dissociative disorder

1. DISSOCIATION IN OTHER PSYCHIATRIC
DISORDERS

2. Epilepsy and dissociation
• There is evidence that temporal lobe seizure activities can
produce dissociative syndrome, which is similar to that
observed in functional cases.
• From these findings, it may be inferred that temporal lobe
epileptic activity is important in the generation of the
dissociative symptoms without a neurological focal lesion
(Spiegel, 1991)

3. Substance use and dissociation
• Many studies conducted on populations with alcohol or other
substance dependence have led to significant data concerning
concurrent dissociative psychopathology.
• Ellason et al (1996) reported that alcohol and drug addiction
occurred in a large proportion of patients with dissociative
identity disorder and in many of these patients, drug abuse
was severe and began at an early age.

4. • High dissociation levels were found in detoxified male
veterans suggesting that dissociation might be due to the
chronic residual effect of long-term substance use, including
both alcohol and cocaine (Wenzel et al, 1996).
Borderline personality disorder and dissociation
• studies have shown a significant proportion (around 60%) of
borderline personality disorder patients had a diagnosis of
dissociative disorder
(Zittel & Westen, 2005; Yee et al, 2005)

5. • Patients with borderline personality disorder and a
dissociative disorder have high levels of reported childhood
trauma.
• Dissociation in response to childhood trauma may be at the
core of the pathogenic process that results in
symptomatology embodied in the diagnosis of both
borderline personality disorder and dissociative disorder.

6. • Chronic efforts to suppress (dissociate) unpleasant thoughts
may in some cases be a regulatory strategy underlying the
relationship between intense negative emotions and
symptoms of borderline personality disorder.
Schizophrenia and dissociation
• Patients of schizophrenia with a comorbid dissociative
disorder have more severe childhood trauma histories, more
comorbidity and higher scores for both positive and negative
symptoms (Ross & Keyes, 2004).

7. • Schneiderian first rank symptoms, have been found to be
more common in dissociative identity disorder in few studies.
• Schneiderian symptoms are highly related to other
dissociative symptom clusters and to childhood trauma (Ross
& Joshi, 1992).

8. Eating disorders and dissociation
• In a study done by Denitrak et al (1990), female patients with
anorexia and bulimia nervosa showed a significantly greater
incidence of dissociative phenomena than a group of age
matched normal female controls.
• Furthermore, the presence of severe dissociative experience
appeared to be specifically related to a propensity for self
mutilation and suicidal behaviour.

9. • The distortion of self and body image experienced by patients
with eating disorders might be related to the greater
propensity of these patients to undergo considerable
dissociative experiences.

10. Mood disorder and dissociation
• In studies of mood disorders, measures of dissociation might
correlate with childhood trauma, symptom severity and
response to medication.
• Among mood disorders, depression is more closely associated
with dissociation.
• The women with childhood sexual abuse, who also became
depressed earlier in life, were more likely to have high
dissociation score.
(Ellason et al, 1996)

11. • In clinical practice, chronic depression and suicidality in
patients with dissociative disorder are usually resistant to
standard biologic treatment modalities but respond positively
to the successful treatment of the dissociative disorder
(Parker et al, 2005)

12. MANAGEMENT

13. TREATMENT MODALITIES
1.Pharmacological intervention
Anxiolytic
Antidepressants
Neuroleptic
2.Psychosocial intervention
Intensive psychotherapy
Hypnosis
3.Client grounding techniques
4.Client education

14. PSYCHOTHERAPY
• Psychotherapy remains the mainstay for management of
dissociative disorder.
• Following are the general techniques of psychotherapy for
dissociative disorders-
• Psychoeducation: Education is an invaluable tool for treating
dissociative disorder. It helps to undo the stigmatization and
shame associated with being ill.

15. • Education appeals to intellectual strengths and the practice of
coping skills improve function and resilience.
• Psychoeducation can be accomplished in focused skill-building
groups, which also have the advantage of increasing
interpersonal connection (Harris, 1998).

16. Pacing and containment
• Pacing and containment are critical in building a foundation
and framework for therapy.
• One of the essential goals of therapy is to maintain function
while doing the work.
• The first stage of therapy is the establishment of safety and
stabilization and the building of the therapeutic alliance.

