DISSOCIATIVE DISORDERS

CONTENTS
• Introduction
• Definitions
• Epidemiology
• ICD-10 Criteria & Clinical features
• Management
 INTRODUCTION
• Dissociative Disorder:
– Separation of mind control over body

• Conversion Disorder:
– Transformation of hidden/unexpressed emotions into physical
symptoms

• Functional disorder:
– Physical manifestations without any appropriate physical/organic cause

• Hysteria:
– Deprived sexual desires resulting in movement of Uterus and
consequent physical manifestations
 WHAT IS DISSOCIATION?
• Partial or complete loss of the normal
integration between memories of the past,
awareness of the identity, immediate
sensations and control of bodily movements.
 EPIDEMIOLOGY
• Review of 5 studies indicate an incidence rate of
5-12 per 1,00,000 per annum.
• Estimates of prevalence vary even more but
with figures around 50 per 1,00,000.
In India:-
• Prevalence rate of dissociative disorders in
psychiatric settings:
– 10%
• FEMALE >MALE
 EPIDEMIOLOGY
DISSOCIATIVE TYPE
WORLD INDIA
P-1.8%
AMNESIA P-7.5%
P-21.25%
FUGUE P-1.5%
P-1.2% P-15%
STUPOR

TRANCE AND POSSESION --- P-30%

P-25%
MOTOR ---

CONVULSION --- P-13.75%

ANAESTHESIA & SENSORY ----
P-2.5%
LOSS
 ETIOLOGY
• No definite cause

• Contributing factors:
– Most important: Significant Stress
– Coping strategy of the concerned individual

• Theory:

– Psychodynamic theories:
• Conversion of emotional distress into physical symptom, which often have
a symbolic meaning
– Social factors:
• Major determination of the onset and development of conversion
symptoms
– Neurophysiological mechanisms:
• Functional neuroimaging shows alterations in brain activation related to
how adverse events are processed and in the links between emotion,
memory and body schema.
 ICD-10 CRITERIA

Diagnostic guidelines
For a definite diagnosis the following should be present:
(a)the clinical features as specified for the individual
disorders in F44.-;
(b)no evidence of a physical disorder that might explain the
symptoms;
(c)evidence for psychological causation, in the form of clear
association in time with stressful events and problems or
disturbed relationships (even if denied by the individual).
• F44 Dissociative [conversion] disorders
F44.0 Dissociative amnesia
F44.1 Dissociative fugue
F44.2 Dissociative stupor
F44.3 Trance and possession disorders
F44.4 Dissociative motor disorders
F44.5 Dissociative convulsions
F44.6 Dissociative anaesthesia and sensory loss
F44.7 Mixed dissociative [conversion] disorders
F44.8 Other dissociative [conversion] disorders
.80 Ganser's syndrome
.81 Multiple personality disorder
.82 Transient dissociative [conversion] disorders occurring in
childhood and adolescence
.88 Other specified dissociative [conversion] disorders
F44.9 Dissociative [conversion] disorder, unspecified
 Amnesia Trance and Possession
Inability to recall Fugue Temporary loss of both
incidents or Features of amnesia + sense of personal identity
experiences that purposeful journey and full awareness of
happened at a away from home or surroundings.
particular time or workplace where self Patient acts as if taken over
care is maintained. by another personality,
one’s personal
spirit, deity or force.
information

De-realization
Objects ,people ,and /or
surroundings seem unreal, distant,
artificial, colorless, lifeless.

Movement and
Stupor Depersonalization
sensation
Profound diminution or Individual feels that his
There is loss of or
absence of voluntary or her own feelings or
interference with
movement and normal experiences are
movements or loss of
responsiveness to ext detached ,distant not
sensations (usually
stimuli his or her own, lost.
cutaneous)
 DISSOCIATIVE AMNESIA
• Inability to recall important personal memories, usually of a
stressful nature that is too extensive for normal forgetfulness.
• Frequently found in those whom suffered extreme acute
trauma or emotional stress.
• Types of dissociative amnesia:

1. Localized Amnesia: Inability to recall events related to a

circumscribed period of time
2. Selective Amnesia: ability to recognize some, but not all
of the events occurring during a circumscribed period of
time
 3)Generalized Amnesia: Failure to recall one’s entire life.

