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Dissociation in teens often linked to family issues: Local study

23 Sep 2021

  • In-depth psycho-social assessment of family essential to diagnose complex cases and provide evidence-based treatment planning
BY Ruwan Laknath Jayakody It is imperative that detailed and in-depth psycho-social assessment be conducted in order to both diagnose complex presentations of dissociation in adolescents and to plan evidence-based treatment, a local study on masked presentations of dissociative disorder among adolescents noted. Dissociative disorders involve a persistent mental state that is marked by feelings of being detached from reality. This was noted in a brief report on “Masked presentations of dissociative disorder among Sri Lankan adolescents” authored by M. Chandradasa, W.K.T.R. Fernando, and K.A.L.A. Kuruppuarachchi, published in the Sri Lanka Journal of Psychiatry 10 (1) in June 2019. Dissociative disorders Dissociative disorders, as explained by Chandradasa et al., are believed to be caused by a discontinuity in the integration of consciousness, identity, emotion, motor control, memory, perception, and behaviour. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) noted that such could occur in adolescence as a response to traumatic and overwhelming life experiences that disrupt essential areas of psychological functioning. The most substantial levels of dissociation are, according to L. Lyssenko, C. Schmahl, L. Bockhacker, R. Vonderlin, M. Bohus, and N. Kleindienst’s “Dissociation in psychiatric disorders: A meta analysis of studies using the dissociative experiences scale”, seen with dissociative disorders, and thereafter in post-traumatic stress disorder (which occurs in people who have experienced or witnessed a traumatic event), borderline personality disorder (difficulty regulating emotion where the patient feels emotions intensely for long periods, in turn making it harder for them to return to a stable baseline after an emotionally triggering event), and conversion disorder (symptoms affecting the nervous system that cannot be explained solely by a physical illness or injury, with the symptoms usually beginning suddenly following a period of emotional or physical distress or psychological conflict), with a low association with substance-use-related disorders, eating disorders, schizophrenia (distortions in thinking, perception, emotions, language, sense of self, and behaviour that interfere with a person’s ability to think clearly, manage emotions, make decisions, and relate to others), anxiety disorder, obsessive compulsive disorder (having recurring and unwanted thoughts, ideas, or sensations that make the patient feel driven to do something repetitively), and affective disorders (affects the way one thinks and feels). Symptoms of dissociation in other psychiatric disorders, as noted in V.O. Haaland and N.I. Landro’s “Pathological dissociation and neuropsychological functioning in borderline personality disorder” and C. Spitzer, S. Barnow, H.J. Freyberger, and H. Joergen Grabe’s “Dissociation predicts symptom related treatment outcome in short term in patient psychotherapy” are linked to maladaptive functioning and poorer response to psychotherapeutic interventions. Simply put, dissociation has a negative impact on treatment outcomes as the subjects dissociate in response to the negative emotions that may arise whilst in therapy. Spitzer et al. also observed that such patients may have an insecure attachment pattern that would weaken the therapeutic relationship. Clinical complications In this regard, Chandradasa et al. pointed out that since the clinical presentation of dissociation is often sophisticated and can thereby mislead clinicians, compounded by the fact that there are limitations in the provision of child and adolescent mental health services in Sri Lanka, as per Chandradasa and Kuruppuarachchi’s “Child and youth mental health in post-war Sri Lanka” and Chandradasa and L.Champika’s “Sub-specialisation in postgraduate psychiatry and implications for a resource limited specialised child and adolescent mental health service”, this scenario results in many adolescents with such presentations not receiving comprehensive psychological assessments. Hence, Chandradasa et al. narrated the cases of three adolescents with complex mental health presentations, who were seen at the Colombo North Teaching Hospital in Ragama, that led to both diagnostic dilemmas and management-related conundrums. The first case  A 16-year-old girl presented to an outpatient psychiatric service with a reduced need for sleep, over-talkativeness, and euphoric mood during a two-week period. Following the first specialised psychiatric evaluation, her presentation was considered to be a manic episode (patients experience unreasonable euphoria, very intense moods, hyperactivity, and delusions) and she was then commenced on antipsychotics. This management approach did not lead to any improvement in her clinical status. She was brought to the hospital by her family. According to the family, she had been more emotionally attached to her father since childhood. However, the father had, following an intense argument with the girl’s mother, left home a day