The dissociative disorders are a group of uncommon and poorly understood conditions where the central feature is a sudden alteration in the normal integration of identity and consciousness. The dissociation often occurs under severe stress and may or may not be recurrent, although it is rarely permanent. The forms of dissociative state relevant to emergency practice are psychogenic amnesia, a temporary loss of memory for important personal details that is not due to an organic cause, and psychogenic fugue, in which a similar loss of memory and assumption of new identity are accompanied by travel away from home. Dissociative disorders are difficult to distinguish from malingering, in which the individual in pursuit of a clear goal, such as avoiding incarceration or military duty, may consciously feign amnesia. As always, organic causes such as drug intoxication or loss of memory such as that resulting from transient global amnesia must be ruled out.
Other conditions in this category include multiple personality disorder and depersonalization disorder. PERSONALITY (AXIS II) DISORDERS
Personality refers to an enduring pattern of perceiving, relating to, and reacting to one's environment and interpersonal relations. When a pattern of behavior is lifelong, not limited to periods of illness, and causes significant impairment in social and occupational functioning or considerable distress, a personality disorder is present. Some individuals are painfully aware of the consequences of their behavior but are unable to alter these fundamental ways of dealing with their world. Most of the patients who are seen clinically in medical and psychiatric settings who are diagnosed with a personality disorder lack a clear awareness of how their behavior alienates others or aggravates their own stress. Even when such insight is possible, actual personality change is unlikely.
The patient presenting with a personality disorder may often be recognized by the characteristic effect the interaction has on the physician and medical staff. Antisocial patients, for instance, are disliked immediately; they seem to be in control of their behavior unlike psychotic or depressed patients, but nonetheless have repeatedly engaged in maladaptive behavior. The patient may be seen as using the emergency department for some vague, or obvious, goal. These disorders are the most common secondary diagnosis in the malingerer.
The emergency physician seldom needs to decide which of the personality disorders relates appropriately to the patient. General categories of personality disorders are grouped in Table280-2. When such features are present and seem to be interfering with some important aspect of the patient's life, personality disorder can be suspected. The presenting complaint should be evaluated appropriately, because patients with well-established character disorders still develop bona fide medical illnesses.
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