Virtual Morning Report – Final

Final Diagnosis:  Severe Acute dissociative/ depersonalization disorder.  Reported recent retirement, stress.    Possible Acute Stress Reaction/PTSD with dissociation, but without apparent traumatic event.  Ongoing Trial of Seroquel to improve sleep/reduce agitation.

Returned to ER after this workup:  Waking up at night, agitated, confused.  Would have bursts of yelling and then not recall.  Admitted Voluntarily to inpatient psych, with worsening anxiety/depression symptoms. 

Diagnosis of exclusion: Patients who go from functional to non-functional after the 3rd decade of life (dramatically reduced incidence of new onset schizophrenia) need full medical workup.

  1. Appropriate imaging (at minimum CT/CTA head, MRI preferred)
  2. Lumbar Puncture (looking for infectious, autoimmune causes)
  3. Paraneoplastic workup (this patient also had a normal CT chest/abd/pelvis)
  4. Careful history taking and screening for substance abuse (THC edibles, psychedelic use)

Course is not typical for Dementia (presentation at max severity, no sentinel events)

Prion disease is unlikely – no motor symptoms, no tremors, no ataxia.

Dissociation — Dissociation is a disruption of the usually integrated functions of consciousness, memory, identity, or awareness of body, self, or environment. Symptoms:

Consciousness –decreased responsiveness to external stimuli.

Memory –canoot recall autobiographical information- usually of a stressful nature.

Identity – Dissociation can cause confusion about or discontinuities in one’s identity.

Awareness of body, self, or environment

Depersonalization – Detachment or estrangement from one’s self;

Derealization – The sense that the external world is strange or unreal.

Overt dissociative amnesia

Dramatic, profound loss of memory for personal history. Patients can be confused, perplexed, and baffled by their deficits, although others appear relatively unconcerned  
Dissociative fugue — A subset  have “apparently purposeful travel or bewildered wandering”
Depersonalization Disorder

can have an episodic, relapsing/remitting, or chronic course   Marked by sig, depersonalization/ derealization without specifically losing memory or changing identity (Dissoc Identity Disorder)   Risk factors:
●Acute and chronic trauma or severe stress
●Psychiatric conditions, most commonly anxiety or depressive disorders
●Substance abuse  
PTSD with Dissociative Features  
●Type I trauma usually single traumatic experiences, hyper-arousal, vivid memories (flashbacks)
●Type II trauma usually exposure to extreme stressors over time – more common to have dissociation   Usually concomitant: anxiety, depression, substance use.

Case Summary Page

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