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MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
Psychiatry II
Dissociative Disorders & Eating Disorders
Page 2 of 6
• Trauma 3. History gathering and mapping
• Physical and/or sexual abuse 4. Metabolism of trauma
– 85-97% among those with Dissociative 5. Working through of recovered materials across the
Identity Disorders alters
• Genetic Factors 6. Integration-Resolution
Clinical Signs and Symptoms: 7. Learning new coping skills
• Memory symptoms 8. Solidification
• Processing symptoms 9. Follow-Up
• Dissociative alterations of identity Principles for Successful treatment
• Child and adolescent presentations Secure treatment frame and firm, consistent
Diagnosis: boundaries.
DSM-IV Criteria for DID Focus on mastery and patient’s active participation.
A. The presence of 2 or more distinct identities or Based on strong therapeutic alliance.
personality states with its own relatively enduring
Uncovering and abreaction.
pattern of perceiving, relating to, and thinking about
Collaboration of the alters.
the environment and self
B. At least 2 or 3 identity states take recurrent control Clear and straight communication.
of the person’s behavior Consistency across all alters.
C. Inability to recall important personal information that Restore morale and inculcate realistic hope.
is too extensive to be explained by ordinary Rule of thirds.
forgetfulness Responsibility.
D. The disturbance is not due to the direct Taking a warm stance.
physiological effects of a substance or a general Correcting cognitive errors.
medical condition
DISSOCIATIVE FUGUE
Differential Diagnosis: Epidemiology:
• Imitative Dissociative Identity Disorder
• Genuine Dissociative Identity Disorder
• Rare disorder
• Schizophrenia and other psychoses • Estimated to affect just 0.2% of the population, nearly
• Rapid-cycling Mood Disorder all of them adults.
• Borderline Personality Disorder • Prevalence increases significantly following a
• Malingering and Factitious Disorder stressful life event, such as wartime experience,
• Partial Complex Seizure Disorder accidents an natural disasters
• Posttraumatic Stress Disorder Etiology:
Course: • Stressor or traumatic event (most common): person
Children may be physically and mentally escaping a
Boys>Girls threatening environment or intolerable situation
Sxs: trancelike accompanied by depression,
amnesic period, hallucinatory voices, • Chronic Stress (Bankruptcy)
disavowal of behaviors, suicidal • Depression or Dysphoria
• Histories of Childhood Abuse or Neglect (not yet
Adolescents
established)
Girls>Boys
Clinical Features:
2 Symptom pattern: • Last from minutes to months
1. Chaotic life with promiscuity, drug use, suicide attempts • May be multiple
2. Withdrawal and childlike behaviors • “Waking fugue”
Males: trouble with law or school officials • Brief and involve only short distances in children
Prognosis: • May be terminated by perplexity, confusion, trance-
Determining variables: number, type, chronicity like behaviors, depersonalization, derealization,
If diagnosed early, children have excellent prognosis conversion symptoms or generalized dissociative
Adolescents have poorer prognosis than children and amnesia
adults • May display mood disorder symptoms, intense
Adult prognosis is dependent on attitude toward suicidal ideation, PTSD and other anxiety disorder
treatment symptoms
Number of alter personalities has moderate effects • Alter identity created under auspices the patient lives
on outcome for a period of time
Poorer in patients with comorbid illness Diagnosis:
Treatment: DSM-IV Criteria for Dissociative Fugue
Insight-Oriented A. Predominant disturbance is sudden, travel away
Psychotherapy from home or work place, with inability to recall
one’s past
Hypnosis
B. Confusion about personal identity or assumes new
Pharmacotherapy? identity (partial or complete)
Stages of Therapy for DID
1. Establishing psychotherapy
2. Preliminary interventions
Psychiatry II
Dissociative Disorders & Eating Disorders
Page 3 of 6
C. Does not occur exclusively during dissociative – Mean age of onset: 16 years old
identity disorder and not due to GMC or effects of Etiology:
substance use 1. Psychodynamic - emphasizes the disintegration of the
D. Cause clinical distress on areas of functioning ego; an affective response in defense of the ego
- triggered by overwhelming painful experiences or
Differential Diagnosis: conflictual impulses
• Dementia 2. Traumatic Stress – 1/3 – 1/2 of patients report histories of
• Delirium significant trauma
• Complex partial epilepsy - as much as 60% of accident victims
• Dissociative amnesia 3. Neurobioligical Theories - N-Methyl-D-aspartate (NMDA)
• Malingering subtype of the glutamate receptor as central to the
• General medical condition genesis of depersonalization symptoms
• Toxic and substance-related disorders - serotoninergic involvement
• Bipolar disorder Diagnosis:
• Schizoaffective disorder DSM-IV-TR Criteria for Depersonalization Disorder
• Schizophrenia A. Persistent or recurrent experiences of feeling
Course & Prognosis: detached from, and as if one is an outside observer
• Lasts for hours to days of, one’s mental process or body (e.g., feeling like
• Less commonly months one is in a dream).
