Dissociative And Eating Disorders

Psychiatry II Dissociative Disorders & Eating Disorders Dra. Aireen Capitan 4th Shifting/Jan. 15, 2009 Yvette, Ralph, Honey, Jam

DISSOCIATIVE DISORDERS DISSOCIATIVE AMNESIA Epidemiology:

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~6% of the general population  Incidence  More often in women and young adults (Can occur at any age)  Increased Prevalence  in times of war  natural disasters  sexual abuse  physical abuse  emotional abuse  Late adolescence and adulthood  Preadolescent children  difficult to assess because limited ability to describe subjective experience. Etiology:  Emotional Content of the Memory  State-dependent learning  memory of a traumatic event, and the emotional state may be so extraordinary that it is hard for an affected person to remember information learned during that state  psychoanalytic approach  defense mechanism  a way of dealing with an emotional conflict or an external stressor  Secondary defenses  Repression

 Denial Diagnosis: DSM-IV-TR Criteria: A. Predominant disturbance is one or more episodes of inability to recall important personal information, usually of traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness B. Disturbance does not occur exclusively during the course of dissociative identity disorder, dissociative fugue, PTSD, ASD, or somatization disorder and is not due to the direct physiological effect of a substance or other medical condition C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Clinical Features:  Occur spontaneously  Precipitated by emotional trauma  sexual fantasy or aggressive impulse  Abrupt onset  May upset the patient or may feel indifferent/ unconcerned  usually conscious before/after the event

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clouding of consciousness surrounding it Depression and anxiety – common predisposing factors May provide protective (primary/secondary) gain – blocking memories Occurs in 3 forms

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Localized amnesia –memory loss for a short time (hours to days)

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Generalized amnesia –a whole lifetime of experience

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Selective or systematized amnesia – failure to recall some details  Confabulation, note taking, stopping activities – coping/adaptive strategy Differential Diagnosis  Ordinary Forgetfulness and Nonpathological Amnesia  Dementia, Delirium, and Organic Amnestic Disorders  Posttraumatic Amnesia  Seizure Disorders  Substance-Related Amnesiay cannot be reversed.  Transient Global Amnesia  Other Dissociative Disorders  Acute Stress Disorder, Posttraumatic Stress Disorder, and Somatoform Disorders  Malingering and Factitious Amnesia Course and Prognosis:  Symptoms usually terminate abruptly  Recovery generally complete

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Patients with secondary gain◊ condition may last a longer time

 Clinicians◊ try to restore patients lost memories ASAP Treatment:  Pharmacological  Non pharmacological 

Hypnosis  relaxing patients to facilitate recall of dissociated memories

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Group Psychotherapy  recommended to help patients incorporate the memories into their conscious states

DISSOCIATIVE IDENTITY DISORDER Epidemiology: • 0.3 to 3 % of general psychiatric hospital patients meet the diagnostic criteria • 5 : 1 to 9 : 1 female to male ratio • Common in late adolescent and young adult • Mean age of diagnosis; 30 years old • Frequently coexist with anxiety, mood, somatoform and other disorders • Suicide is also common. Etiology:

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

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Trauma Physical and/or sexual abuse – 85-97% among those with Dissociative Identity Disorders • Genetic Factors Clinical Signs and Symptoms: • Memory symptoms • Processing symptoms • Dissociative alterations of identity • Child and adolescent presentations Diagnosis: DSM-IV Criteria for DID A. The presence of 2 or more distinct identities or personality states with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self B. At least 2 or 3 identity states take recurrent control of the person’s behavior C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness D. The disturbance is not due to the direct physiological effects of a substance or a general medical condition • •