4)Continuous Amnesia: Failure to recall successive events as they occur.

5)Systematized Amnesia: Failure to remember a category of

information such as all memories relating to one’s family or to a

particular person

Diagnostic guidelines (F44.0)

a) amnesia, either partial or complete, for recent events that are of a
traumatic or stressful
nature (these aspects may emerge only when other informants are
available);
(b)absence of organic brain disorders, intoxication, or excessive fatigue.
 DISSOCIATIVE FUGUE
• Sudden, unexpected travel away from home or one’s
customary place of daily activities, with inability to
recall some or all of one’s past

• Accompanied by confusion about personal identity

or even the assumption of a new identity.

• Symptoms must cause clinically significant distress or

impairment in social, occupational or other
important areas of functioning.
Diagnostic guidelines (F44.1)
(a)the features of dissociative amnesia (F44.0);
(b)purposeful travel beyond the usual everyday range (the
differentiation between travel and wandering must be made
by those with local knowledge)
(c)maintenance of basic self-care (eating, washing, etc.) and
simple social interaction with strangers (such as buying tickets
or petrol, asking directions, ordering meals).
 DISSOCIATIVE STUPOR
• Patient is motionless and mute
• Do not respond to stimulation
• Aware of surroundings

Diagnostic guidelines(F44.2)
a)Stupor is diagnosed on the basis of profound diminution or
absence of voluntary movement and normal responsiveness to
external stimuli such as light, noise and touch .
• Lies or sits motionless for long periods of time.
Speech and spontaneous and purposeful movements are
completely or almost completely absent.
 Some degree of consciousness may be present,
muscle tone, posture, breathing and
sometimes eye opening and coordinated eye
movements.
(b)absence of a physical or other psychiatric
disorder that might explain the stupor; and
(c)evidence of recent stressful events or current
problems.
TRANCE AND POSSESSION DISORDERS
• Temporary, marked alteration in the state of
consciousness or by loss of the customary sense of
personal identity without the replacement by an
alternate sense of identity.

• Possession and trance involves single or episodic

alternations in the state of consciousness
characterized by the exchange of the person’s
identity with a new identity like spirit, divine power,
deity or another person.
• There is often a limited but repeated set of
movements, postures, and utterances.

• Only trance disorders that are involuntary or

unwanted, and that intrude into ordinary activities by
occurring outside religious or other culturally
accepted situations should be included here.
 DISSOCIATIVE MOTOR DISORDER

• Loss of ability to move the whole or a part of

a limb or limbs.
• Paralysis may be partial, with movements
being weak or slow, or complete.
• Ataxia may be evident particularly in the legs
leading to bizarre gait or inability to stand
unaided (Astasia-abasia)
• Exaggerated trembling or shaking of one or
more extremities or the whole body.
• May present as ataxia, apraxia, akinesia,
aphonia, dysarthria, dyskinesia or paralysis.
 DISSOCIATIVE CONVULSIONS
• Mimic epileptic seizures very closely in terms
of movements.
• tongue biting, serious bruising due to falling
and incontinence of urine are rare.
• No loss of consciousness or replaced by state
of stupor.
Feature Seizure Pseudoseizure

Clinical features
Nocturnal seizure Common uncommon

Stereotyped aura Usually none

Cyanotic skin changes
during seizures common none
Self-injury common rare
Incontinence common rare
Postictal confusion Present none
Body movements tonic or clonic or both asynchronous
EEG features
Spike and waveforms present absent
Postictal slowing present absent
lnterictal abnormalities variable variable
 DISSOCIATIVE ANAESTHESIA AND
SENSORY LOSS
• Anesthesia of selective areas of skin
• Loss of vision(rare) or visual disturbances are
often a loss of acuity, general blurring of
vision or tunnel vision
• Dissociative deafness and anosmia less
common.
 MIXED DISSOCIATIVE DISORDER
• If 2 or more than 2 dissociative disorders are
present .
 OTHER DISSOCIATIVE DISORDERS
-Ganser’s syndrome
-Multiple personality disorders
-Transient dissociative disorders occurring in
childhood and adolescence
-Other specified dissociative disorders
 Ganser’s syndrome
• Characterized by the giving of approximate
answers (paralogia) together with a clouding
of consciousness and is frequently
accompanied by hallucinations and other
dissociative symptoms.
 Multiple personality disorder
• Apparent existence of two or more distinct
personalities within an individual with only one of
them being evident at a time.