• Involves extensive travel (thousands of miles) B. During the depersonalization experience, reality
• Spontaneous recovery testing remains intact.
• Possible to recur C. The depersonalization causes clinically significant
Treatment: distress or impairment in social, occupational, or
• Most widely accepted technique requires mixture of other important areas of functioning.
abreactions of the past trauma and integration of the D. The depersonalization experience does not occur
trauma into a cohesive self that no longer requires exclusively during the course of another mental
fragmentation to deal with the trauma disorder, such as schizophrenia, panic disorder,
• TOC: Expressive-Supportive Psychodynamic acute stress disorder, o another dissociative
Psychotherapy disorder, and is not due to the direct physiological
• Psychotherapy-help patients incorporate precipitating effects of a substance (e.g., temporal lobe
stressors in a healthy manner epilepsy).
• Psychiatric and drug-assisted interviewing
Clinical Features:
• Hypnosis-helps to reveal the psychological stressors • central characteristic: quality of unreality and
that precipitated the fugue episode estrangement
• feel different and no longer appear to have any
DEPERSONALIZATION DISORDER relation or significance to the person parts of the
• a persistent or recurrent alteration in the perception of body or the entire physical being may seem foreign as
self to the extent that a person’s sense of his or her well as mental operations and accustomed behavior.
own reality is temporarily lost
• Feeling of “mechanical, “in a dream”, “detached from Hemidepersonalization – feeling that half of the body is
their bodies” unreal or does not exist may be related to
• ego-dystonic episodes contralateral parietal lobe disease.
• patients realize unreality of symptoms
• Anxiety is often included
Depersonalization vs Derealization • Complains of distortions in their senses of time and
Depersonalization: feeling that the body or the personal space
self is strange and unreal • May feel that the point of consciousness is outside
their bodies—as if they were totally different people.
Derealization: perception of objects in the external world • Reduplicative paramnesia / double orientation -
as strange and unreal
believing that the patient is in two places at the same
time.
Epidemiology:
• Patient is aware of the disturbances in their sense of
• An occasional isolated experience
reality.
• Common and not necessarily pathological
Differential Diagnosis:
• Occur in 70% of population
Temporal Lobe Seizures ( epilepsy )
– No significant difference between men and
Atypical forms of Migraine and Headache
women
Schizophrenia
– Children: develop capacity for self-
Acute Stress Disorder
awareness
Panic Disorder
– Adults: temporary sense of unreality while
Another Dissociative Disorder – Fugue - Identity
traveling
Drug Abuse
• Recent studies
– Women 2x as frequent as in men
Course and Prognosis:
– Rare in >40 years old
Psychiatry II
Dissociative Disorders & Eating Disorders
Page 4 of 6
• Symptoms appear suddenly. Few report a gradual D. In postmenarcheal females, amenorrhea
onset.
