dissociation versus repression

[DrGachet]

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How do you distinguish the two?

 

[whopper]

Difficult because the two phenomenon are difficult to measure externally.

For dissociation one could use the DES. Clinically, I tend to notice dissociation in those that at specific times of the day appear "zonked" without any medication and in response to specific stressors. E.g. I had someone who lay down, did not response to questions, and after finding out her estranged husband was going to take her back immediately was better. A few days later he decided not to take her back and there she was again in her room, in a corner staring at the ground and doing so for several hours straight.

Of course, I guess a slap would've snapped her out of it but we're not allowed to do that.

Repression: Asfar as I know, you're just going to have to interview the patient and ask them how they deal with specific stimuli.

 

[sunlioness]

I think they're pretty apples and oranges. Repression is a psychoanalytic defense mechanism from Freud. Dissociation is a clinical concept that can be measured with evidence-based tools. So when I suspect dissociation, I'll use the DES. Repression, I don't worry about so much.

I've heard others try to explain the difference as dissociation being more of a "vertical split" in which disagreeable memories or personality fragments are split off from the whole. These people state that in repression, these things are pushed downward into the subconscious. That explanation never seemed particularly scientific or useful to me.

I think this mostly comes up when discussing the idea of "recovered memories", a phenomenon that is actually more likely to be secondary to a dissociative process. But the whole "repressed/recovered memory" thing gives me a squicky feeling (and yes, that's the technical term 🙂 ), given the often-times unethical, boundary-impaired providers who are more often than not the proponents of such things.

 

[DrGachet]

I think they're pretty apples and oranges. Repression is a psychoanalytic defense mechanism from Freud. Dissociation is a clinical concept that can be measured with evidence-based tools. So when I suspect dissociation, I'll use the DES. Repression, I don't worry about so much.

I've heard others try to explain the difference as dissociation being more of a "vertical split" in which disagreeable memories or personality fragments are split off from the whole. These people state that in repression, these things are pushed downward into the subconscious. That explanation never seemed particularly scientific or useful to me.

I think this mostly comes up when discussing the idea of "recovered memories", a phenomenon that is actually more likely to be secondary to a dissociative process. But the whole "repressed/recovered memory" thing gives me a squicky feeling (and yes, that's the technical term 🙂 ), given the often-times unethical, boundary-impaired providers who are more often than not the proponents of such things.

I am familiar with the vertical/horizontal distinction that you mention. Though I agree with you that they are quite different, I don't think they're easily distinguishable.

I see repression more as a reaction to wishes and impulses (Freudian concept, as you noted) whereas dissociation is response to outside circumstance. However, there are times that the situation is personally relevant to the person and it may involve both...which confuses me.

 

[whopper]

A patient with multiple disorders is like trying to figure out what's in a complex recipe only by tasting it.

It's easy to figure out what ingredients are in your oatmeal. That's like someone with 1 disorder.

Having someone with over 1 Axis I disorder, and mix in a few personality disorder symptoms, it could get difficult. Just like complex dishes, however, with experience you will be able to figure it out if you choose to do your job for real.

The person you are mentioning may have repression and dissociation. I would not find that surprising because for someone to dissociate to a pathological degree, there are likely more things going on than simply that phenonmenon.

I got a patient that finally after a week I think I'm confident what the person has...

Personality Change due to Fetal Alcohol Syndrome: combined type, Labile and Disinhibited
AD/HD
Borderline Personality Disorder
Antisocial Personality Disorder

Let's just say it's been a heck of a ways to get to the diagnosis and while I'm confident, I'm not 100% certain. Nothing going on was fitting the too easy diagnosis he had before---Bipolar Disorder. E.g. antipsychotics made him feel more hyper, they did not sedate him (I'm talking over 400 mg Thorazine in less than an hour), mood stabilizers-no benefit, I wasn't going to try a stimulant at this phase, the guy was clear for a few hours, then he'd start screaming and disrobe because according to him he thought it was funny......

 

[DrGachet]

A patient with multiple disorders is like trying to figure out what's in a complex recipe only by tasting it.

It's easy to figure out what ingredients are in your oatmeal. That's like someone with 1 disorder.

Having someone with over 1 Axis I disorder, and mix in a few personality disorder symptoms, it could get difficult. Just like complex dishes, however, with experience you will be able to figure it out if you choose to do your job for real.

The person you are mentioning may have repression and dissociation. I would not find that surprising because for someone to dissociate to a pathological degree, there are likely more things going on than simply that phenonmenon.

I got a patient that finally after a week I think I'm confident what the person has...

Personality Change due to Fetal Alcohol Syndrome: combined type, Labile and Disinhibited
AD/HD
Borderline Personality Disorder
Antisocial Personality Disorder

Let's just say it's been a heck of a ways to get to the diagnosis and while I'm confident, I'm not 100% certain. Nothing going on was fitting the too easy diagnosis he had before---Bipolar Disorder. E.g. antipsychotics made him feel more hyper, they did not sedate him (I'm talking over 400 mg Thorazine in less than an hour), mood stabilizers-no benefit, I wasn't going to try a stimulant at this phase, the guy was clear for a few hours, then he'd start screaming and disrobe because according to him he thought it was funny......

