1. Dissociative Disorders Maha S Younis

2. 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.”

3. (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.

4. DSM IV Dissociative disorders dissociative identity disorder depersonalization disorder dissociative amnesia dissociative fugue dissociative disorder not otherwise specified (NOS)

5. 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.

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

7. 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.

8. 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.

9. Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatient clinics Alan J CarsonaAlan J Carsona, Brigitte RingbaueraBrigitte Ringbauera, Jon StonebJon Stoneb, Lesley McKenziebLesley McKenzieb, Charles WarlowcCharles Warlowc, Michael Sharpea 2000;68:207-210 doi:10.1136/jnnp.68.2.207

10. Table 17-2. Prevalence of Dissociative Disorders in General Population Samples StudyRoss (1997)Johnson et al. (2006)Sar et al. (2007) MeasuresDES and DDISAdapted from DES, SCID, SCID-II, and GAFS DDIS, SCID-PTSD, and SCID-II Number of subjects502658628 (female) DiagnosisSubjects (%) Dissociative amnesia6.01.87.3 Dissociative fugue00.2 Dissociative identity disorder1.31.51.1 Depersonalization disorder2.8.81.4 Dissociative disorder not otherwise specified (NOS).24.38.3 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 disorders12.29.118.3 Prevalence of Dissociative Disorders in General Population Samples (CTP)

11. Clinical features Conversion disorder- motor symptoms Paralysis, functional weakness, gait disturbance, fits resembling epilepsy, and abnormal movements. Sensory symptoms – sensory loss,visual loss

12. Disability and prognosis Often poor. Short history and young age is good prognosis.

13. Management No/ very few RCT Cochrane review –all studies were of poor methodological quality.

14. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD005331. Psychosocial interventions for conversion disorder. Ruddy RRuddy R, House A.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. Management-Team work( liaison services) Needs collaboration from psychologists, nurses, physiorherapists, and occupational therapists. IP care may be needed.

16. 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.

17. 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.

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. 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)International Journal of Clinical and Experimental Hypnosis Publisher: Routledge, part of the Taylor & Francis GroupRoutledge, part of the Taylor & Francis Group

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

21. 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.