Differential Diagnosis: • Imitative Dissociative Identity Disorder • Genuine Dissociative Identity Disorder • Schizophrenia and other psychoses • Rapid-cycling Mood Disorder • Borderline Personality Disorder • Malingering and Factitious Disorder • Partial Complex Seizure Disorder • Posttraumatic Stress Disorder Course:  Children  Boys>Girls  Sxs: trancelike accompanied by depression, amnesic period, hallucinatory voices, disavowal of behaviors, suicidal  Adolescents  Girls>Boys  2 Symptom pattern: 1. Chaotic life with promiscuity, drug use, suicide attempts 2. Withdrawal and childlike behaviors  Males: trouble with law or school officials Prognosis:  Determining variables: number, type, chronicity  If diagnosed early, children have excellent prognosis  Adolescents have poorer prognosis than children and adults  Adult prognosis is dependent on attitude toward treatment  Number of alter personalities has moderate effects on outcome  Poorer in patients with comorbid illness Treatment:  Insight-Oriented Psychotherapy

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Hypnosis  Pharmacotherapy? Stages of Therapy for DID 1. Establishing psychotherapy 2. Preliminary interventions

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History gathering and mapping Metabolism of trauma Working through of recovered materials across the alters 6. Integration-Resolution 7. Learning new coping skills 8. Solidification 9. Follow-Up Principles for Successful treatment  Secure treatment frame and firm, consistent boundaries.  Focus on mastery and patient’s active participation.  Based on strong therapeutic alliance.  Uncovering and abreaction.  Collaboration of the alters.  Clear and straight communication.  Consistency across all alters.  Restore morale and inculcate realistic hope.  Rule of thirds.  Responsibility.  Taking a warm stance.  Correcting cognitive errors. DISSOCIATIVE FUGUE Epidemiology: • Rare disorder

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Estimated to affect just 0.2% of the population, nearly all of them adults. • Prevalence increases significantly following a stressful life event, such as wartime experience, accidents an natural disasters Etiology: • Stressor or traumatic event (most common): person may be physically and mentally escaping a threatening environment or intolerable situation • • •

Chronic Stress (Bankruptcy) Depression or Dysphoria Histories of Childhood Abuse or Neglect (not yet established) Clinical Features: • Last from minutes to months • May be multiple • “Waking fugue” • Brief and involve only short distances in children • May be terminated by perplexity, confusion, trancelike behaviors, depersonalization, derealization, conversion symptoms or generalized dissociative amnesia • May display mood disorder symptoms, intense suicidal ideation, PTSD and other anxiety disorder symptoms • Alter identity created under auspices the patient lives for a period of time Diagnosis: DSM-IV Criteria for Dissociative Fugue A. Predominant disturbance is sudden, travel away from home or work place, with inability to recall one’s past B. Confusion about personal identity or assumes new identity (partial or complete)

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C. D.

Does not occur exclusively during dissociative identity disorder and not due to GMC or effects of substance use Cause clinical distress on areas of functioning

Differential Diagnosis: • Dementia • Delirium • Complex partial epilepsy • Dissociative amnesia • Malingering • General medical condition • Toxic and substance-related disorders • Bipolar disorder • Schizoaffective disorder • Schizophrenia Course & Prognosis: • Lasts for hours to days • Less commonly months • Involves extensive travel (thousands of miles) • Spontaneous recovery • Possible to recur Treatment: • Most widely accepted technique requires mixture of abreactions of the past trauma and integration of the trauma into a cohesive self that no longer requires fragmentation to deal with the trauma • TOC: Expressive-Supportive Psychodynamic Psychotherapy • Psychotherapy-help patients incorporate precipitating stressors in a healthy manner • Psychiatric and drug-assisted interviewing •

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Hypnosis-helps to reveal the psychological stressors that precipitated the fugue episode DEPERSONALIZATION DISORDER a persistent or recurrent alteration in the perception of self to the extent that a person’s sense of his or her own reality is temporarily lost Feeling of “mechanical, “in a dream”, “detached from their bodies” ego-dystonic episodes patients realize unreality of symptoms

Depersonalization vs Derealization Depersonalization: feeling that the body or the personal self is strange and unreal Derealization: perception of objects in the external world as strange and unreal Epidemiology: • An occasional isolated experience • Common and not necessarily pathological • Occur in 70% of population – No significant difference between men and women – Children: develop capacity for selfawareness – Adults: temporary sense of unreality while traveling • Recent studies – Women 2x as frequent as in men – Rare in >40 years old

