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Dissociative Disorders

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Josephine Reyes

on 23 April 2014

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Transcript of Dissociative Disorders

mayi temika dixon
tita marie green
josephine reyes
adrienn denise white
an MFT 620 Presention:
1. Definitions, Etiology, Symptoms and syndromes in accordance to DSM-IV-TR (2000)
(Tita and Josephine)

2. Family system analysis: i.e. heredity, stress, dysfunctional family system, etc; the impact of the chronic mental illness on the family system and individuals in the family; and attend to larger systemic issues, such as gender, race, ethnicity, and socioeconomic factors.
(Mayi)

3. Treatment options: from the biopsychosocial perspective. Include therapy, medication and other treatment options, if applicable.
(Adrienn)

Content:
Family of Origin
Contributing Factors
Abuse or neglect

Major trauma, sexual abuse during infancy or early childhood

Communication & attachment

Developmental model of family environment
(Lyons-Ruth, 2008)
)
Developmental model of family environment
A difficult family environment, i.e.exposure to trauma or abuse
= increase in borderline, antisocial, and dissociative features.

Current Family Processes:

Response to stress, guilt, should emphasize creating a supportive environment

Major adjustments ex. adjusting to alters i.e. Dissociative Identity Disorder

Address shame, guilt, and confusion

Loyalty Dynamics

Amnesia....................300.12
Fugue........................300.13
Identity Disorder.....300.14
Depersonalization....300.6
NOS..........................300.15
Dissociative Types and ICD Codes
Dissociative Amnesia

(300.12)
(formerly known as Psychogenic Amnesia)
Dissociative Amnesia is characterized by an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
DSM-IV-TR (2000)

Essential Features of Dissociative Disorders
Disruptive integration of conciousness relative to memory, identity, or perception of the environment

Disconnection maybe gradual, transient, or chronic
…most commonly presents as a retrospectively reported gap or series of gaps in recall for aspects of the individual’s life history
…gaps usually related to traumatic or extremely stressful events
…amnesia for episodes of self-mutilation, violent outbursts, or suicide attempts
Outcome of Dissociation
Everywhere but nowhere – almost

Dx by private practioners; tend to find what they expect

Specialty centers or clinics
Location Factors
implies a gap (ex: hopes for the pothole at the corner will one day be filled in)

temporary loss of memory that will recover within a period of days or weeks

ex: hypnosis as Tx tool in surgery, dental, medical, and psychotherapy
Typical
had been identified in the affective blunting of Schizophrenia

developed numbing sensations PTSD patients toward their traumatic experiences

found as free- standing
Atypical
e.g., uninjured survivor of a car accident where a family member was killed has inability to recall anything from time of accident through or up to 2 days later
Localized
Failure of recall encompasses the person’s entire life
Generalized
Failure of recall for events subsequent to a specific time up to and including the present
Continuous
Common Memory Disturbances:
Loss of memory for certain categories of information, such as all memories relating to one’s family or to a particular person
Systematized
e.g., combat veteran can recall only parts of a series of violent combat experiences
Selective

More
Details
about
Dissociative
Amnesia
Individuals who exhibit Generalized, Continuous, and Systematized types of Dissociative Amnesia may ultimately be diagnosed as having a more complex form of Dissociative Disorder (e.g., Dissociative Identity Disorder)
Can present in any age group
Diagnosis in preadolescent children is more difficult.
Can be confused with other disorders...
(ADHD, Anxiety, ODD, etc.)
More Prevalent now...

Possibly due to a greater awareness of the diagnosis amongst mental health professionals

DSM-IV-TR (2000)
Diagnostic
Criteria for
Dissociative
Amnesia
The predominant disturbance is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
one
The disturbance does not occur exclusively during the course of Dissociative Identity Disorder, Dissociative Fugue, PTSD, Acute Stress Disorder, or Somatization Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a neurological or other general medical condition (e.g., Amnestic Disorder Due to Head Trauma)
two
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
three
Formerly known as Psychogenic Fugue.