• Each personality is complete with its own memories,

behavior, and preferences.

• One personality is usually dominant but neither has

access to the memories of the other and the two are
almost always unaware of each other’s existence.
 GAINS
• Primary Gain:
– Relief obtained by the conversion of Stress
mental distress generated by a
hypothesized neurotic conflict into
physical symptoms, thereby allowing
Patient is anxious but
the conflict to remain unconscious
handle the stress in
• Secondary Gain: maladaptive way
– A significant external benefit or Functional
avoidance of unwanted Physical
responsibilities, as a result of symptoms
symptoms. Patient is relieved by:
• La belle indifference: 1: forgetting the stress and anxiety
Primary gain
– Conversion symptoms do not normally
2: People gives extra care to patient
reflect the appropriate physiological or Secondary gain
pathological mechanisms 3: Patient is not concerned with his
symptoms: La belle
 MANAGEMENT OF
DISSOCIATIVE DISORDER
 INTRODUCTION
• Dissociation is the ultimate form of human response to
chronic developmental stress.
• The cardinal feature of dissociation is a disruption in one
or more mental functions.
• The disruption of usually integrated functions of
consciousness, memory, identity, or perception.
• In contrast to several other psychiatric disorders, there is
as yet no specific drug treatment for dissociative
disorders.
• However, pharmacotherapy is often used in an attempt
to alleviate comorbidity and distressing symptoms.
• This is a unique spectrum of conditions which presents
challenges to mental health delivery systems, and to
psychiatry and medicine in particular.
 ASSESSMENT & DIAGNOSIS
• Diagnosis of dissociation should be made after complete
assessment & ruling out physical disorder that may explain the
symptoms.
• Any associated psychiatric co-morbidity.
• Common comorbidities : depressive disorder, anxiety disorders,
adjustment disorders, oppositional defiant disorder and specific
developmental disorder etc.
• Socio-occupational disturbances LIKE academic difficulties, family
problems, peer problems, sibling rivalry and at times difficult
situations like marriage etc.
• Any family history of psychiatric illness or similar illness (role
model).
• Pre - morbid personality assessment.
DIAGNOSIS OF DISSOCIATIVE DISORDER SHOULD NOT
BE MERELY BASED ON THE ABSENCE OF OBJECTIVE
SIGNS OF PHYSICAL DISORDER.
 DIFFERENTIAL DIAGNOSIS

• Affective disorder • Neurological and seizure

• Psychotic disorder disorder
• Anxiety disorder • Factitious disorder
• Post traumatic stress • Malingering
disorder
• Personality disorder
• Neurocognitive disorder
INVESTIGATIONS & EXAMINATIONS

• Investigations :
– Ct scan/ neuroimaging , EEG , I.Q tests, urine drug
screening, blood tests.
• Clinical mental state examination
• Screening instruments and standardized diagnostic
interviews.
SELF REPORT SCREENING MEASURES

SCALE CHARACTERISTICS STRUCTURE USE

Dissociative experience scale To assess trait dissociation in Average score of 28 items Score ≥ 30 gives strong
(DES) adults. rated 0-100% of the time predictive validity of
Translated in 40 different experienced. dissociation.
languages.

Adolescent DES (A-DES) For Adolescents Average score 30 items Score ≥ 4 predicts high levels
Similar scale Rated 0-10 of dissociation.
Never to always

Child dissociative checklist 5-12 years of age 20 items High discriminant validity
(CDC) Parents ,teachers, caregivers Score 1-5 among:
reports Not at all to extremely • Normal control girls
• Sexually abused girls
• Boys & girls with
dissociative NOS
• DID
DIAGNOSTIC MEASURES

CHARACTERISTICS STRUCTURE USE

Multidimensional inventory Diagnostic self report 218 items self reporting Very reliable scale.
of dissociation (MID) Score 0-10 Validity over DES.
30-90 min.

