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.
- Appropriate imaging (at minimum CT/CTA head, MRI preferred)
- Lumbar Puncture (looking for infectious, autoimmune causes)
- Paraneoplastic workup (this patient also had a normal CT chest/abd/pelvis)
- 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
|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.