17. • The second is of trauma processing; the integration of
traumatic recollection and intense affect.
• The third is postintegration of self and relational development
• Containment skills can be taught through psychoeducation
and imagery.

18. • Therapists must start by normalizing feelings as an integral
part of human being.
• Affect modulation involves the identification of feelings,
followed by the contextual relationship, and then modulation.
• Learning to identify a specific feeling and giving it context is
the beginning of control and understanding.

19. • Modulation also involves teaching self-soothing, mindfulness,
or distracting strategies.
• The therapist and patient can collaboratively create a list of
strategies to keep at hand for difficult moments or days
• Grounding skills: Dissociative processes adaptively modulate
intolerable anxiety and stress resulting from trauma at the
same time that these processes exact the price of destroying
the context and meaning of experience.

20. • Grounding is the process of being psychologically present and
particularly effective in dealing with depersonalization
experiences. Grounding skills can be divided into two areas
1. sensory awareness
2. cognitive awareness

21. • Sensory awareness encourage patients focus in the present by
using all five senses in awareness of their body position; e.g.,
patients often find it helpful to hold a ball, small stone or
other palm-sized objects to enhance their sense of touch.
• Similarly, sensory cues are used for other sensations like
vision, hearing, smell and taste.
• Cognitive awareness grounding skills involve orienting the
patient to day, date, age and location (Turkus, 2006).

22. • Traumatic reenactment
• For patients who can stabilize and form a reasonable working
alliance in treatment, longer-term treatment goals involve
detailed, affectively intense, psychotherapeutic processing of
life experiences for the individual.
• Authorities emphasize that, in most cases, intensive, detailed
psychotherapeutic work with traumatic memories should only
be initiated after the patient has demonstrated the ability to
use symptom management skills independently

23. • The patient should be able to give informal consent and
should have a realistic understanding of the potential risks
and benefits of intensive focus on traumatic material.
• Furthermore, patient shouldn’t be in the midst of an acute life
crisis or major life change, comorbid medical and psychiatric
disorders should be stabilized, the patient must have ego-
strength and psychological resources to withstand the rigors
of the process, and there must be adequate resources, such
as support by significant others, to support the patient for
additional sessions.

24. Safety planning
• Establishing a written safety should take if in crisis can be very
useful early in the treatment process when the therapist is
developing a rapport with the patient.
• The basic intent of such a plan is an agreement between
patient and therapist that if the patient has attempted to
manage the crisis independently using skills such as
relaxation, grounding or containment, then the patient will
contact the therapist before acting on any self harming
impulses and wait for the therapist to call back so that
impulses can be discussed.

25. Healing place
• Clinical practice in the field of trauma and dissociation is
replete with the creation of “safe place” imagery to manage
fear and anxiety.
• The installation of a healing place is a valuable therapeutic
intervention.

26. • After installation of healing place, the therapist should invite
the patient to describe and share the experience for
affirmation and reinforcement or to discuss any problems
encountered.
• The place may need to be modified if there is intrusion of
resistance or traumatic material (Turkus, 2006).

27. MANAGEMENT OF INDIVIDUAL
DISORDERS

28. DISSOCIATIVE AMNESIA
PSYCHOTHERAPY
1.Free recall-
• Patients with acute and chronic forms of amnesia may
respond well to free recall strategies in which they allow
memory material to enter into consciousness.
2.Cognitive therapy-
• It may have specific benefit for individuals with trauma
disorders.
• Identifying the specific cognitive distortions that are based in
the trauma may also provide an entry into autobiographical
memory for which the patient experiences amnesia.

29. 3.Hypnosis
• Hypnosis is not treatment itself; rather, it is a set of adjunctive
techniques that facilitate certain psychotherapeutic goals.
• It can be used in a number of different ways.
• In particular, hypnotic intervention can be used to contain,
modulate, and titrate the intensity of symptoms

30. • To facilitate controlled recall of dissociated memories, to
provide support and ego strengthening for the patient; and,
finally, to promote working through and integration of
dissociated material (Loweinstein & Putnam, 2005).

