Dissociative disorders: Clinical

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Dissociative disorders: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 45-year-old man is brought to the family medicine clinic by his wife because of memory loss occurring over the past year. The patient has no history of prior medical illness. His wife reports that slightly over a year ago, a devastating tornado destroyed their old home. Since that instant, the wife states that the patient has forgotten that they lived in that old home. When asked, the patient denies ever having lived in a home destroyed by a tornado. The patient is able to recall recent events. When questioned further, the patient is able to remember obscure details such as the color of their old mailbox and the flowers in their old backyard. Physical examination reveals a well-appearing and well-groomed man in no distress. Mini mental status examination shows a score of 27 out of 30. Which of the following is the most likely diagnosis?


Dissociative disorders cause a disconnection or a lack of continuity between the individuals and their own thoughts, memories, actions, and identity.

For example, people might have out of body experiences or they might not remember important aspects of a traumatic event that they’ve been through - and that can cause distress and impairment.

Switching off from reality is a normal defense mechanism that helps the person cope during a traumatic time. In other words, it's a form of denial.

This behaviour becomes pathological when the traumatic event has ended but the person still hasn’t dealt with it properly.

People who dissociate may feel disconnected from themselves and the world around them, and these experiences can last for a relatively short time - hours or days, or for much longer - weeks or months.

When diagnosing a dissociative disorder, all other mental disorders should be ruled out.

Also, the symptoms should not be attributable to the physiological effects of a substance and should cause significant distress or impairment in all areas of functioning.

Environmental factors that contribute to dissociative disorders include a history of psychological trauma, especially traumatic experiences like physical, sexual or emotional abuse during childhood, or experiences such as war, kidnapping, or even serious medical procedures.

According to DSM-5, there are five related conditions: dissociative identity disorder, dissociative amnesia, depersonalization/derealization disorder, other specified dissociative disorder, and unspecified dissociative disorder.

First, there’s dissociative identity disorder which is where individuals have two or more distinct personality states.

When a person is experiencing another identity they typically lose their normal sense of self and control, and can have differences in emotion, behavior, consciousness, memory, perception, cognition, sensations, and movement.

For example, individuals might suddenly start acting like a totally different person for a few moments, then immediately switch back to their old self.


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