Today we will cover elements of the mental status exam that are particularly important in dissociative disorders. These are important clues that will help you with diagnosis as well as gauge treatment response. Let's get started.
Today's Content Level: Beginner; Intermediate
REMINDER OF THE MENTAL STATUS EXAM COMPONENTS
APPEARANCE & BEHAVIOR 1
•Write this section with the goal of later being able to reconjure the person's most salient features on physical appearance and their behavior.
There is no one-size-fits-all when it comes to appearance and behavior of patients with dissociative disorders.
Many patients with dissociative disorder are suffering on the inside but still able to present themselves as well-kept and presentable.
Some patients with chronic debilitating dissociative symptoms may lack the focus and energy to bathe or properly groom and dress themselves or appear disheveled.
Some patients may present acutely in a dramatic clinical disturbance that results in the patient being brought quickly to medical attention. This may occur in those who have experienced extreme acute trauma or in the context of profound emotional stress or intrapsychic conflict. These patients may present with florid alterations in consciousness, somatoform symptoms, depersonalization, derealization, trance states, spontaneous age regression, and ongoing anterograde dissociative amnesia.
Some patients may have comorbid anxiety and present with "psychomotor agitation" associated with feelings of inner tension (hand wringing, hair pulling, pulling of clothes, pacing, fidgeting, hand or voice tremor, inability to sit still, avoidance, or hyper-vigilance.
Some patients may have comorbid depression and present with "psychomotor depression" which can be seen as generalized slowing of movements and speech (stooped posture, minimal spontaneous movements, downcast gaze, minimal eye contact with interviewer). Also observe for evidence of self-harm such as cut marks, burns, or scars.
SPEECH / LANGUAGE
•Pay attention to rate, tone, volume, and rhythm of speech.
•Patients with severe comorbid anxiety may have difficulty speaking such as stammering or a vocal tremor. Patients with comorbid depression may have decreased rate and volume and variation in tone of speech (slow, soft, and monotone).
•In dissociative identity disorder (DID) there may be observable differences in speech, mannerisms, thoughts, and attitudes between multiple identities / personalities. Also, dissociative and conversion disorders may blur and difficulties with speech (dysphonia) have been rarely reported. 2
MOOD / AFFECT
•In many cases of dissociative disorders, the psychosocial environment out of which the symptoms develop is massively conflictual. Patients may experience intolerable emotions of shame, guilt, despair, rage, and desperation.
•Patient's may describe their mood in a number of ways such as anxious, afraid, absent, hopeless, distant, depressed, worthless, guilty, miserable, or exhausted.
•Other patients may express their suffering with vague phrases such as "nothing seems real" or "I feel dead" or "I feel like I'm falling" or "I'm standing outside of myself".
•The emotional range can vary. They may present as blunted or restricted which are reductions in the range and intensity of emotional expression. They may also be guarded, which means filtering their emotional expression and using caution in disclosing information. Those with significant increased arousal may show more lability and higher emotional expression when experiencing acute anxiety.
•Others, particularly depersonalized patients, may not adequately convey the distress they experience. While complaining bitterly about how this is ruining their life, they may nonetheless appear remarkably undistressed.
THOUGHT PROCESS / THOUGHT CONTENT 3
•Disorders in thought process relate to the way in which ideas and languages are formulated and organized. Dissociative disorders do not typically cause a disorganized thought process in the same way that psychosis does.
Depression and suicidal thoughts are reported in many patients. Most patients with dissociative disorders meet criteria for a mood disorder, usually one of the depression spectrum disorders. Considerable overlap may exist between PTSD symptoms of anxiety, disturbed sleep, and dysphoria and mood disorder symptoms. Obsessive-compulsive personality traits are also common in dissociative identity disorder as well as a subgroup manifesting OCD symptoms.
Thought content can commonly include negative beliefs about themselves or the world, distorted sense of self-blame, feelings of guilt or anger, and perseverations or worry about past traumatic events. They may focus on feeling detached from others, themselves, and the world. They may feel unable to experience positive emotions.
If present, clearly describe in your documentation the extent of their suicidal (and homicidal) thoughts and include their specific thoughts, their intent, plans, research, preparatory actions, etc. This will weigh heavily in your risk assessment and safety plan. Risk assessments are discussed in detail here and here.
•In DID the different identities or personality states differ from one another in that each has its own pattern of perceiving, relating to, and thinking about the environment. Thus, thought process and content may different throughout the interview.
PERCEPTUAL DISTURBANCES 4
Dissociative symptoms are not considered symptoms of psychosis, however they do share some common features.
Depersonalization (feeling of being detached from your mental process or body) and derealization (feeling of unreality of surroundings). Individuals may experience a number of different perceived sensations such as bodily changes, duality of self as observer and actor, being cut off from others, or being cut off from one's own emotions. Patients experiencing depersonalization often have great difficulty expressing what they are feeling.
Dissociative changes in identity may manifest as odd first person plural or third-person self-references. They may refer to themselves using their own first names or make depersonalized self-references, such as “the body,” when describing themselves and others. In some instances, they may describe a division or conflict between parts of themselves. These parts may have proper names or may be designated by their predominate affect or function, for example, “the mean one” or “the husband.”
Flashback = a type of dissociative reaction where you may temporarily lose connection with your present situation and feel like you are actually transported back to the traumatic event. In severe flashbacks you may see, hear, or smell things that are not actually present (compare with psychosis). Amnesia may also occur for flashbacks or behavioral re-experiencing episodes related to trauma.
Fugue = a subtype of DID. Unexpected travel away from home or typical place of daily activities and inability to recall some or all of one's past. Termination of fugue can be accompanied by dissociative symptoms, amnesia, trance-like behaviors, and conversion symptoms.
Substance: Make sure to specify that the symptom does not occur during an episode of intoxication.
•Commonly obtained through a general sense of cognitive functioning obtained through conversation, however additional tests (MMSE, MoCA) can expand this exam if needed.
•As mentioned previously, dissociative disorders commonly involve amnesia towards certain events, particularly past traumatic events. Additionally, preoccupation on the effects of the trauma may leave little mental energy for other tasks.
•Memory deficits in dissociative amnesia are primarily for autobiographical information; intellectual and cognitive abilities are preserved. In contrast, memory loss associated with neurocognitive disorders is accompanied with progressive changes in cognitive, linguistic, affective, attentional, and behavioral disturbances.
INSIGHT / JUDGEMENT
•Does the patient attribute their symptoms to a mental disorder? Are they unconvinced of a problem?
•Judgment is best assessed by reviewing patients' actions in the recent past and their behaviors during the interview.
•Quick note on falsified dissociative disorders (factitious or malingering presentations) -> suggestive features include symptoms exaggeration, lies, use of symptoms to excuse antisocial behavior (e.g., amnesia only for bad behavior), amplification of symptoms when under observation, refusal to allow collateral contacts, and legal problems. Patients with genuine dissociative identity disorder are usually confused, conflicted, ashamed, and distressed by their symptoms and trauma history. 5
Nice work today. We covered some important factors regarding the mental status exam in patients with dissociative disorder. Next lesson will be a discussion on treatment of dissociative disorders.
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