Dissociative Fugue is characterized by sudden, unexpected travel away from home or one’s customary place of work, accompanied by an inability to recall one’s past and confusion about personal identity or the assumption of a new identity.

DSM-IV-TR (2000)
Dissociative
Disorder
NOS

ICD 300.15
Dissociative Disorder
Not Otherwise Specified

NOS is included for coding disorders in which the predominant feature is a dissociative symptom, but does not meet the criteria for any specific Dissociative Disorder

DSM-IV-TR (2000)
Identity
Dissociative
Disorder
ICD 300.14
(formerly Multiple Personality Disorder/Split Personality)
A
Criterion A: two or more distinct identities or personality states are present in the individual.
C
Criterion C: the individual is unable to recall important personal information, and this inability is too severe to be attributed to mere ordinary forgetfulness.
B
Criterion B: these distinct identities take control over the behavior recurrently.
Dissociative Identity Disorder Diagnostics:
D
Criterion D: the disturbance is not an outcome of substance abuse or general medical condition.
Image retrieved on April 11, 2013 from: http://www.biography.com/imported/images/Biography/Images/Bio-now/Hero%20Images/08-2011/Bio-Now-Roseanne-Barr.jpg
Image retrieved on April11, 2013 from: http://img2.imagesbn.com/p/9781416537489_p0_v2_s260x420.jpg
Celebrities with Dissociative Identity Disorder
Roseanne
Barr
a subjective sensation, discomfort, or change in functioning that a patient or informant complains about.
SYMPTOMS:
Headache
Memory loss - amnesia
Time loss
Trances
Depression
Mood swings
Suicidal tendencies
Sleep disorders:
insomnia
night terrors
sleep walking
Anxiety
Panic Attacks
Phobias
Flashbacks
Reactions to stimuli
"Triggers"
Alcohol and drug abuse
Compulsions

Rituals
Psychotic-like symptoms
Hallucinations
Symptoms:
Headache
Memory loss - amnesia
Time loss
Trances
Depression
Mood swings
Anxiety, panic attacks, and phobias (flashbacks, reactions to stimuli or "triggers")
Psychotic-like symptoms (including auditory and visual hallucinations)
Sleep disorders (insomnia, night terrors, and sleep walking)
Suicidal tendencies
Alcohol and drug abuse
Compulsions and rituals
Confused and disoriented state:
Others around may discern that the switch has happened by specific symptoms such as rapid blinking, facial changes, changes in voice or demeanor, or sudden change of track of the individual’s thoughts

Personality Alters:
Main or primary- carries the person's given name; When this primary identity takes over or regains consciousness, the individual is usually passive, dependent, guilty and depressed.

Alternate identities:
Usually dominant; have personalities which contrast the primary personality. Ex: may be dominating, hostile, aggressive, etc. Time required to switch between two identities may be a few seconds, or may be gradual.
Signs: as noticed by others
http://www.imdb.com/title/tt0183505/
Individualized life experience characterized by distinct personal history, self-image, and identity variance in age, gender, and name

Comorbid Dx such as Eating disorders, MDD, OCD, Panic DO, Anxiety DO, PTSD
Particular pattern of collective symptoms, signs, and events in simultaneous occurrence, indicative of a disorder
Syndromes:
Disintegrated aspects of identity, memory, and consciousness
Dx 3-9x > females: males
15 > identities: females
8 > identities: males
Identity confusion or identity alteration about who a person is
Distorted time, place, or situation experiences
Each personality is cognizant of each other-self
Contorted social skills