Wow, it would take me a hell of a lot longer than that to diagnose such a complex case. I admire your skills. Though I don't want to have the responsibility (and I don't) of assessing these types of cases, I do like a good puzzle. 🙂

Do you do assessments in a forensic setting? In other words, had this person committed a crime? BPD and ASPD, that's some scary combo!

 

[loveoforganic]

Ok... multiple personality disorders is awfully damn hard to google thanks to the old DID term... How common is it to have someone present with multiple PD's? I have been under the assumption that PD's were intended to provide an all-encompassing view of what guides someone's behavior, minus axis i stuff. Looking between the DSM criteria for the two, I can certainly see the overlap that would lead someone to meet the criteria for both ASPD and BPD, but one really doesn't characterize the behavior better than the other?

 

[DrGachet]

Ok... multiple personality disorders is awfully damn hard to google thanks to the old DID term... How common is it to have someone present with multiple PD's? I have been under the assumption that PD's were intended to provide an all-encompassing view of what guides someone's behavior, minus axis i stuff. Looking between the DSM criteria for the two, I can certainly see the overlap that would lead someone to meet the criteria for both ASPD and BPD, but one really doesn't characterize the behavior better than the other?

I think it's a matter of how we have defined the diagnostic criteria. DSM-V is going to bring major changes.

As it stands, comorbidity of personality disorders is fairly high. A large percentage of people with BPD have other Cluster B PDs as well (e.g. NPD, ASPD), perhaps as high as 50% though I need to look at the latest research for exact numbers.

 

[OldPsychDoc]

A patient with multiple disorders is like trying to figure out what's in a complex recipe only by tasting it.

It's easy to figure out what ingredients are in your oatmeal. That's like someone with 1 disorder.

Having someone with over 1 Axis I disorder, and mix in a few personality disorder symptoms, it could get difficult. Just like complex dishes, however, with experience you will be able to figure it out if you choose to do your job for real.
......

Love the cooking analogy! My problem is, all my patients use LOTS of wine and vodka in their recipes, an occasionally season with cocaine as well... 😉

 

[loveoforganic]

I think it's a matter of how we have defined the diagnostic criteria. DSM-V is going to bring major changes.

As it stands, comorbidity of personality disorders is fairly high. A large percentage of people with BPD have other Cluster B PDs as well (e.g. NPD, ASPD), perhaps as high as 50% though I need to look at the latest research for exact numbers.

I don't have a DSM on campus with me - is there not a "unless better accounted for by ..." clause with PD's like there is with axis i diagnoses?

 

[sunlioness]

Ok... multiple personality disorders is awfully damn hard to google thanks to the old DID term... How common is it to have someone present with multiple PD's?

DID is actually the current term. And DID/MPD is an Axis I disorder that technically has nothing to do with personality disorders. So Multiple Personality Disorder (currently called Dissociative Identity Disorder) is different than having more than one diagnosed personality d/o on Axis II.

 

[loveoforganic]

I was trying to google multiple comorbid personality disorders, but kept getting crappy hits, thanks to the old term for DID, MPD. Sorry for the unclear sentence 🙂

 

[sunlioness]

Ah, I got it now. 🙂

 

[Suedehead]

Love the cooking analogy! My problem is, all my patients use LOTS of wine and vodka in their recipes, an occasionally season with cocaine as well... 😉

this made my day

 

[whopper]

Do you do assessments in a forensic setting? In other words, had this person committed a crime? BPD and ASPD, that's some scary combo!

I got the advantage of having a great psychologist work with me and the hospital being a host to a psychology master's program where we can have the master's students do plenty of testing. I didn't use testing on this guy because his acting out was so extreme he was not appropriate for testing until yesterday.

The trick with this guy IMHO was that Clonidine greatly stabilized him and he had a few hours of no problems. There were no psychotic symptoms that were clearly psychosis (e.g. no negative symptoms, no delusions, no paranoia), he often acted out if he did not get immediate gratification, and he said antipsychotics made him feel more hyper and they did not sedate him.

Then I found out his mother drank like a fish when she was pregnant. He does show some FAS facial characterstics but that is too nonspecific a test.

What helped me was hours of observation, experience and when we gave an emergency medication, only giving one so we knew exactly what each medication we gave did to him. It came to a head about 3 days ago. I gave him Thorazine 100 mg oral, then 20 minutes later, Prolixin 15 mg oral and crushed, then 25 minutes later Thorazine 100 IM, then put him in restraints. I will not give him Haldol because there is a medical record showing he had seizure a few years ago after he got injected with it. Each time we gave him an antipsychotic he said it just made him feel more hyper. I felt that giving him more was just being a fly hitting the window. I tried Clonidine after he was released from restraints and he told me that for the first time in years he actually felt a medication causing him some improvement. Given that it treats ADHD, he had symptoms of ADHD and that it's not a substance of abuse, I figured this was ADHD of the worst extreme I ever saw.

