Dissociative Disorders

Maha S Younis

Definition

(DSM-IV-TR)- “the essential feature of the dissociative disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. The disturbance may be sudden or gradual, transient or chronic.”

(ICD-10) classifies the dissociative disorders among the neurotic, stress-related, and somatoform disorders. The ICD-10 explicitly states that the term hysteria should be avoided because of its lack of precision.

DSM IV Dissociative disorders dissociative identity disorder depersonalization disorder dissociative amnesia dissociative fugue dissociative disorder not otherwise specified

(NOS)

ICD 10

dissociative amnesia, dissociative fugue, dissociative stupor, trance and possession disorder, and dissociative disorders of movement and sensation (roughly equivalent to the DSM-IV-TR conversion disorder diagnosis). The latter includes dissociative motor disorders, dissociative convulsions, and dissociative anesthesia and sensory loss. Ganser syndrome and multiple personality disorder are classified under other dissociative disorders. Depersonalization disorder is classified separately. 

Terminology

Conversions applies to somatic symptoms and dissociative applies to psychological symptoms.

Several authors, most recently E.A. Holmes and R.J. Brown, have suggested a heuristic dichotomy between

dissociative detachment (e.g., depersonalization) and dissociative compartmentalization (e.g., amnesia and dissociative identity disorder self-states),

each with their own empirically or hypothesized, underlying neurobiological and neurocognitive correlates.

Conscious vs Unconscious

Model proposed by Spence invokes a consciousness that acts upon the body and the world as opposed to the psychodynamic model (conversion) which invokes an unconscious mechanism.

Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatient clinics

Alan J Carsona, Brigitte Ringbauera, 

Jon Stoneb, Lesley McKenzieb, Charles Warlowc,Michael Sharpea

2000;68:207-210 doi:10.1136/jnnp.68.2.207

Table 17-2. Prevalence of Dissociative Disorders in General Population SamplesStudy Ross (1997) Johnson et al. (2006) Sar et al. (2007)

Measures DES and DDIS Adapted from DES, SCID, SCID-II, and GAFS

DDIS, SCID-PTSD, and SCID-II

Number of subjects 502 658 628 (female)

Diagnosis Subjects (%) Subjects (%) Subjects (%)

Dissociative amnesia 6.0 1.8 7.3

Dissociative fugue 0 0 .2

Dissociative identity disorder 1.3 1.5 1.1

Depersonalization disorder 2.8 .8 1.4

Dissociative disorder not otherwise specified (NOS) .2 4.3 8.3

Dissociative disorder NOS with multiple personality states

    4.1

Dissociative disorder NOS with indirect cues for personality states

    2.4

Derealization without depersonalization     1.1

Dissociative trance disorder     .6

All dissociative disorders 12.2 9.1 18.3

Prevalence of Dissociative Disorders

in General Population Samples (CTP)

Clinical features

Conversion disorder- motor symptoms Paralysis, functional weakness, gait

disturbance, fits resembling epilepsy, and abnormal movements.

Sensory symptoms – sensory loss,visual loss

Disability and prognosis

Often poor. Short history and young age is good

prognosis.

Management

No/ very few RCT Cochrane review –all studies were of poor

methodological quality.

Cochrane Database Syst Rev. 2005 Oct 19;(4):CD005331.Psychosocial interventions for conversion disorder.

Ruddy R, House A.University of Leeds,Academic Unit of Psychiatry & Behavioural Sciences,15 Hyde

Terrace,Leeds,UK LS2 9LT. R.A.Ruddy@leeds.ac.uk

Management-Team work( liaison services) Needs collaboration from psychologists,

nurses, physiorherapists, and occupational therapists.

IP care may be needed.

Management

Exclude organic conditions. To explain the there is no underlying serious

organic disorder. Explanation of symptoms that is

comprehensible to the patient. Better to use the word functional rather than

psychological.

Long term – behavioral techniques. Psychological- CBT,IPT Hypnosis Pharmacological- SSRI and TCA benefit

medically unexplained symptoms( such as poor sleep and pain) whether or not depression is present.

Antidepressants and Cognitive-Behavioral Therapy for Symptom Syndromes

Jeffrey L. Jackson, MD, MPH, Patrick G. O’Malley, MD, MPH, and Kurt Kroenke, MD

CNS Spectr. 2006;11(3)212-222

A Randomized Controlled Clinical Trial of a Hypnosis-Based Treatment for Patients with Conversion Disorder, Motor Type

Authors: Moene F.C.; Spinhoven P.; Hoogduin K.A.L.; Dyck R.V.Source: International Journal of Clinical and Experimental Hypnosis, Volume

51, Number 1, January 2003 , pp. 29-50(22)Publisher: Routledge, part of the Taylor & Francis Group

Imaging studies

Functional neuro omaging studies suggest that some amount of disruption in the neural circuits linking volition, movement, and perception.

Pre frontal cortex.

Summary.

Lot of debate regarding definition, classification.

Course and prognosis can frequently be bad. Liaison with multiple service providers may

be need. Studies not much about effectiveness of

interventions. Generates of interest because of inter

disciplinary nature of the disorder.