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Toronto Notes 2019 Dissociative Disorders Dissociative Disorders
Definition
• severedissociationresultinginbreakdownofintegratedfunctionsofconsciousnessandperceptionof self
• differentialdiagnosis:PTSD,acutestressdisorder,borderlinepersonalitydisorder,somaticsymptom disorder, substance abuse, GMC (various neurologic disorders including complex/partial seizures, migraine, Cotard syndrome)
Dissociative Identity Disorder
• disruptionofidentitycharacterizedby≥2distinctpersonalitystatesoranexperienceofpossession
• canmanifestassuddenalterationsinsenseofselfandagency(ego-dystonicemotions,behaviours,speech)
• featuresrecurrentepisodesofamnesia(declarativeorprocedural)
Dissociative Amnesia
• inabilitytorecallimportantautobiographicalinformation,usuallyofatraumaticorstressfulnature,thatis inconsistent with normal forgetting and not attributable to a psychiatric disorder or medical illness
• localized/selectiveamnesia:failuretorecallall/someeventsduringaprescribedperiodoftime
• generalizedamnesia:(morerare)completelossofmemoryforone’slifehistory,±proceduralknowledge,
± semantic knowledge; usually sudden onset; often presents with perplexity, disorientation, and aimless wandering
Depersonalization/Derealization Disorder
• persistent or recurrent episodes of one or both of:
■ depersonalization: experiences of detachment from oneself, feelings of unreality, or being an outside
observer to one’s thoughts, feelings, speech, and actions (can feature distortions in perception
including time, as well as emotional and physical numbing)
■ derealization: experiences of unreality or detachment with respect to the surroundings (e.g. feeling
as if in a dream, or that the world is not real; external visual world is foggy or distorted)
• transient(s-h)experiencesofthisnaturearequitecommoninthegeneralpopulation
• episodescanrangefromh-yr,patientsareoftenquitedistressedandverbalizeconcernof“goingcrazy”
Sleep Disorders
• formoreinformationregardingnormalsleepcyclesandtheillnessesdescribed,seeNeurology,Sleep Disorders, N46
Overview
• adequatesleepisessentialtonormalfunctioning;deprivationcanleadtocognitiveimpairmentand increased mortality
• circadianrhythmshelpregulatemoodandcognitiveperformance
• neurotransmitterscommonlyimplicatedinpsychiatricillnessesalsoregulatesleep
■ acetylcholine activity and decreased activity of monoamine neurotransmitters is associated with greater REM sleep
■ decreased adrenergic and cholinergic activity are associated with NREM sleep
• depressionisassociatedwithdecreased∆(deep,slow-wave)sleep,decreasedREMlatency,and
increased REM density
• criteria
■ must cause significant distress or impairment in normal functioning ■ not due to a GMC or medications/drugs (unless specified)
Management
• pharmacologicaltreatmentsareillness-specific
■ non-benzodiazepines preferable (e.g. trazodone, zoplicone, quetiapine), but benzodiazepines a short
term option
■ medication should not be prescribed without having first made a diagnosis and considering major
psychiatric illnesses (major depression and alcohol use disorders are common etiologies)
• sleephygieneisasimple,effective,butoftenunderutilizedmethodforaddressingsleepdisturbances;
recommendations include:
■ waking up and going to bed at same time every day, including on weekends
■ avoiding long periods of wakefulness in bed
■ not using bed for non-sleep activities (reading, TV, work)
■ avoiding napping
■ discontinuing or reducing consumption of alcohol, caffeine, drugs
■ exercising at least 3-4x per week (but not in the evening, if this interferes with sleep)
Psychiatry PS29
Fugue
Purposeful travel or bewildered wandering while in amnesic state
During depersonalization or derealization, patients usually have intact reality testing, which adds to their alarming nature
• CognitiveBehaviouralTherapyforinsomnia(CBTi)