– Mean age of onset: 16 years old Etiology: 1. Psychodynamic - emphasizes the disintegration of the ego; an affective response in defense of the ego - triggered by overwhelming painful experiences or conflictual impulses 2. Traumatic Stress – 1/3 – 1/2 of patients report histories of significant trauma - as much as 60% of accident victims 3. Neurobioligical Theories - N-Methyl-D-aspartate (NMDA) subtype of the glutamate receptor as central to the genesis of depersonalization symptoms - serotoninergic involvement Diagnosis: DSM-IV-TR Criteria for Depersonalization Disorder A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one’s mental process or body (e.g., feeling like one is in a dream). B. During the depersonalization experience, reality testing remains intact. C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The depersonalization experience does not occur exclusively during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder, o another dissociative disorder, and is not due to the direct physiological effects of a substance (e.g., temporal lobe epilepsy). Clinical Features: • central characteristic: quality of unreality and estrangement • feel different and no longer appear to have any relation or significance to the person parts of the body or the entire physical being may seem foreign as well as mental operations and accustomed behavior. Hemidepersonalization – feeling that half of the body is unreal or does not exist may be related to contralateral parietal lobe disease. • •

Anxiety is often included Complains of distortions in their senses of time and space • May feel that the point of consciousness is outside their bodies—as if they were totally different people. • Reduplicative paramnesia / double orientation believing that the patient is in two places at the same time. • Patient is aware of the disturbances in their sense of reality. Differential Diagnosis: Temporal Lobe Seizures ( epilepsy ) Atypical forms of Migraine and Headache Schizophrenia Acute Stress Disorder Panic Disorder Another Dissociative Disorder – Fugue - Identity Drug Abuse Course and Prognosis:

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Symptoms appear suddenly. Few report a gradual onset. • Start = 15 & 30 y/o, but can be seen as young as 10 • Occur less frequently after age 30 • In more than 50% of cases, it tends to be long lasting. • It usually run a steady course w/o significant 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, recurs, or causes distress • Any stresses associated with the beginning of the depersonalization disorder must also be addressed • Approaches: – Psychotherapy – Cognitive therapy – Medication – Family therapy – Creative therapies (art therapy, music therapy) – Clinical hypnosis

D. In postmenarcheal females, amenorrhea Clinical Features: • Physchological/Behavioral • Physical

Differential Diagnosis: Disorder Depressive Disorders

EATING DISORDERS • • •

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ANOREXIA NERVOSA Greek term for “loss of appetite” a Latin word implying nervous origin. Anorexia nervosa is a syndrome characterized by three essential criteria: – Self-induced starvation to a significant degree – Relentless drive for thinness or a morbid fear of fatness – Presence of medical signs and symptoms resulting from starvation Anorexia nervosa is often associated with disturbances of body image

Distinguishing Features Depressed Decreased appetite; feelings, crying depressive agitation; not spells, sleep preoccupied with recipes, disturbance, caloric content of foods, obsessive and preparation of ruminations, gourmet feasts; no occasional suicidal intense fear of obesity or thoughts disturbance of body image

Somatization Disorder

Weight fluctuations, vomiting, peculiar food handling

Weight loss not as severe as that of anorexia nervosa; does not express morbid fear of becoming overweight

Schizophrenia

Bizarre eating habits

Delusions about food are seldom concerned with caloric content; they believe to be poisoned; rarely preoccupied with a fear of becoming obese; do not have hyperactivity

Bulimia Nervosa

begin after a more concerned about period of dieting by pleasing others, being people who are attractive to others, and fearful of becoming having intimate obese, driven to relationships; more become thin, sexually experienced and preoccupied with active; display fewer of food, weight, and the obsessive qualities; appearance, and more likely to have long struggling with histories of mood swings, feelings of becoming easily depression, frustrated or bored, and anxiety, and the have trouble coping need to be perfect; effectively or controlling disturbed attitudes their impulses; more towards eating medical complications

Types:  Restricting Type

 Binge-Eating/Purging Type Epidemiology: • 4 percent of adolescent and young adult students. • Female > male • The most common ages of onset: • Midteens • DSM-IV-TR: between 14 and 18 years • Up to 5% have the onset early 20s. Etiology: • Biological Factors • Social Factors • Psychological & psychodyanamic Factors Diagnosis: DSM-IV-TR Criteria A. Refusal to maintain body weight at or above a minimally normal weight for age and height B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

