A 25-year-old woman is brought to the office by her husband, who is concerned about her intense mood swings and unusual behavior. The patient has rapid mood shifts that last for a few hours. Although she is typically quiet and reserved, the husband reports that she can suddenly become enraged without provocation. The patient does not remember these episodes. The husband was also alarmed when he found her at a local bar dressed in a seductive outfit; when he called her name she did not respond to him and just walked away. When he confronted her at home she denied having been at the bar and hid behind a chair crying. When she was finally convinced to come out she was speaking in a childlike voice, saying, "leave me alone." The patient has experienced depression and anxiety since childhood but has never received psychiatric evaluation or treatment. She was physically and sexually abused at age 5-16. She is medically healthy and does not use alcohol or illicit drugs. When interviewed alone, the patient has difficulty giving a detailed history and has many gaps in her memory. Her mood is anxious and she hears voices that she describes as coming from inside her head. Which of the following is the most likely diagnosis?

Question

A 25-year-old woman is brought to the office by her husband, who is concerned about her intense mood swings and unusual behavior.  The patient has rapid mood shifts that last for a few hours.  Although she is typically quiet and reserved, the husband reports that she can suddenly become enraged without provocation.  The patient does not remember these episodes.  The husband was also alarmed when he found her at a local bar dressed in a seductive outfit; when he called her name she did not respond to him and just walked away.  When he confronted her at home she denied having been at the bar and hid behind a chair crying.  When she was finally convinced to come out she was speaking in a childlike voice, saying, "leave me alone."  The patient has experienced depression and anxiety since childhood but has never received psychiatric evaluation or treatment.  She was physically and sexually abused at age 5-16.  She is medically healthy and does not use alcohol or illicit drugs.  When interviewed alone, the patient has difficulty giving a detailed history and has many gaps in her memory.  Her mood is anxious and she hears voices that she describes as coming from inside her head.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7c6_a760_bc81_2f30d3fc9ee8_MD0003_00 This patient's gaps in autobiographical memory and recall of everyday events, and behavior suggestive of different personality states (ie, uncharacteristically aggressive and sexual behavior; regressive behavior and speaking in a childlike voice) are consistent with dissociative identity disorder (DID). DID is a severe, chronic condition in which 2 or more distinct identities, or personality states, alternately take control of an individual. Patients also experience memory loss that is too extensive to be explained by ordinary forgetfulness. Transition from one personality to another can be sudden and is usually precipitated by stress. DID is strongly associated with a history of severe and prolonged childhood trauma (eg, physical, sexual, or emotional abuse, neglect). Personality states are often connected to traumatic experiences such as a terrified, crying child or an angry, persecutory figure. Patients with DID commonly have chronic auditory hallucinations that have been present since childhood and are perceived as inside the patient's head (as opposed to psychotic disorders, in which voices seem to come from outside the head). Treatment consists of long-term, trauma-focused psychotherapy. (Choices A, B, F, and G) Patients with DID typically present with a complex mix of psychiatric symptoms (ie, mood symptoms, psychotic-like symptoms, dissociative symptoms) that overlap with those in other psychiatric disorders. DID is the only disorder that requires the presence of multiple personality states. Labile moods with characteristics of hypersexuality or aggression can be seen in bipolar disorder but typically last more than a few hours. Patients with borderline personality disorder and PTSD also exhibit mood instability and trauma-related dissociation, but neither condition presents with distinct personalities. Auditory hallucinations are characteristic of schizoaffective disorder, but these patients also have other psychotic symptoms. (Choices C and D) Patients with DID frequently experience both depersonalization/derealization and dissociative amnesia. These dissociative disorders would not be diagnosed separately in a patient with DID. Educational objective: Dissociative identity disorder is characterized by switching among two or more distinct personality states that take control of the patient's behavior and by an extensive inability to recall important personal information. The disorder is associated with severe childhood trauma and treated with long-term psychotherapy. References: Dissociative identity disorder: An empirical overview. (http://www.ncbi.nlm.nih.gov/pubmed/24788904) Revisiting the etiological aspects of dissociative identity disorder: A biopsychosocial perspective. (http://www.ncbi.nlm.nih.gov/pubmed/28496375)

A 25-Year-Old Woman Is Brought to the Office by Her