Rx of “other-self” behavior = disgusting, revolting, loathsome, frowned on
Affects of DID
http://withfriendship.com/images/g/31401/Derealization-image.gif
Derealization:
The feeling that the world has changed or is not real, feeling of self-alienation
image retrieved on April 11, 2013 from: http://pulse.sfstation.com/files/2012/11/adamduritz.jpg
Adam Duritz is known as the frontman of the popular alternative rock group, Counting Crows. He's also known for dating famous actresses like Jennifer Anniston, Winona Ryder and currently Emmy Rossum. What many people don't know about Duritz is his struggle with Depersonalization Disorder, an illness that makes him feel disconnected from reality. He opened up about the disorder to Men's Health Magazine.
Depersonalization:
ICD 300.6
Mrs. Spinner is a 46 year old woman who was referred by her husband who described "attacks" of dizziness that his wife experienced that left her incapacitated. She described being overcome with dizziness and nausea 4-5 times a week, when the room would begin to "shimmer" and she had the feeling that she was " floating" and could not maintain her balance. The attacks almost always occurred at about 4PM, after which she had to lie down until 7 or 8PM. After feeling better she would spend the rest of the night watching TV, would fall asleep on the couch and go to the bedroom at around 3AM.

The patient was evaluated medically and all tests were negative. She was in fine physical condition. When asked about her marriage she stated that her husband was abusive verbally and demanding of her and her children. She admitted that she dreaded his arrival home from work each day. When she was unable to make dinner, her husband and children would have to go out to eat. He came home, watched TV and had no conversation with his wife.
Case Study:
Mrs. Spinner
about Mrs. Spinner
Questions
1. What is her diagnosis?

2. What are the symptoms that helped you make this diagnosis? What diagnostic criteria do they relate to?

3. What are two other possible diagnoses and why did you not choose them?

3. What are two other possible diagnoses and why did you not choose them?

5. What therapeutic approach would you consider and why?
?
In this case, the circumscribed nature of the amnesia and the perplexity and disorientation during the amnestic period, all following a psychologically stressful event, are quite characteristic.


DSM-IV-TR Case Book (2002)
With the amobarbital interview it becomes clear that the amnestic period developed following a particularly traumatic and life-threatening experience. Amnesia that does not occur exclusively during the course of DID and is not caused by Delirium, Dementia, or Amnestic Disorder justifies the diagnosis of Dissociative Amnesia.
The differential diagnosis of acute memory loss begins with a consideration of a Cognitive Disorder, such as Delirium, Dementia, or Amnestic Disorder, which may be caused by head trauma, cerebrovascular accidents, or drug use.

The normal physical and neurological exam and absence of a history of drug use rule out these possibilities in this patient.
DSM-IV-TR Case Book (2002)
Case Study:
The Sailor
Brand, B. L., Myrick, A. C., Loewenstein, R. J., Classen, C. C., Lanius, R., McNary, S. W., & ... Putnam, F. W. (2012). A survey of practices and recommended treatment interventions among expert therapists treating patients with dissociative identity disorder and dissociative disorder not otherwise specified. Psychological Trauma: Theory, Research, Practice, And Policy, 4(5), 490-500. doi:10.1037/a0026487

Brand, B. L., Lanius, R., Vermetten, E., Loewenstein, R. J., & Spiegel, D. (2012). Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5. Journal Of Trauma & Dissociation, 13(1), 9-31. doi:10.1080/15299732.2011.620687

Chilebowski, S. M., & Gregory, R. J. (2012). Three cases of dissociative identity disorder and co-occurring borderline personality disorder treated with dynamic deconstructive psychotherapy. American Journal Of Psychotherapy, 66(2), 165-180.
References
Treatment for
Dissociative Disorders
Treatment
Psychotherapy is the primary treatment for dissociative disorders. This form of therapy, also known as talk therapy, counseling or psychosocial therapy, involves talking about your disorder and related issues with a mental health provider. Your therapist will work to help you understand the cause of your condition and to form new ways of coping with stressful circumstances.

Psychotherapy for dissociative disorders often involves techniques, such as hypnosis, that help you remember and work through the trauma that triggered your dissociative symptoms. The course of your psychotherapy may be long and painful, but this treatment approach often is very effective in treating dissociative disorders.
Other Dissociative Disorder
treatment may include:
Creative Art Therapy. 
Cognitive Behavioral Therapy. 
Medication. 
Creative Art Therapy
This type of therapy uses the creative process to help people who might have difficulty expressing their thoughts and feelings. Creative arts can help you increase self-awareness, cope with symptoms and traumatic experiences, and foster positive changes.