Another advantage is I work in a long-term facility. In that setting you can devote several hours on one patient a day. In a short term facility, you have to get them out as soon as possible or the institution starts losing money.

It took me about 6 days to figure this out, and another few days to reinforce my theory. Of course nothing is ever 100% but it's to the point where he said he feels better and I'm not giving him anything that can be used for abuse. He's gone through years of being diagnosed with bipolar disorder and being given an antipsychotic and mood stabilizer that did nothing or made him worse. Right now I got him on a starting dose of Wellbutrin and a Clonidine patch and he's been fine for a few days.

I am though doubting he has antisocial PD because since he's been stabilized, he's told me he's regretted some of his prior behaviors. He also calls a family member regularly and cries over the phone because that's his only relative and that person is not in good health. IMHO this is FAS and ADHD to the worst extreme I've seen it--to the point where the guy cannot control impulses to cause a ruckus and he had an urge to cause one moment to moment. Now that he's been a bit more stable, he told me he has an urge to stir things up and the Clonidine's calmed it down. He's not been charged before the incident for which I'm seeing him now, but he has done several misdemeanor level behaviors that could've gotten him arrested but he got away with it. (E.g. screaming in a public place, baiting people into fights in public, etc).

 

[DrGachet]

What helped me was hours of observation, experience and when we gave an emergency medication, only giving one so we knew exactly what each medication we gave did to him.

Yes, giving one at a time. Same with psychological treatments where I work. Hedging one's bets can seem like an attractive option but does not help the health professional figure out what's causing what inside the patient.

I am though doubting he has antisocial PD because since he's been stabilized, he's told me he's regretted some of his prior behaviors. He also calls a family member regularly and cries over the phone because that's his only relative and that person is not in good health. IMHO this is FAS and ADHD to the worst extreme I've seen it--to the point where the guy cannot control impulses to cause a ruckus and he had an urge to cause one moment to moment. Now that he's been a bit more stable, he told me he has an urge to stir things up and the Clonidine's calmed it down. He's not been charged before the incident for which I'm seeing him now, but he has done several misdemeanor level behaviors that could've gotten him arrested but he got away with it. (E.g. screaming in a public place, baiting people into fights in public, etc).

I am surprised that someone with this sort of one of a kind impulsive ADHD and FAS (lower IQ perhaps?) has not been arrested before. Unless there are neurological/medical conditions (I'm not a physician so I'm just speculating) or meds/drugs issues complicating the case presently, he must either have much greater control over his behavior on a daily basis, or else have superior intelligence--to have evaded the law.

What an interesting case indeed. I can appreciate the complexity of the case, given that impulsiveness in your patient is common to many illnesses, including the diagnoses that you have been considering: ASPD, BPD, but also ADHD and FAS. I think it's wonderful that you were able to help him in such speedy manner and yet gain valuable information about the cause(s) behind his unmanageable behavior.

 

[whopper]

Other factors that tremendously helped me.

1) I talked to his father about 1 hour a day for 3 days and got every single bit of history I could from him. The father told me that when family members tried to restrict the mother from drinking, she actually started drinking household chemicals not designed for consumption but with at least some alcohol in it ranging from beauty to cleaning products. The father's input further reinforced the theory that this was not psychosis or mania but impulsivity to the worst degree I've ever seen.

2) Every single time this guy did something that required emergency medications (and this happened several several times, soemtimes 3 in an hour), they were IMHO the act I'd see in a difficult to control child but this guy was an adult. The first few times we did the usual antipsychotic + cogentin or anthistamine + ativan. After the 3rd day I decided to just give one med at a time because we needed to move forward.

3) Each time he spoke, while tremendously angry, he was not tangential or grandiose. Things he said actually made sense. He could hold it together whenever he talked to his father, often times for over 30 minutes. I decided from these things that it could not be mania.

This is simply what IMHO should be averge work. I have the time to do this type of observation in a long term facility. Since it's also a forensic facility, the Court keeps them there for months. Unfortunately, what I usually see are doctors simply doing what is needed to shut the person up and letting business go along as usual even in this situation. E.g. give the person as much Klonopin or Ativan as they want, only medicate the person to the point where they're no longer violent, but the person stays psychotic for months with no further medication adjustments, etc.

In a short-term facility, I can understand even a well meaning and experienced doctor missing this guy's diagnosis because you only got a few days to work with a case like this and you got to see all your patients in the day. In a long term facility you only have to see your patients once a week allowing me to devote hours to a specific patient (and I see some doctors in my facility write their notes about once a month, and bad notes at that!). I was able to give this case about 5 hours of work a day.

Was it hard? Overall no because usually during my 32 hour work week at that specific job (I also do private practice 16 hours a week) I only find myself working for real about 12 hours. Pretty much all my patients that are on my unit for months I get stable in about 2-3 weeks. Then after that they stew there and I can't discharge the patient because they are court-ordered to be there. I've even written several letters to judges telling them to discharge the patient and they just stew there at a cost of over $700/day to the taxpayer.