31. PHARMACOTHERAPY
• There is no known pharmacotherapy for dissociative amnesia
other than pharmacologically facilitated interview.
• A variety of agents have been used for this purpose, including
sodium amobarbital, thiopental, oral benzodiazepines and
amphetamines.
• At present, no adequately controlled studies have been
conducted that assess the efficacy of any of these agents in
comparison with one another or with other treatment
methods.

32. DISSOCIATIVE FUGUE
• Dissociative fugue is usually treated with an eclectic,
psychodynamically informed psychotherapy that focuses on
helping the patient recover memory for identity and recent
experience.
• Hypnotherapy and pharmacologically facilitated interviews
are frequently necessary adjunctive techniques to assist with
memory recovery.
• The initial phase is centered on establishing clinical
stabilization, safety, and a therapeutic alliance using
supportive and educative interventions.

33. • Once stabilization is achieved, subsequent therapy is focused
on helping the patient regain memory for identity, life
circumstances and personal history.
• During this process, extreme emotions related to trauma or
severe psychological conflict, or both, may emerge that
require working through.

34. • In general, the therapist should take a supportive and
nonjudgmental stance, especially if the fugue has been
precipitated by intense guilt or shame over an indiscretion.
• At the same time, it is important for the therapist to balance
this with being a spokesperson for the patient, taking realistic
responsibility for misbehaviour.
Loweinstein & Putnam, 2005

35. DISSOCIATIVE IDENTITY DISORDER
PSYCHOTHERAPY
• A vast majority of clinicians consider psychotherapy as the
primary and most efficacious treatment modality.
• The initial phase of psychotherapy consists of
psychoeducation and setting up treatment frame and
boundaries, development of skills to manage symptoms and
cognitive therapy.
• The second phase deals with the traumatic memories.
• The third phase consists of fusion, integration, resolution and
recovery of personality.

36. PHARMACOTHERAPY
Available treatment methods are given below-
Affective symptoms
• Affective symptoms are only infrequently responsive to mood
stabilizing medications.
• They often have only partial, response to antidepressant
medications, usually SSRIs or TCAs.
• Refractory patients may need a series of antidepressant trials
or combination therapy with two antidepressants.

37. Pseudopsychotic symptoms-
• pseudopsychotic symptoms rarely are ameliorated by
antipsychotic medications, even in higher doses.
• On the other hand, in many patients with dissociative identity
disorder and severe, intrusive PTSD, anxiety, confusion and
cognitive dysfunction , low doses of atypical neuroleptics
(risperidone, quetiapine, ziprasidone, olanzepine) may
ameliorate these symptoms.

38. Anxiety symptoms
• Many patients with dissociative identity disorder may require
long-term treatment with benzodiazepines for persistent
anxiety symptoms.
• Obsessive-compulsive symptoms in dissociative identity
disorder preferentially respond to medication like fluvoxamine
and clomipramine.

39. PTSD symptoms
• A variety of uncontrolled studies have shown efficacy of mood
stabilizers (carbamazepine, valproate , lamotrigine) for PTSD
symptoms in dissociative identity disorder.
• A subgroup of patients of dissociative identity disorder with
PTSD symptoms responds to beta-blockers for severe
hyperarousal symptoms, such as pronounced startle response.

40. • Long-acting forms of propranolol are used most frequently for
this indication.
• Similarly, the α-agonist clonidine may be effective in a few
patients for the same indication (Loweistein, 2005)

41. ELECTROCONVULSIVE THERAPY
• A clinical picture of major depression with persistent,
refractory melancholic features across all alters may predict a
positive response to ECT.
• However, this response is usually only partial

42. DEPERSONALIZATION DISORDER
PHARMACOTHERAPY
• Patients with depersonalization disorder are usually clinically
refractory group.
• Over the past decade there have been anecdotal reports of
improvement in this condition with SSRIs (e.g., fluoxetine) or
clomipramine.
• A double-blind placebo-controlled study comparing 25
patients receiving fluoxetine with 25 patients receiving
placebo for 10 weeks found that fluoxetine was no better than
placebo for this condition .
Simeon et al, 2004

43. • Sierra et al (2003), in another double-blind placebo-controlled
study, found lamotrigine no better than placebo for
depersonalization disorder.
• Many patients who respond to SSRIs or mood stabilizers have
comorbid psychiatric conditions like depression or anxiety and
that might the reason for improvement.
• Nevertheless, SSRIs remain the most frequently prescribed
medication for this condition

44. PSYCHOTHERAPY
Many different types of psychotherapy have been used with
depersonalization disorder patients including
• psychodynamic
• Cognitive
• cognitive-behavioural,
• hypnotherapeutic and supportive.