Clinician administered Clinician administered - Good validity

dissociative scale (CADSS) 28 items Highly reliable.
0-4 score

Dissociative disorder 132 items Inquires about ; dissociation, Inter-rater reliable.

interview schedule (DDIS) Clinician administered drug/sexual abuse, s/s of
Yes/no format depression, personality etc.
30-90 min.
 TREATMENT

• Dissociation and dissociative disorders can be treated

succesfully because they originate from a mechanism
which is not pathological per se.
• Appropriate treatment - Reversible.
• Inappropriate treatment – complicated / most difficult to
treat cases.
• The treatment usually consists of two parts:
– (a) early treatment directed toward symptom
removal and
– (b) long-term treatment directed toward the
resolution of stressors and prevention of further
episodes.
 PRINCIPLES OF ACUTE MANAGEMENT

1. Rapport and therapeutic alliance

2. Psycho-social explanation of dissociative symptoms
3. Solving the psychosocial problems
4. Symptom substitution
5. Secondary gains
6. Abreaction and aversion therapy
7. Medication
8. Need for hospitalization
1. Rapport and therapeutic alliance
– good doctor–parent relationship .
– alter overprotective and overindulgent attitude of
family members.
2. Psycho-social explanation of dissociative symptoms
– Rule out physical causes by careful assessment &
involving the patient & explaining the expected
outcome.
– Ensure family about no signs suggestive of physical
illness.
– Convey the possibility that it could be due to body
mind interaction problems.
3. Solving the psychosocial problems
– Systematically assess the severity & temporal
correlation of stressor with onset of symptoms.
– Once the causes are known, then attempts should be
made to solve the “problem.”
– Paying attention on patients functioning rather than
on the symptoms. This helps in speedy recovery.
4. Symptom substitution
– As the dissociative symptoms begin to subside, the
patient may sometimes manifest other new
dissociative symptoms (called as symptom
substitution).
– Occasionally, distress may be expressed by
deliberate self-harm, demanding, and histrionic
behaviour or the patient may develop depressive
symptoms.
– In such a situation, consistent limit setting may be
essential for continuation of psychological
treatment.
– Regularity of follow-up visits is important so that the
patient does not need to “produce” a symptom to
visit the therapist.
5. Secondary gains
– Reduction in secondary gains is not advisable very early in the
treatment and without adequate explanations to the family
because of three reasons.
• First, the physician himself may not be certain about the
origin of the symptoms.
• Second, the family may perceive reduction in secondary gain
as neglect of the child.
• Furthermore, initially, the family may not have full
confidence in the physician and the hospital’s ability to take
total care of their child.
6. Abreaction and aversion therapy
– Aversion therapy for unwanted behaviour has often
been employed in resistant cases,
• for example, using liquor ammonia, aversive faradic
stimulation, pressure over trochlear notch, tragus of
ear or over the sternum, and closing the nose and
mouth.
– Aversion therapy for unwanted behaviour is not advised
as it may harm the patient and has a pejorative
connotation equivalent to punishment.
– It may provide only temporary benefits, if any.
– Abreaction is bringing to conscious awareness,
thoughts, affects, and memories for the first time, with
or without the use of drugs.
– This may be achieved by hypnosis, free association, or
drugs.
– Abreaction may further foster dissociative states.
7. MEDICATION
– Medication may be used only for concomitant
anxiety, depression, or behavioural problems and not
for the dissociative symptoms.
– The family should be tactfully made to understand
that medications are neither required nor approved
for dissociative symptoms.
– On persistent request placebo can be given,.
8. NEED FOR HOSPITALIZATION
– Hospitalization is required when ;
• there is doubt in the diagnosis,
• severe symptoms are present,
• the family is very distressed, or
• the symptoms are recalcitrant and
• resistant to outpatient treatment.
TREATMENT OF CHRONIC DISSOCIATIVE DISORDER

1.Cognitive behaviour therapy.

