Dissociative Disorders


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Dissociative Disorders

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Dissociative Disorders

  1. 1. Dissociative Disorders A Brief Overview. 30.1.10
  2. 2. Definition <ul><li>(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.” </li></ul>
  3. 3. <ul><li>(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. </li></ul>
  4. 4. DSM IV Dissociative disorders <ul><li>dissociative identity disorder </li></ul><ul><li>depersonalization disorder </li></ul><ul><li>dissociative amnesia </li></ul><ul><li>dissociative fugue </li></ul><ul><li>dissociative disorder not otherwise specified (NOS) </li></ul>
  5. 5. ICD 10 <ul><li>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.  </li></ul>
  6. 6. Terminology <ul><li>Conversions applies to somatic symptoms and dissociative applies to psychological symptoms. </li></ul>
  7. 7. <ul><li>Several authors, most recently E.A. Holmes and R.J. Brown, have suggested a heuristic dichotomy between </li></ul><ul><li>dissociative detachment (e.g., depersonalization) and dissociative compartmentalization (e.g., amnesia and dissociative identity disorder self-states), </li></ul><ul><li>each with their own empirically or hypothesized, underlying neurobiological and neurocognitive correlates. </li></ul>
  8. 8. Conscious vs Unconscious <ul><li>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. </li></ul>
  9. 9. Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatient clinics Alan J Carson a ,  Brigitte Ringbauer a ,  Jon Stone b ,  Lesley McKenzie b ,  Charles Warlow c , Michael Sharpe a 2000; 68 :207-210 doi:10.1136/jnnp.68.2.207
  10. 10. Prevalence of Dissociative Disorders in General Population Samples (CTP) Table 17-2. Prevalence of Dissociative Disorders in General Population Samples 18.3 9.1 12.2 All dissociative disorders .6     Dissociative trance disorder 1.1     Derealization without depersonalization 2.4     Dissociative disorder NOS with indirect cues for personality states 4.1     Dissociative disorder NOS with multiple personality states 8.3 4.3 .2 Dissociative disorder not otherwise specified (NOS) 1.4 .8 2.8 Depersonalization disorder 1.1 1.5 1.3 Dissociative identity disorder .2 0 0 Dissociative fugue 7.3 1.8 6.0 Dissociative amnesia Subjects (%) Subjects (%) Subjects (%) Diagnosis 628  (female) 658 502 Number of subjects DDIS, SCID-PTSD, and SCID-II Adapted from DES, SCID, SCID-II, and GAFS DES and DDIS Measures Sar et al. (2007) Johnson et al. (2006) Ross (1997) Study
  11. 11. Clinical features <ul><li>Conversion disorder- motor symptoms </li></ul><ul><li>Paralysis, functional weakness, gait disturbance, fits resembling epilepsy, and abnormal movements. </li></ul><ul><li>Sensory symptoms – sensory loss,visual loss </li></ul>
  12. 12. Disability and prognosis <ul><li>Often poor. </li></ul><ul><li>Short history and young age is good prognosis. </li></ul>
  13. 13. Management <ul><li>No/ very few RCT </li></ul><ul><li>Cochrane review –all studies were of poor methodological quality. </li></ul>
  14. 14. 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
  15. 15. Management-Team work( liaison services) <ul><li>Needs collaboration from psychologists, nurses, physiorherapists, and occupational therapists. </li></ul><ul><li>IP care may be needed. </li></ul>
  16. 16. Management <ul><li>Exclude organic conditions. </li></ul><ul><li>To explain the there is no underlying serious organic disorder. </li></ul><ul><li>Explanation of symptoms that is comprehensible to the patient. </li></ul><ul><li>Better to use the word functional rather than psychological. </li></ul>
  17. 17. <ul><li>Long term – behavioral techniques. </li></ul><ul><li>Psychological- CBT,IPT </li></ul><ul><li>Hypnosis </li></ul><ul><li>Pharmacological- SSRI and TCA benefit medically unexplained symptoms( such as poor sleep and pain) whether or not depression is present. </li></ul>
  18. 18. 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
  19. 19. 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
  20. 20. Imaging studies <ul><li>Functional neuro omaging studies suggest that some amount of disruption in the neural circuits linking volition, movement, and perception. </li></ul><ul><li>Pre frontal cortex. </li></ul>
  21. 21. Summary. <ul><li>Lot of debate regarding definition, classification. </li></ul><ul><li>Course and prognosis can frequently be bad. </li></ul><ul><li>Liaison with multiple service providers may be need. </li></ul><ul><li>Studies not much about effectiveness of interventions. </li></ul><ul><li>Generates of interest because of inter disciplinary nature of the disorder. </li></ul>