before the onset of the symptoms. The antipsychotics were discontinued and several solution-focused brief family therapy sessions were held with the parents. Subsequently, her symptoms resolved entirely, and she remained psychologically stable after her father returned home. The second case A 14-year-old boy had presented to the health services during the time of the inter-ethnic conflict. The law enforcement authorities had been informed about him after he was found by a group of villagers. He apparently spoke in Tamil and mentioned names of several terrorist leaders. Many villagers were suspicious of him as this happened at the height of the armed conflict when there was a constant threat of deadly bombing by the militants. His behaviour suggested that he did not comprehend Sinhalese. He also exhibited manic-like symptoms with euphoric mood, over-talkativeness, physical over-activity, grandiose ideas, and the reduced need for sleep, for over a month. There was no presence of multiple identities. Subsequent social investigations revealed that he was from a Sinhalese family, and that he had witnessed violence towards him and his mother at home, prior to the change in his behaviour. In “Dissociative disorder presenting as foreign accent syndrome”, N. Rajpal and S. Chakrabarti had found limited evidence of a rare speech-related disorder known as the foreign accent syndrome, where the defining characteristic is the appearance of a new accent, different from the speaker’s native language and which is perceived as foreign by others. In the case of the boy in the second case, Tamil, though not being a foreign language to him, was however a new language. Rajpal and Chakrabarti explained that even though in the majority of such patients, this presentation is secondary to focal brain damage (areas of localised damage and includes contusions and lacerations), it has also been reported in association with psychiatric disorders, including dissociative disorders. Treatment with an abreaction, an antidepressant, and trauma-focused cognitive behaviour interventions helped him recover. An abreaction is the expression and consequent release of a previously repressed emotion, achieved through reliving the experience that caused it, typically through hypnosis or suggestion. In this instance, a clinician interviewed the patient under the influence of a drug. It is as N.A. Poole, A. Wuerz, and N. Agrawal mentioned in “Abreaction for conversion disorder: Systematic review with meta analysis”, a technique of emotional catharsis. That said, Poole et al. emphasised that the available systematic reviews show that the evidence for the effectiveness of drug interviews is of poor quality. However, Poole et al. observed that it may be of benefit in the treatment of acute dissociative disorder. The third case A 16-year-old boy had presented with irritability, disinhibition, a reduced need for sleep, over-activity, and regressed behaviour. He had been seen by several psychiatrists in outpatient settings, and had been diagnosed as having a manic episode and had been commenced on antipsychotics. A detailed psychological assessment revealed an underlying depressive state with anhedonia (inability to feel pleasure in normally pleasurable activities), reduced energy, and thoughts of hopelessness and guilt. Information from family members revealed that there had been intense conflicts between his older brother and father. He was treated the same way as the boy in the second case report, and he reached a stable psychological status and recovered. All three adolescents were diagnosed by a consultant psychiatrist as having unspecified dissociative disorder, per DSM-5. Assessment Discussing the three cases mentioned above, Chandradasa et al. noted that the adolescent trio had developed manic episode-like suggestive presentations in the context of intense psychological conflicts, which however mislead clinicians and led in turn to the initiation of unsuccessful treatment strategies. Furthermore, treatment within outpatient settings for juvenile bipolar affective disorder (a mood disorder characterised by a combination of manic, hypomanic, and depressive episodes or severe mood swings, where there are periods of deep, prolonged, and profound depression that alternate with periods of excessively elevated or irritable mood known as mania) had not facilitated their recovery but comprehensive psychological formulations which took into consideration psycho-social stressors, had helped in the diagnosis of masked dissociative symptoms and to then adopt targeted management, thus leading in turn to clinical recovery.
  1. Bob, P. Selesova, J. Raboch, and L. Kukla noted in “Dissociative symptoms and mother’s marital status in the young adult population” that conflicts in the relationship between parents could be associated with dissociative symptoms in young persons. Family-based conflicts were seen in all three local cases, prior to the onset of the symptoms.
Therefore, Chandradasa et al. noted that the relevant social investigations, and collecting information from parents and family must be carried out when assessing children and adolescents presenting with possible dissociative symptoms.


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