2.Insight oriented dynamic psychotherapy.
1. Cognitive behaviour therapy.
– The aim of CBT is to maximize functioning and reduce the dissociative
symptoms.
– The following are the principles of CBT in chronic dissociative states:
1. Give positive explanations for symptoms
2. Persuade the child that change is possible, he or she is not “damaged,”
and they do have the potential to recover
3. Discuss the treatment rationale with the patient and the key family
members
4. Encourage engagement in daily routine activities
5. Teach relaxation and distraction away from unpleasant thoughts and the
symptoms
6. Encourage the patient to rationally reconsider unhelpful and negative
thoughts
7. Negotiate a phased return to work and studies
8. Joint activities with family in symptom-free periods.
2. Insight oriented dynamic psychotherapy.
– Long-term insight-oriented psychotherapy is chosen
not on the basis of dissociative symptoms but on the
total personality structure of the patient.
– The treatment is focussed upon specific problems
hence an alternative term “focal psychotherapy”.
– The total length of therapy may be five years or more.
MANAGEMENT OF INDIVIDUAL
DISORDERS
 DISSOCIATIVE AMNESIA

• HYPNOSIS :
– It is a set of adjunctive techniques that facilitates
certain psychotherapeutic goals:
• Used to contain, modulate, and titrate the
intensity of symptoms.
• To facilitate controlled recall of dissociated
memories.
• To provide support & ego strengthening of
patients
• To promote working through and integration of
dissociated material.
• SOMATIC THERAPIES:
– No pharmacotherapy.
– A variety of agents can be used :
• Sodium amobarbitol
• Thiopental
• Oral benzodiazepines
• amphetamines
 DISSOCIATIVE FUGUE
• Dissociative fugue is usually treated with an eclectic,
psycho-dynamically informed psychotherapy that
focuses on helping the patient recover memory for
identity and recent experience.
• Hypnotherapy and pharmacologically facilitated
interviews are frequently necessary adjunctive
techniques to assist with memory recovery.
• Therapy should be carefully paced.
• The initial phase is centered on establishing clinical
stabilization, safety, and a therapeutic alliance using
supportive and educative interventions.
• once stabilization is achieved, subsequent therapy is
focused on helping the patient regain memory for
identity, life circumstances and personal history.
• During this process, extreme emotions related to trauma
or severe psychological conflict, or both, may emerge that
require working through.
• In general, the therapist should take a supportive and
nonjudgmental stance, especially if the fugue has been
precipitated by intense guilt or shame over an
indiscretion.
 DISSOCIATIVE IDENTITY
DISORDER
• PSYCHOTHERAPY
– Psychotherapy is consider as primary and most
efficacious tretment modality.
– Initial phase of psychotherapy consists of:
• psycho-education
• setting up treatment frame and boundaries,
development of skills to manage symptoms
• cognitive therapy.
– second phase deals with the traumatic memories.
– third phase consists of fusion, integration,
resolution and recovery of personality.
• PHARMACOTHERAPY
– Psychopharmacologic interventions are primarily
adjunctive and empirical in nature in the treatment
of dissociative identity disorder
– Affective symptoms- in dissociative identity disorder
are only infrequently responsive to mood stabilizing
medications.
– But they often have noteworthy partial response to
antidepressant medications, usually SSRIs (sertraline,
fluoxetine) or TCAs ( imipramine, desipramine).
– Refractory patients may need a series of
antidepressant
 PSEUDOPSYCHOTIC SYMPTOMS :

• In patients with dissociative identity disorder,

pseudopsychotic symptoms rarely are ameliorated by
antipsychotic medications, even in higher doses.
• low doses of atypical neuroleptics (risperidone,
quetiapine, ziprasidone, olanzapine) may ameliorate
these symptoms.
• Occasionally, an extremely disorganized, overwhelmed,
chronically ill dissociative identity disorder patient, who
has not responded to trials of other neuroleptics,
responds favorably to a trial of clozapine.
 refrences

• Şar V. (2014). The many faces of dissociation: opportunities for innovative

research in psychiatry. Clinical psychopharmacology and neuroscience : the
official scientific journal of the Korean College of
Neuropsychopharmacology, 12(3), 171–179.
• Agarwal V, Sitholey P, Srivastava C. Clinical practice guidelines for the
management of dissociative disorders in children and adolescents. Indian J
Psychiatry 2019;61:247-53.
• Kaplan & Sadock’s Comprehensive textbook of Psychiatry,Tenth
edition,Vol.I, chapter 17, pg.1965-2027 .
• Kaplan & Sadock’s Synopsis of psychiatry,10th edition,chapter 20th,pg
no.665-679.
• ICD 10
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