Similarities

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Course and Prognosis: • Variable – full recovery (40-60%) – fluctuating pattern of weight gain followed by a relapse (75% ) – progressively deteriorating course over many years (5-18%) – Death (causes: starvation, electrolyte imbalance, heart failure, and suicide) • Indicators of GOOD outcome: - admission of hunger - lessening of denial & immaturity - improved self-esteem • Indicators of POOR Outcome: - Childhood - Neuroticism - Parental conflict - Bulimia nervosa - Vomiting - Laxative abuse - Behavioral manifestations Co-morbidity: • Depression – 65% • Social phobia – 34% • Obsessive-compulsive disorder – 26% Management: • Hospitalization – nutritional state HOSPITALIZATION Nutritional State

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PSYCHOTHERAPY • CognitiveBehavioral Therapy • Individual • Dynamic psychotherapy • Family Therapy • Group Therapy

PHARMACOTHERAPY • CyproheptaDine (Periactin) • Amitriptyline (Elavil) • Clomipramin e • Pimozide (Orap) • Chlorpromaz ine (Thorazine) • Fluoxetine

BULIMIA NERVOSA More prevalent than anorexia More prevalent in women One-tenth found in men 1-3% women have a history of obesity 40% found in college women

Biologic Factors: • Cycles of binging and purging can be associated with various neurotransmitters. • Serotonin and norepinephrine have been implicated. • The feeling of well-being after vomiting that some of these patients experience may be mediated by raised endorphin levels. • According to DSM-IV-TR, there is an increased frequency of bulimia nervosa in first-degree relatives of persons with the disorder.

Psychological Factors: • Difficulties with adolescent demands. • More outgoing, angry, and impulsive than those with anorexia nervosa. • Associated with alcohol dependence, shoplifting, and emotional lability (including suicide attempts). • Experience uncontrolled eating as more ego-dystonic than anorexia nervosa patients and so seek help more readily. Social Factors: • Tend to be high achievers and respond to societal pressures to be slender. • Many are depressed and have increased familial depression, but their families are generally less close and more conflictual than the families of anorexia nervosa patients. • Describe their parents as neglectful and rejecting. Clinical Features: • Vomiting – most common feature • Depression – called ‘post binge anguish • Concerned about body image and appearance Diagnosis: DSM-IV-TR Diagnostic Criteria (1) Episodes of binge eating occur relatively frequently (twice a week or more) for at least 3 months; (2) Compensatory behaviors are practiced after binge eating to prevent weight gain, primarily selfinduced vomiting, laxative abuse, diuretics, or abuse of emetics (80 percent of cases), and, less commonly, severe dieting and strenuous exercise (20 percent of cases) (3) Weight is not severely lowered as in anorexia nervosa; and (4) The patient has a morbid fear of fatness, a relentless drive for thinness, or both and a disproportionate amount of self-evaluation depends on body weight and shape Summary: • Recurrent episodes of binge eating • A sense of lack of control over eating during the eating binges • Self-induced vomiting • The misuse of laxatives or diuretics • Fasting • Excessive exercise to prevent weight gain • Persistent self-evaluation unduly influenced by body shape and weight • Binging precedes vomiting by about 1 year Course and Prognosis:  Higher rates of partial and full recovery than anorexia nervosa  Treated patients  fare much better than untreated  10 yr follow-up study: women who continued to meet full criteria for bulimia nervosa has declined as the duration of follow-up increased  Untreated: remain chronic; show unimpressive improvements

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30% continue to engage in recurrent binge-eating or purging behaviors  WORSE: Substance use Longer duration of disorder before treatment Prognosis depends on:  Age of onset  Types of purging behaviours  Presence of any other psychiatric conditions or disorders Better prognosis than Anorexia Nervosa At 5 to 10 years, half of the patients fully recover, while 20% continued to meet full diagnostic criteria If left untreated, spontaneous remission occurs in 1 to 2 years 

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 selfconcept 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 Classmates, this is just a compilation of the visual aids of our reports. Better read the book!