Creative art therapy includes:
Art
Dance and movement
Drama
Music
Poetry
+
Cognitive therapy
This type of talk therapy helps you identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones.

It's based on the idea that your own thoughts — not other people or situations — determine how you behave. Even if an unwanted situation has not changed, you can change the way you think and behave in a positive way.
Medication
Although there are no medications that specifically treat dissociative disorders, your doctor may prescribe antidepressants, anti-anxiety medications or tranquilizers to help control the mental health symptoms associated with dissociative disorders.
Alternative Medicine: Hypnosis
Your therapist may recommend using hypnosis, which is sometimes referred to as hypnotherapy or hypnotic suggestion, as part of your treatment for a dissociative disorder.

Hypnosis creates a state of deep relaxation and quiets the mind. When you're hypnotized, you can concentrate intensely on a specific thought, memory, feeling or sensation while blocking out distractions. Because you're more open than usual to suggestions while under hypnosis, there is some controversy that therapists may unintentionally "implant" false memories by suggestion. However, when conducted under the care of a trained therapist, hypnosis is generally safe as a complementary treatment method.
What is the Prognosis?
Dissociative Disorders can be effectively managed with intensive psychotherapy, and medication, when necessary. Psychotherapy, sleep and stress management, and psycho-education can significantly diminish the frequency and intensity of dissociative episodes. The earlier in life a person is diagnosed and treated, the better the prognosis. However, dissociative symptoms may be so disabling, a person with a Dissociative Disorder may have difficulty seeking help or staying in treatment. People with Dissociative Disorders may also experience depression, mood lability, suicidal thoughts or attempts, sleep disorders (insomnia, night terrors, and sleep walking),or panic attacks and phobias (flashbacks, reactions to reminders of the trauma). Furthermore, compulsions and rituals, borderline psychotic symptoms, somatization issues such as headaches, trances or “out of body experiences” or eating disorders may occur.
How Can Friends
and Family Help?
Family members, a spouse, or friends can educate themselves to understand when a person with a Dissociative Disorder and history of psychological trauma is dissociating or is in crisis.

At these times, they can compel the person to seek professional help. They can also monitor medications and ensure that therapy appointments are maintained. Family members are likely to help a person with dissociation enter a treatment facility, providing emotional support and financial resources.
What factors can slow recovery?
Persons with a Dissociative Disorder and history of psychological trauma may be reluctant or afraid to seek treatment. Finding the proper diagnosis and appropriate treatment plan is especially important. Chemical dependency or alcoholism, or co-occurring psychological problems may also be prevalent among persons with dissociation. Concurrent substance abuse dramatically interferes with effective psychological and medical treatment. Persons with a Dissociative Disorder may have isolated themselves from family or loved ones, thus lacking an effective social support structure that is important to assist with their recovery.
When Should a Client enter a treatment center?
Any person with a severe history of psychological trauma or Dissociative Disorder should seek help from a qualified mental health professional. When dissociative episodes are occuring with frequency, or are profound, or when a person suffers from multiple identities, an intensive treatment program is an important choice. Weekly psychotherapy or medication will be ineffective at managing serious consequences of a Dissociative Disorder. A treatment facility, like PCH Treatment Center, has extensive experience working with persons suffering from dissociative episodes related to psychological trauma.
5. Stimulants:
These are used as dissociative identity disorder drugs when the patient displays severe depression, or in cases where depression is a cause of dissociative identity problems. Stimulants improve the central nervous system's response and make the person alert, wakeful, and active. This medication should only be taken in recommended doses and on a physician’s prescription. In addition, these medications are not suitable for some dissociative identity disorder patients. Examples of stimulant drugs include midafinil, methylphenidate, caffeine, and dextroamphetamine.
4. Anxiety medication:
These drugs are used for the treatment of dissociative identity patients who display excessive anxiety, or when anxiety is a trigger for dissociative identity disorder behavior. Anxiety can sometimes be an associated condition caused by dissociative identity problems. These medications help reduce anxiety. Xanax®, librium, valium, and ativan are some examples.
3. Antipsychotics:
These include chlorpromazine, aripiprazole, Risperdal®, Haldol®, and mellaril. These dissociative identity disorder drugs are used when the patient exhibits psychotic behavior. They work as mood stabilizers as well. Even if the dissociative identity patient is not diagnosed with psychosis, these drugs can be used to tranquilize and stabilize the mood. The drugs should be used strictly under the prescription and guidance of an expert physician.
2. Depressants:
Depressants are used to calm down certain dissociative identity disorder patients displaying violent and manic behavior. These drugs temporarily diminish hyperactivity of the brain. They are used to prevent seizures or respiratory disorders that can be associated with a dissociative identity disorder. Examples of depressants include carisoprodol, atropine, benzodiazepines, and cyclobenzaprine.
1. Antidepressant drugs:
These include citalopram, venlafaxine, phenelzine, fluoxetine, and sertraline. These drugs help reduce depression in some dissociative identity disorder patients. Antidepressants must be taken only under expert guidance as some of them have several side effects. Any change in the patient’s behavior due to the effect of medication must be monitored consistently.
Dissociative Disorders
1. Antidepressant drugs

