dissociative disorders

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.”

DSM IV Dissociative disorders

dissociative identity disorder depersonalization disorder dissociative amnesia dissociative fugue dissociative disorder not otherwise specified (NOS)

ICD 10

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.

Table 17-2. Prevalence of Dissociative Disorders in General Population Samples

Study
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

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 symptomsParalysis, 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.

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,IPTHypnosisPharmacological- 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 SyndromesJeffrey L. Jackson, MD, MPH, Patrick G. O’Malley, MD, MPH, and Kurt Kroenke, MD CNS Spectr. 2006;11(3)212-222

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.