Day # 113: Clinical Pearls for Dissociative Disorders

Up to this point we have covered core features of dissociative disorders, diagnostic criteria, epidemiology, risk factors, and pathogenesis. Today we are going to have a discussion on clinical pearls for dissociative disorders which will include tips on the clinical interview, validated questionnaires, and differential diagnosis. Let's get started.

Today's Content Level: Intermediate

REMINDER 1

Before we start our discussion it will be helpful to review the dissociative disorders. See full criteria on day # 111: Intro to Dissociative Disorders.

• Dissociative Identity Disorder (DID): Identity disruption manifested as the existence of ≥2 personality states. Also includes recurrent memory lapses.

• Dissociative Amnesia: Inability to recall important autobiographical information that is inconsistent with ordinary forgetfulness.

• Depersonalization / Derealization Disorder: Depersonalization = detachment from self such as a sense of unreality or detachment from one’s body, thoughts, feelings, or actions. Derealization = detachment or sense of unreality from surroundings.

• Other Specified Dissociative Disorder: Do not meet the full criteria for a specific dissociative disorder. Examples include dissociative trance, identity disturbance due to prolonged and intense coercive persuasion, and chronic and recurrent syndromes of mixed dissociative symptoms.

CLINICAL INTERVIEW

Here are some sample questions to give you an idea for how you can screen for dissociative symptoms:

• Do you ever have blackouts? Blank spells? Memory lapses?

• Some people find that they have no memory for some important events in their lives (for example, a wedding or graduation). What percentage of the time does this happen to you? (DES # 9)

• Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something as if they were looking at another person. How often does this happen to you? (DES # 7)

• Do you ever have the experience of feeling that other people, objects, and the world around you are not real? How often does this happen?

• Have you ever traveled a considerable distance without recollection of how you did this or where you went exactly?

• Do you ever feel that there is another person or persons inside you? (DDIS # 99)

Overview of the clinical interview: 2, 3, 4

• Clarify onset/duration of symptoms with patient and family.

• Screen for traumatic events that may have occurred during childhood or earlier in life. Childhood physical or sexual abuse or neglect is present in 80-90% of patients with dissociative disorders.

• Screen for all dissociative disorders-> identity disturbances, derealization, depersonalization, amnesia and fugue states.

• Determine how their symptoms are affecting their function to include school/work/social/relationship difficulties, time spent in dissociative experiences, poor self care, consequences of behaviors, etc.

• Assess the patients cultural norms. Some experiences such as a trance or possession may be a normative cultural-bound experience.

• Psychiatric review of systems - particular attention to post-traumatic stress disorder (with dissociation), depressive disorders, bipolar disorder, psychotic disorders, anxiety disorders, and personality disorders (particularly borderline PD).

• Substance use - determine if comorbid substance abuse. Distinguish dissociative disorders from the physiologic effects of a substance.

• Medical and family history - screen for recent illness and medical co-morbidities particularly seizure disorders.

• Risk assessment for suicide and aggression - risk/safety assessments covered in full here.

• Optional rating scales: Dissociative Experiences Scale (DES); Dissociative Disorders Interview Schedule (DDIS); Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R); Multidimensional Inventory of Dissociation (MID).

DIFFERENTIAL DIAGNOSIS 5

•Before making any psychiatric diagnosis it is important to consider other related disorders and appropriately determine the best fit according to the patients symptoms, biological, psychological, and social factors. Also, remember that dissociative disorders are highly comorbid with other psychiatric disorders and general medical conditions. There are multiple reasons for this including shared genetic and environmental vulnerabilities, potential causal relationships, and consequences of treatment.

Differential diagnosis:

• Ordinary forgetfulness: common phenomenon that is benign, does not involve loss of biographical information, and unrelated to stressful events.

• Substance induced: dissociative events ("black outs") may occur in the context of repeated intoxication with alcohol or other substances / medications. Common recreational drugs that can cause dissociative symptoms include marijuana, hallucinogens, ketamine, ecstasy, and salvia.

• Neurocognitive disorders (dementia): memory deficits in dissociative amnesia are primarily for autobiographical information; intellectual and cognitive abilities are preserved. In neurocognitive disorders memory loss is accompanied with progressive changes in cognitive, linguistic, affective, attentional, and behavioral disturbances.

• Amnestic disorders due to medical conditions: causes of organic amnestic disorders include traumatic brain injury (post-traumatic amnesia), Korsakoff's psychosis, cerebral vascular accident (CVA), postoperative amnesia, postinfectious amnesia, anoxic amnesia, and transient global amnesia.

• Malingering and Factitious disorder: there is no reliable method that accurately distinguishes dissociation from feigned symptoms. According to the DSM "feigned dissociation is more common in individ­uals with 1) acute, florid dissociative amnesia; 2) financial, sexual, or legal problems; or 3) a wish to escape stressful circumstances.

• Post-traumatic stress disorder: Some individuals with PTSD cannot recall part or all of a specific traumatic event. They may also experienced depersonalization or derealization. This is called PTSD with dissociative symptoms.

• Mood disorder: patients with depression may experience loss of concentration/memory, numbness, deadness, apathy, and sense of being in a dream.

• Anxiety disorder: depersonalization or derealization can occur in the context of a panic attack.

• Psychotic disorder: the presence of intact reality testing specifically regarding the dissociative symptoms is essential to differentiating depersonal­ ization/derealization disorder from psychotic disorders.

• Personality disorder: a significant number of patients with borderline personality disorder experience stress-related dissociation.

• Other medical conditions with presentations that may mimic dissociation: delirium, seizures, traumatic brain injury, brain tumors, metabolic abnormalities, migraines, vertigo, and Ménière's disease have been reported.

CONCLUSION

I hope you enjoyed these clinical pearls. Today's lesson was geared towards an intermediate audience, but I hope all of the readers got something out of today's topic.

Resources for today's post include: Kaplan & Sadock's Synopsis of Psychiatry, DSM-5, First Aid for the Psychiatry Clerkship, and Pocket Psychiatry.

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