45. • Stress management strategies, distraction techniques,
reduction of sensory stimulation, relaxation training and
physical exercise may be somewhat helpful in some patients.
• Hunter et al (2005), in an open study, involving 21 patients
with depersonalization disorder, found cognitive behaviour
therapy (for a period of 2 years), significantly effective for
depersonalization- derealization symptoms, as well as for
anxiety and depressive symptoms.

46. • All the patients were symptomatic despite getting
psychopharmacologic intervention before CBT was started
and 29% of them no longer met the diagnostic criteria for
depersonalization disorder at the end of the trial.

47. CONVERSION DISORDER WITH MOTOR AND SENSORY
SYMPTOMS
• In acute cases without a prior history of conversion, accurate
reassurance coupled with reasonable rehabilitation to fit the
symptoms is warranted.
• Confrontation of the patient about the so-called false nature
of the symptoms is contraindicated.
• Chronic cases are more difficult to treat. Comorbid psychiatric
illness need to be treated aggressively.

48. • Treatment needs open explanation to the patient about the
findings, and education aimed at helping the patient
understand that, although the symptoms are real and causing
impairment, there is a hope for full recovery.

49. Three specific treatments must then be considered.
• First, psychomotor and sensory rehabilitation.
• Anxiolytic and antidepressant medication may decrease some
of the symptoms to allow the patient to engage in physical
rehabilitation or psychotherapy.
• Finally, psychotherapy may be useful but also may be
contraindicated in a patient who remains highly resistant to it
or who gets worse when it is initiated.

50. • Therapy is directed at increasing function and having the
patient demonstrate to himself or herself that the symptom
or deficit is alterable and that it is related to psychological or
social phenomena (Hollifield, 2005)

51. CONVERSION SEIZURE (PSEUDOSEIZURE)
Explaining conversion and pseudoseizure
• It is important to explain the diagnosis in a way that educates
the patient, provides a cognitive framework of understanding,
reduces shame and motivates willingness to undertake
treatment.
• Including the family in the discussion is recommended.
• Conversion symptoms are generated unconsciously and
express unconscious emotions and conflicts. Simple
metaphors are helpful in explaining these abstract concepts to
the patient.

52. Exploring the causes
• The second step is explanation of the causes of conversion in
an individual patient.
• Adequate evaluation of the causes requires open-ended,
nonleading questions about trauma or abuse.
• Treatment focuses on identifying the emotions that these
events raise and exploring the trauma.

53. • Conversion seizures usually decrease sharply after the conflict
is verbalized in individual psychotherapy and the patient is
assisted in discussing it in family therapy
Treatment proper
• Antidepressants should be used if there is comorbid PTSD,
panic or major depression. Some patients with overwhelming
anxiety may require initial treatment with anxiolytics until
their anxiety or trauma is resolved in psychotherapy.

54. • The primary principles of psychotherapy are a nonjudgmental,
supportive and educative approach that addresses
alexithymia and encourages verbal expression, problem
solving skills and resolution of trauma.
• Patients should focus on their symptoms, their dissociative
defenses, and the stress or emotions that trigger conversion
seizures.
• Clinician should emphasize hope,ability to gain control over
symptom and need to identify and verbalize emotion.

55. REFERENCES
• Kaplan & sadock’s comprehensive textbook of psychiatry,ninth edition
• Kaplan & sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry,
10th edition
• Glutamate and post-traumatic stress disorder: toward a psychobiology of
dissociation. semin clin neuropsychiatry. 1999
• Lanius ra, brain activation during script-driven imagery induced dissociative
responses in ptsd: a functional magnetic resonance imaging investigation. biol
psychiatry. 2002
• Epidemiology of dissociative disorders: an overview,epidemiology research
international volume 2011)