2. Depressants

3. Antipsychotic medication

4. Anxiety medication

5. Stimulants
Specific Medications
MFT & Dissociative Disorder
Dissociative Identity Disorder and the Process of Couple Therapy
1. Little Research is on couple therapy and trauma

2. Research supports the benefit of family support and childhood trauma

3. DID patients and Couples work

Case Study with “Lisa” and “Don”
* Communication
* Balancing Needs
* Responding to Child Alters
* Sexuality
* Education
(MacIntosh, H. 2013)
CO-Morbid
PTSD

Sexual Abuse

Trauma

Depression
Can you name and TV shows or movies that display a type of Dissociative Disorder?
Have you seen me?
Dissociative Disorder and Pop Culture
Reference
Brand, B. L., Myrick, A. C., Loewenstein, R. J., Classen, C. C., Lanius, R., McNary, S. W., & ... Putnam, F. W. (2012). A survey of practices and recommended treatment interventions among expert therapists treating patients with dissociative identity disorder and dissociative disorder not otherwise specified. Psychological Trauma: Theory, Research, Practice, And Policy, 4(5), 490-500. doi:10.1037/a0026487
Brand, B. L., Lanius, R., Vermetten, E., Loewenstein, R. J., & Spiegel, D. (2012). Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5. Journal Of Trauma & Dissociation, 13(1), 9-31. doi:10.1080/15299732.2011.620687
Chilebowski, S. M., & Gregory, R. J. (2012). Three cases of dissociative identity disorder and co-occurring borderline personality disorder treated with dynamic deconstructive psychotherapy. American Journal Of Psychotherapy, 66(2), 165-180.
Dell, P. F. (2006). A new model of dissociative identity disorder. Psychiatric Clinics of North America, 29, 1-26.2

Diagnostic Criteria from DSM -IV-TR/Dissociative Disorders-Depersonalization/Desk Reference/APA/2000/ISBN 0-89042-027-0.

Emery, RE. and Oltman, TF/Dissociative Disorders-Depersonalization/Essentials of Abnormal Psychology/2000/Prentice Hall/Upper Saddle River, New Jersey/ISBN 0-13-083330-4.

Herman, J. L. (2012). Review of 'Special issue: Guidelines for treating dissociative identity disorder in adults (3rd revision)'; 'Rebuilding shattered lives: Treating complex PTSD and dissociative disorders'; and 'Understanding and treating dissociative identity disorder: A relational approach'. Psychoanalytic Psychology, 29(2), 267-269.
References
Morrison, J/Dissociative Disorders-Depersonalization/Diagnosis made easier Principles and Techniques for Mental Health Clinicians/The Guilford Press, New York/2007/ISBN-13: 978-1-59385-331-0/14:213-234.

MacIntosh, H (2013) . Dissociative Identty Disorder and the Process o Couple Therapy. Journal of Trauma & Dissociation,14:84-96
References
end.
Full transcript