• Start = 15 & 30 y/o, but can be seen as young as 10
• Occur less frequently after age 30 Clinical Features:
• In more than 50% of cases, it tends to be long lasting. • Physchological/Behavioral
• It usually run a steady course w/o significant • Physical
fluctuations in intensity
• Little is known about precipitating factors
• Observed to begin during a period of relaxation after a
person experienced psychological stress.
• Sometimes accompanied w/ acute anxiety, frequently
by hyperventilation.
Treatment:
• usually recommended only if the disorder persists, Differential Diagnosis:
recurs, or causes distress
• Any stresses associated with the beginning of the Disorder Similarities Distinguishing
depersonalization disorder must also be addressed Features
• Approaches:
– Psychotherapy Depressive Depressed Decreased appetite;
– Cognitive therapy Disorders feelings, crying depressive agitation; not
– Medication spells, sleep preoccupied with recipes,
– Family therapy disturbance, caloric content of foods,
– Creative therapies (art therapy, music obsessive and preparation of
therapy) ruminations, gourmet feasts; no
– Clinical hypnosis occasional suicidal intense fear of obesity or
thoughts disturbance of body
image
EATING DISORDERS
ANOREXIA NERVOSA
• Greek term for “loss of appetite” Somatization Weight Weight loss not as severe
• a Latin word implying nervous origin. Disorder fluctuations, as that of anorexia
• Anorexia nervosa is a syndrome characterized by vomiting, peculiar nervosa; does not
three essential criteria: food handling express morbid fear of
– Self-induced starvation to a significant becoming overweight
degree
– Relentless drive for thinness or a morbid fear
of fatness
– Presence of medical signs and symptoms
resulting from starvation Schizophrenia Bizarre eating Delusions about food are
• Anorexia nervosa is often associated with habits seldom concerned with
disturbances of body image caloric content; they
Types: believe to be poisoned;
Restricting Type rarely preoccupied with a
fear of becoming obese;
Binge-Eating/Purging Type do not have hyperactivity
Epidemiology:
• 4 percent of adolescent and young adult students.
• Female > male
• The most common ages of onset: Bulimia Nervosa begin after a more concerned about
• Midteens period of dieting by pleasing others, being
people who are attractive to others, and
• DSM-IV-TR: between 14 and 18 years fearful of becoming having intimate
• Up to 5% have the onset early 20s. obese, driven to relationships; more
Etiology: become thin, sexually experienced and
• Biological Factors preoccupied with active; display fewer of
• Social Factors food, weight, and the obsessive qualities;
• Psychological & psychodyanamic Factors appearance, and more likely to have long
Diagnosis: struggling with histories of mood swings,
DSM-IV-TR Criteria feelings of becoming easily
A. Refusal to maintain body weight at or above a depression, frustrated or bored, and
minimally normal weight for age and height anxiety, and the have trouble coping
B. Intense fear of gaining weight or becoming fat, even need to be perfect; effectively or controlling
though underweight. disturbed attitudes their impulses; more
C. Disturbance in the way in which one's body weight or towards eating medical complications
shape is experienced, undue influence of body
weight or shape on self-evaluation, or denial of the
seriousness of the current low body weight.
Psychiatry II
Dissociative Disorders & Eating Disorders
Page 5 of 6
Treatment:
COGNITIVE AND BEHAVIORAL THERAPY
◊ 18-20 sessions over 5-6 mos
1. Interrupt the self maintaining behavioral cycle of self
bingeing and dieting
2. Alter the individuals dysfunctional conditions; belies
about food, weight, body image and overall self-
concept
DYNAMIC PSYCHOTHERAPY
PSYCHOTHERAPY
ANTIDEPRESSANTS
SEROTONIN UPTAKE INHIBITORS
• FLUOXETINE (60-80 mg/day)
• Imipramine (Tofranil)
• Desipramine (Norpramine)
• MAOIs
By OUTPATIENT TREATMENT
◊Needs hospitalization if:
• Exhibits additional psychiatric
symptoms: suicidal and substance
abuse
• Has electrolyte and metabolic
disturbance
First line tx: PSYCHOTHERAPY