes:

• An innate ability to dissociate easily.
• Repeated episodes of severe physical or sexual abuse in childhood.
• The lack of a supportive or comforting person to counteract abusive relative(s).
• The influence of other relatives with dissociative symptoms or disorders.

Progression of Dissociative Disorders

The natural history of dissociative disorders varies by type.

1. Dissociative Amnesia: This condition will present in adolescence, usually terminate abruptly and recur infrequently within affected patients.
2. Dissociative Fugue: The course if usually brief, lasting up to a few days. In few cases, the condition may last for months, but recovery occurs rapidly and spontaneously with recurrences a rare phenomenon.
3. Dissociative Personality Disorder: The course is chronic and severe. Recovery may occur, but will typically be incomplete.
4. Depersonalisation disorder: Usually sudden onset under the age of 40 years, tending to follow a persistent and chronic course.

How is Dissociative Disorders Diagnosed?

When a doctor is evaluating a patient with dissociative symptoms, he or she will first rule out physical conditions that sometimes produce amnesia, depersonalization, or derealization. These physical conditions include epilepsy, head injuries, brain disease, side effects of medications, substance abuse or intoxication, AIDS dementia complex, or recent periods of extreme physical stress and sleeplessness. In some cases, the doctor may give the patient an electroencephalogram (EEG) to exclude epilepsy or other seizure disorders.

If the patient appears to be physically normal, the doctor will rule out psychotic disturbances, including schizophrenia.

Prognosis of Dissociative Disorders

The prognosis of dissociative disorders varies by type. Dissociative amnesia and dissociative fugue have a good prognosis, resolving spontaenously and recurring rarely.

Dissociative identity disorder and depersonalisation disorder are chronic forms of the condition, that tend to persist throughout life requiring constant monitoring and treatment.

How is Dissociative Disorders Treated?

The requirement for therapy and the choice of approach depends on the type of dissociative disorder present:

• Dissociative amnesia and dissociative fugue will usually recover without treatment.
• Dissociative personality disorder andd depersonalisation disorder will usually require long term therapy for control of psychiatric symptoms.

Modes of therapy include:

1. Hypnosis : This may permit patients to recall aspects of their previous identity and true personality.
2. Drug-assisted interview: The use of certain sedatives during apatient interview may increase the likelihood of the patient recalling their true personality and experiencing an improvement in their condition.
3. Psychotherapy: Psychiatric techniques may reduce the severity of psychiatric symptoms and improve the likelihood of recovery.

Dissociative Disorders References

1. Kumar P, Clark M. Clinical Medicine. Fourth Ed. WB Saunders, 2002.
2. National Institute of Mental Health (US).
3. Sadock BJ, Sadock VA. Kaplan and Sadock’s Pocket Handbook of Clinical Psychiatry 3rd Edition. Lippincott Williams and Wilkins, Philadelphia USA.