A 17-year-old girl is brought to the office by her parents due to recurrent episodes where "she seems to be lost in her own world." The parents say that the episodes began about 2 years ago, but seem to be occurring more frequently since a difficult breakup with her boyfriend several months ago. The patient acknowledges that she seems to "space out" easily. She says, "I often feel numb, like I'm in a fog or a dream. Sometimes, I feel as if I'm not myself, as if things are happening to someone else." The patient uses nonsteroidal anti-inflammatory drugs for menstrual cramps. She has no other medical conditions. She smokes cigarettes but does not use alcohol or illicit drugs. Physical and neurologic examinations are normal. On mental status examination, the patient is cooperative with a mildly anxious mood and flat affect. Which of the following is the most likely diagnosis?

Question

A 17-year-old girl is brought to the office by her parents due to recurrent episodes where "she seems to be lost in her own world."  The parents say that the episodes began about 2 years ago, but seem to be occurring more frequently since a difficult breakup with her boyfriend several months ago.  The patient acknowledges that she seems to "space out" easily.  She says, "I often feel numb, like I'm in a fog or a dream.  Sometimes, I feel as if I'm not myself, as if things are happening to someone else."  The patient uses nonsteroidal anti-inflammatory drugs for menstrual cramps.  She has no other medical conditions.  She smokes cigarettes but does not use alcohol or illicit drugs.  Physical and neurologic examinations are normal.  On mental status examination, the patient is cooperative with a mildly anxious mood and flat affect.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3615_ea7e_9249_8b986b7b57d7_MD0001_00 Although transient experiences of depersonalization and derealization are common in the general population, this patient's persistent and recurrent episodes are consistent with depersonalization/derealization disorder. It is classified as one of the dissociative disorders and should be differentiated from dissociative amnesia and dissociative identity disorder. Episodes of depersonalization are characterized by a feeling of detachment or estrangement from the self or a sense of being an outside observer of the self. Derealization is a subjective sense of detachment or unreality regarding surroundings. In contrast to psychotic disorders, reality testing is intact during these unusual experiences (ie, individuals may feel detached from their bodies but know this is not true). (Choice A) Absence seizures typically begin in childhood and are frequently associated with staring, repetitive eyelid movements, automatisms, and lack of awareness of the episodes. (Choice B) This patient's intact reality testing and absence of psychotic symptoms (eg, delusions, hallucinations, disorganized speech and behavior) make brief psychotic disorder unlikely. (Choices D and E) Dissociative amnesia involves gaps in autobiographical memory, usually associated with a traumatic event. Dissociative identity disorder is a rare condition associated with severe trauma that involves fragmentation of identity into ≥2 distinct personality states. (Choice F) Depersonalization/derealization is not diagnosed as a separate disorder when it occurs as a feature of post-traumatic stress disorder (PTSD). However, this patient does not meet other criteria for PTSD: exposure to life-threatening trauma, intrusion (eg, nightmares, flashbacks), avoidance of reminders, and hyperarousal (eg, insomnia, hypervigilance). Educational objective: Depersonalization/derealization disorder is a dissociative disorder involving recurrent episodes of feeling detached from one's body or surroundings and/or feelings of unreality. __________ References: Dissociative disorders in DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/23394228) Dissociative disorders in medical settings. (http://www.ncbi.nlm.nih.gov/pubmed/24014229)

A 17-Year-Old Girl Is Brought to the Office by Her