Dissociative Disorders (2008)

Medical undergraduate lecture 2008

1. Dr Zahiruddin Othman 3 rd December 2008 Dissociative Disorders

2. Epidemic Hysteria In epidemic (communicable) or mass hysteria there is often background of tension in an institution, an initial symptoms appear in an influential figure and spread to others by suggestion

3. Hysterical or Histrionic Personality Disorder Hysterical (hystrionic) behavior is consciously motivated, unlike the unconscious motivation underlying symptoms in dissociative (conversion) disorders

4. Hysterical Psychosis Berserkers (or Berserks) were Norse warriors who wore coats of wolf or bear skin and who were commonly understood to have fought in an uncontrollable rage or trance of fury, hence the modern word berserk

5. St Louis hysteria [Briquet’s syndrome] a.k.a. somatization disorder, and refers to individuals with recurrent and multiple unexplained physical symptoms commencing before the age of 30 years and of chronic duration

6. Hysteria Dissociation Conversion Somatoform Mental symptoms without organic cause Physical symptoms without organic cause Neurological symptoms without organic cause ICD-10 Hysterical Neurosis

7. ICD-10 F44 Dissociative [conversion] disorders F44.0 Dissociative amnesia F44.1 Dissociative fugue F44.2 Dissociative stupor F44.3 Trance and possession disorders F44.4 Dissociative motor disorders F44.5 Dissociative convulsions F44.6 Dissociative anaesthesia and sensory loss F44.7 Mixed dissociative [conversion] disorders F44.8 Other dissociative [conversion] disorders .80 Ganser’s syndrome .81 Multiple personality disorder .82 Transient dissociative [conversion] disorder occuring in childhood and adolescent Somatoform Disorders Somatoform disorder Conversion disorder Pain disorder Hypochondriasis Body dysmorphic disorder Dissociative disorders Dissoc. Amnesia Dissoc. Fugue Dissoc. Identity Disorder Depersonalization disorder DSM-IV

8. Professor Charcot (left) of Paris' Salpêtrière demonstrates hypnosis on a "hysterical" patient, "Blanche" (Marie) Wittman, who is supported by Dr. Joseph Babiński. DISSOCIATION, HYPNOSIS AND THE UNCONSCIOUS Hypnosis raise into consciousness those mental elements are rendered unconscious Amnesias, trance states, and variety of localized paralyses, anaesthesias, paraesthesias, and hallucinations induced by hypnosis were indistinguishable from those occurring symptomatically in hysteric patients Persons with dissociative disorders have a high degree of hypnotizability

9. Deficit Model [Janet] Pathological poverty or deficiency of the basic mental energy that enable a healthy person to combine the various mental functions (sensation, volition, memories) into a stable, unified psychological structure under the conscious domination and control of self or ego

10. Conflict Model [Freud] Ego vigorously protect itself from psychological pain trough the operation of the defensive mechanism of repression – a process manifested phenomenologically as dissociation Aztec Mask: The Three Faces of Life

11. Dissociative Amnesia The severity of loss of memory (partial or complete) for recent events of traumatic or stressful nature contrasts with the otherwise very good preservation of other cognitive functions and the individual’s ability to utilize memory that are not of a personal nature DDx: transient global amnesia

12. Dissociative Fugue Features of dissociative amnesia + purposeful travel beyond the usual everyday range and maintenance of basic self-care. Simple social interactions with strangers are usually preserved. Loss of personal identity and of one’s entire past life, by assumption of a new identity.

13. Betty is a waitress in a diner, who pours coffee behind her back while her eyes are glued to her favorite soap opera A Reason to Love . She has no idea that her husband is selling drugs at his car dealership, that he is having an affair with his secretary, or that he intends on leaving Betty. Betty witnesses the murder and experiences a fugue state, escaping the reality of murder into the comforting fantasy of the soap opera. In her mind, she assumes the identity of one of the characters in the daytime drama, a nurse.

14. Dissociative Identity Disorder There exist within the person 2 or more distinct personalities or personality states, at least 2 of which recurrently take full control of the person’s behavior. The alters are separated by a varying degree of an amnestic barrier.

15. The Three Faces of Eve [1957] Eve White is a quiet, self-effacing wife and mother who has headaches and occasional blackouts. Eventually she is sent to see a personality psychiatrist Dr. Luther, and while under hypnosis her "alter personality", wild, fun-loving Eve Black , discloses herself. With Eve Black on the loose, Eve White's husband leaves her and abandons their daughter. Under continued therapy, a third personality appears, the relatively stable Jane . Chris Costner Sizemore walking the red carpet at the 51st Anniversary Encore Presentation of the World Premiere of The Three Faces of Eve, 18 September 2008 at Augusta, Georgia.

16. People less easily hypnotized use other coping strategy and DID does not developed Childhood Trauma between ages 4 and 6 People skilled at self-hypnosis use it to develop a second personality, which bears the brunt of the trauma When a new and different trauma is experienced, a third personality is created, because the strategy of creating another personality successfully relieved the earlier trauma Model of Dissociative Identity Disorder [DID]

17. Dissociative Trance Disorder Trance: temporary marked alteration in the state of consciousness or loss of customary sense of personal identity without replacement of alternate identity Possession trance: with replacement of customary personal identity with a new identity attributed to the influence of a spirit, power, deity or other person.

18. DSM-IV Exclusion criteria: The trance or possession state causes clinically significant distress or impairment in social, occupational, or other important area of functioning

19. DSM-IV Exclusion criteria: The trance or possession state is not accepted as a normal part of a collective cultural or religious practice

20. http://worldrec.info/2008/09/10/smk-tanjung-lumpur-kuantan-pahang-malaysia-the-worlds-most-haunted-school

21. What did the affected students see? (i) most claimed that they saw a being with long hair (ii) others claimed they were possessed by an old woman. That was apparently the reason why they acted and sounded like one. But some victim’s parents disagreed, like Mariah Mat Zain who said: I’ve seen my daughter [form 2 student] turning her head more than 180 degrees. She could also overpower five men when possessed. She had been transferred to another school but she still suffers from bouts of hysteria. Don’t tell me she is faking it. She’s too young to do it. Hysteria at SMK Tanjung Lumpur, Kuantan, Pahang, Malaysia The Exorcist [1973]

22. Dissociative Disorders NOS Individuals subjected to periods of prolonged and intense coercive persuasion e.g., brainwashing, or indoctrination while captive Culture-bound syndrome e.g., amok, latah, and pibloqtoq Ganser syndrome:

23. Amok is often described as a culture-bound (or culture-specific) syndrome, which is a psychological condition whose manifestation is strongly shaped by cultural factors. Amok is also sometimes considered one of the subcategories of dissociative disorders (cross-cultural variant)

24. Ganser Syndrome May be present in association with variety of dissociative symptoms. Mainly in men, especially those imprisoned in penal institutions. Characterized by pseudostupidity in the person’s speech and behavior The person gives ridiculous answer to simple question – replying “five” for instance when asked “how much is two and two?”

25. Dissociative [conversion] disorders have an unconscious motivation to resolve intrapsychic conflict, and may show the following Primary gain [to resolve conflict or reduce anxiety] Secondary gain [e.g., the attention of others] Symptom choice may be symbolic of the conflict and reflect modeling of symptoms either the individual or others have experienced La belle indifference [calm acceptance of symptoms]