Dissociative Spectrum Disorders in the Primary Care Setting

Abstract

Dissociative disorders have a lifetime prevalence of about 10%. Dissociative symptoms may occur in acute stress disorder, posttraumatic stress disorder, somatization disorder, substance abuse, trance and possession trance, Ganser's syndrome, and dissociative identity disorder, as well as in mood disorders, psychoses, and personality disorders. Dissociative symptoms and disorders are observed frequently among patients attending our rural South Carolina community mental health center. Given the prevalence of mental illness in primary care settings and the diagnostic difficulties encountered with dissociative disorders, such illness may be undiagnosed or misdiagnosed in primary care settings. We developed an intervention model that may be applicable to primary care settings or helpful to primary care physicians. Key points of the intervention are identification of dissociative symptoms, patient and family education, review of the origin of the symptoms as a method of coping with trauma, and supportive reinforcement of cognitive and relaxation skills during follow-up visits. Symptom recognition, Education of the family, Learning new skills, and Follow-up may be remembered by the mnemonic device SELF. We present several cases to illustrate dissociative symptoms and our intervention. Physicians and other professionals using the 4 steps and behavioral approaches will be able to better recognize and triage patients with dissociative symptoms. Behaviors previously thought to be secondary to psychosis or personality disorders may be seen in a new frame of reference, strengthening the therapeutic alliance while reducing distress and acting-out behaviors.

A Case of Persistent Generalized Retrograde Autobiographical Amnesia Subsequent to the Great East Japan Earthquake in 2011

“…Most of such cases are probably ignored as subthreshold in the catastrophic situations in the aftermath. Physicians and other professionals who take care of victims of disaster should be aware of such dissociative spectrum disorders [ 16 ].…”

Challenges in the early assessment and protection of refugee survivors of torture and extreme violence

“…Such spirits include the "chen" in Uganda in the last example or those responsible for the "nightmare death" described in Hmong survivors of the Vietnam war (103,104). Rituals to appease the ghost and resolve the internal conflict and feeling of unfulfilled obligation are consequently common and would be added to or replace treatment (105,106) but might be interrupted in war or displacement. Culture specific explanatory models for symptoms or illness must also be considered (111), as symptoms for example of PTSD might be attributed not to torture, but to other including metaphysical problems like witches or spirits (112).…”

Dermatitis artefacta in a vulnerable adult with a dissociative state

“…Dissociative symptoms have been described in situations of acute stress, post‐traumatic stress disorder, somatization disorder, substance abuse, trance, Ganser syndrome, psychoses and personality disorders . Dissociative symptoms may be negative, positive, psychoform, or somatoform, or may be associated with alteration of consciousness .…”

“…A dissociative state indicates that the person is detached from reality, and the condition is on a spectrum, ranging from a defence mechanism to altered states of consciousness. Dissociative symptoms may surface during periods of acute interpersonal or situational difficulties . It is suggested that traumatic experiences cause dissociative symptoms as an adaptive response, and scores on the Dissociative Experiences Scale are closely correlated with childhood trauma…”