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.

Fugue/Amnesia
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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